Jill L. Guttormson

Effects of Patient-Directed Music Intervention on Anxiety and Sedative Exposure in Critically Ill Patients Receiving Mechanical Ventilatory Support: A Randomized Clinical Trial

IMPORTANCE Alternatives to sedative medications, such as music, may alleviate the anxiety associated with ventilatory support. OBJECTIVE To test whether listening to self-initiated patient-directed music (PDM) can reduce anxiety and sedative exposure during ventilatory support in critically ill patients. DESIGN, SETTING, AND PATIENTS Randomized clinical trial that enrolled 373 patients from 12 intensive care units (ICUs) at 5 hospitals in the Minneapolis-St Paul, Minnesota, area receiving acute mechanical ventilatory support for respiratory failure between September 2006 and March 2011. Of the patients included in the study, 86% were white, 52% were female, and the mean (SD) age was 59 (14) years. The patients had a mean (SD) Acute Physiology, Age and Chronic Health Evaluation III score of 63 (21.6) and a mean (SD) of 5.7 (6.4) study days. INTERVENTIONS Self-initiated PDM (n = 126) with preferred selections tailored by a music therapist whenever desired while receiving ventilatory support, self-initiated use of noise-canceling headphones (NCH; n = 122), or usual care (n = 125). MAIN OUTCOMES AND MEASURES Daily assessments of anxiety (on 100-mm visual analog scale) and 2 aggregate measures of sedative exposure (intensity and frequency). RESULTS Patients in the PDM group listened to music for a mean (SD) of 79.8 (126) (median [range], 12 [0-796]) minutes/day. Patients in the NCH group wore the noise-abating headphones for a mean (SD) of 34.0 (89.6) (median [range], 0 [0-916]) minutes/day. The mixed-models analysis showed that at any time point, patients in the PDM group had an anxiety score that was 19.5 points lower (95% CI, -32.2 to -6.8) than patients in the usual care group (P = .003). By the fifth study day, anxiety was reduced by 36.5% in PDM patients. The treatment × time interaction showed that PDM significantly reduced both measures of sedative exposure. Compared with usual care, the PDM group had reduced sedation intensity by -0.18 (95% CI, -0.36 to -0.004) points/day (P = .05) and had reduced frequency by -0.21 (95% CI, -0.37 to -0.05) points/day (P = .01). The PDM group had reduced sedation frequency by -0.18 (95% CI, -0.36 to -0.004) points/day vs the NCH group (P = .04). By the fifth study day, the PDM patients received 2 fewer sedative doses (reduction of 38%) and had a reduction of 36% in sedation intensity. CONCLUSIONS AND RELEVANCE Among ICU patients receiving acute ventilatory support for respiratory failure, PDM resulted in greater reduction in anxiety compared with usual care, but not compared with NCH. Concurrently, PDM resulted in greater reduction in sedation frequency compared with usual care or NCH, and greater reduction in sedation intensity compared with usual care, but not compared with NCH. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00440700.

Quiet time for mechanically ventilated patients in the medical intensive care unit

OBJECTIVE Sleep disruption occurs frequently in critically ill patients. The primary aim of this study was to examine the effect of quiet time (QT) on patient sedation frequency, sedation and delirium scores; and to determine if consecutive QTs influenced physiologic measures (heart rate, mean arterial blood pressure and respiratory rate). METHOD A prospective study of a quiet time protocol was conducted with 72 adult patients on mechanical ventilation. SETTING A Medical Intensive Care Unit (MICU) in the Midwest region of the United States. RESULTS Sedation was given less frequently after QT (p=0.045). Those who were agitated prior to QT were more likely to be at goal sedation after QT (p<0.001). Although not statistically significant, the majority of patients who were negative on the Confusion Assessment Method (CAM-ICU) prior to QT remained delirium free after QT. Repeated measures analysis of variance (ANOVA) for three consecutive QTs showed a significant difference for respiratory rate (p=0.035). CONCLUSION QT may influence sedation administration and promote patient rest. Future studies are required to further understand the influence of QT on mechanically ventilated patients in the intensive care unit.

Quiet Time for Mechanically Ventilated Patients in a Medical Intensive Care Unit

Sleep disruption occurs frequently in critically ill patients. The purpose of this study was to (a) determine if a quiet time (QT) affected patient sedation frequency and sedation and delirium scores, and (b) measure the patient’s physiological responses (heart rate, mean arterial blood pressure, and respiratory rate) to consecutive QTs. Topf’s Environmental Stress Model (ESM) guided the design and selection of variables. Noise in the critical care environment creates stressors that induce adverse physiological and psychological responses in patients. QT, by reducing noise and patient interruptions, may (a) improve the quality and quantity of patient sleep, (b) decrease sedative medication administration, and (c) prevent or reduce delirium. This was a prospective study of a QT protocol with 72 mechanically ventilated patients. Patients were recruited over a year from one medical intensive care unit (ICU) at an academic medical center. The QT protocol involved a reduction of light and sound within the patient’s room, and minimizing interruptions. The QT occurred daily from 2:00 p.m. to 4:00 p.m. for those enrolled in the study. Sedation was given less frequently after QT (p = .045), and those who were agitated prior to QT were more likely to be at the goal sedation score after QT (p < .001). Although not statistically significant, the majority of patients who were negative on the Confusion Assessment Method (CAM-ICU) prior to QT remained delirium free after QT. Repeatedmeasures ANOVA for 3 consecutive QTs showed a significant difference for respiratory rate (p = .035). Our findings suggest that the QT protocol may influence sedation administration; however, future research is needed to understand the effect of QT on the use of sedative medications. While the impact of QT on delirium was inconclusive in this study, it warrants further investigation. It is recommended that future studies implement experimental study designs that incorporate objective measures of sleep to further explicate the effects of QT on mechanically ventilated patients in the ICU.