Author
Brenda T. Pun
Other affiliations: Veterans Health Administration, Vanderbilt University
Bio: Brenda T. Pun is an academic researcher from Vanderbilt University Medical Center. The author has contributed to research in topics: Delirium & Intensive care. The author has an hindex of 19, co-authored 29 publications receiving 5999 citations. Previous affiliations of Brenda T. Pun include Veterans Health Administration & Vanderbilt University.
Topics: Delirium, Intensive care, Intensive care unit, Sedation, Coma
Papers
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Stanford University1, Maine Medical Center2, University of California, San Francisco3, Veterans Health Administration4, McGill University5, University of Texas at Austin6, Scripps Health7, Northeastern University8, University of Chicago9, University of Washington10, University of Wisconsin-Madison11, University of Maryland, Baltimore12, University of Cincinnati13, University of Virginia14, Baylor University Medical Center15, Virginia Commonwealth University16, Université de Montréal17, McMaster University18
TL;DR: These guidelines provide a roadmap for developing integrated, evidence-based, and patient-centered protocols for preventing and treating pain, agitation, and delirium in critically ill patients.
Abstract: Objective:To revise the “Clinical Practice Guidelines for the Sustained Use of Sedatives and Analgesics in the Critically Ill Adult” published in Critical Care Medicine in 2002.Methods:The American College of Critical Care Medicine assembled a 20-person, multidisciplinary, multi-institutional task f
3,005 citations
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Tufts Medical Center1, Northeastern University2, McGill University3, Johns Hopkins University4, Utrecht University5, Vanderbilt University Medical Center6, Brigham and Women's Hospital7, New York University8, McMaster University9, Ohio State University10, Radboud University Nijmegen11, University of Western Ontario12, London Health Sciences Centre13, University of Montpellier14, RMIT University15, University of Poitiers16, Maine Medical Center17, University of Washington18, University of Chicago19, Intermountain Healthcare20, Deakin University21, Johns Hopkins University School of Medicine22, Yale University23, University of Grenoble24, University of California, San Francisco25, Monash University26, Case Western Reserve University27, New York Medical College28, University of Toronto29, Stanford University30
TL;DR: Substantial agreement was found among a large, interdisciplinary cohort of international experts regarding evidence supporting recommendations, and the remaining literature gaps in the assessment, prevention, and treatment of Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) in critically ill adults.
Abstract: Objective:To update and expand the 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU.Design:Thirty-two international experts, four methodologists, and four critical illness survivors met virtually at least monthly. All section groups g
1,935 citations
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Vanderbilt University Medical Center1, The Ohio State University Wexner Medical Center2, Ohio State University3, Sutter Health4, University of California, San Francisco5, VA Palo Alto Healthcare System6, Stanford University7, Innovative Solutions & Support8, University of North Carolina at Chapel Hill9, Tufts Medical Center10, University of Chicago11, Houston Methodist Hospital12, Society of Critical Care Medicine13, Novant Health14, Saint Joseph Mercy Health System15, University of Pennsylvania16, Johns Hopkins University17
TL;DR: ABCDEF bundle performance showed significant and clinically meaningful improvements in outcomes including survival, mechanical ventilation use, coma, delirium, restraint-free care, ICU readmissions, and post-ICU discharge disposition.
Abstract: Objective:Decades-old, common ICU practices including deep sedation, immobilization, and limited family access are being challenged. We endeavoured to evaluate the relationship between ABCDEF bundle performance and patient-centered outcomes in critical care.Design:Prospective, multicenter, cohort st
571 citations
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TL;DR: To describe the motoric subtypes of delirium in critically ill patients and compare patients aged 65 and older with a younger cohort is compared.
Abstract: OBJECTIVES: To describe the motoric subtypes of delirium in critically ill patients and compare patients aged 65 and older with a younger cohort.
DESIGN: Prospective cohort study.
SETTING: The medical intensive care unit (MICU) of a tertiary care academic medical center.
PARTICIPANTS: Six hundred fourteen MICU patients admitted during a process improvement initiative to monitor levels of sedation and delirium.
MEASUREMENTS: MICU nursing staff assessed delirium and level of consciousness in all MICU patients at least once per 12-hour shift using the Confusion Assessment Method for the Intensive Care Unit and the Richmond Agitation-Sedation Scale. Delirium episodes were categorized as hypoactive, hyperactive, and mixed type.
RESULTS: Delirium was detected in 112 of 156 (71.8%) subjects aged 65 and older and 263 of 458 (57.4%) subjects younger than 65. Mixed type was most common (54.9%), followed by hypoactive delirium (43.5%) and purely hyperactive delirium (1.6%). Patients aged 65 and older experienced hypoactive delirium at a greater rate than younger patients (41.0% vs 21.6%, P<.001) and never experienced hyperactive delirium. Older age was strongly and independently associated with hypoactive delirium (adjusted odds ratio=3.0, 95% confidence interval=1.7–5.3), compared with no delirium in a model that adjusted for other important determinants of delirium including severity of illness, sedative medication use, and ventilation status.
CONCLUSION: Older age is a strong predictor of hypoactive delirium in MICU patients, and this motoric subtype of delirium may be missed in the absence of active monitoring.
566 citations
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TL;DR: How ICU professionals can use knowledge and resources to limit the burden of delirium on patients by reducing modifiable risk factors despite the imposed heavy workload and difficult clinical challenges posed by the COVID-19 pandemic is discussed.
Abstract: The novel coronavirus, SARS-CoV-2-causing Coronavirus Disease 19 (COVID-19), emerged as a public health threat in December 2019 and was declared a pandemic by the World Health Organization in March 2020. Delirium, a dangerous untoward prognostic development, serves as a barometer of systemic injury in critical illness. The early reports of 25% encephalopathy from China are likely a gross underestimation, which we know occurs whenever delirium is not monitored with a valid tool. Indeed, patients with COVID-19 are at accelerated risk for delirium due to at least seven factors including (1) direct central nervous system (CNS) invasion, (2) induction of CNS inflammatory mediators, (3) secondary effect of other organ system failure, (4) effect of sedative strategies, (5) prolonged mechanical ventilation time, (6) immobilization, and (7) other needed but unfortunate environmental factors including social isolation and quarantine without family. Given early insights into the pathobiology of the virus, as well as the emerging interventions utilized to treat the critically ill patients, delirium prevention and management will prove exceedingly challenging, especially in the intensive care unit (ICU). The main focus during the COVID-19 pandemic lies within organizational issues, i.e., lack of ventilators, shortage of personal protection equipment, resource allocation, prioritization of limited mechanical ventilation options, and end-of-life care. However, the standard of care for ICU patients, including delirium management, must remain the highest quality possible with an eye towards long-term survival and minimization of issues related to post-intensive care syndrome (PICS). This article discusses how ICU professionals (e.g., physicians, nurses, physiotherapists, pharmacologists) can use our knowledge and resources to limit the burden of delirium on patients by reducing modifiable risk factors despite the imposed heavy workload and difficult clinical challenges posed by the pandemic.
369 citations
Cited by
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St George's Hospital1, New York University2, McMaster University3, Brown University4, Catholic University of the Sacred Heart5, Hebron University6, University of Manitoba7, Emory University Hospital8, Hebrew University of Jerusalem9, Sunnybrook Health Sciences Centre10, University of Pittsburgh11, Saint Thomas - West Hospital12, University College London13, Vanderbilt University Medical Center14, Keio University15, Memorial Hospital of South Bend16, Cooper University Hospital17, University of Mississippi Medical Center18, Rush University Medical Center19, University of Ulsan20, Federal University of São Paulo21, Regions Hospital22, St. Michael's Hospital23, Washington University in St. Louis24, Ottawa Hospital25, University of Sydney26, Mount Sinai Hospital27, University of New South Wales28, Fujita Health University29, Christiana Care Health System30, Stanford University31, King Abdullah University of Science and Technology32, University of Kansas33, Harvard University34, California Pacific Medical Center35, University of Amsterdam36, Houston Methodist Hospital37
TL;DR: Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality.
Abstract: To provide an update to “Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012”. A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable. The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions. Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality.
4,303 citations
01 Jan 2006
TL;DR: For example, Standardi pružaju okvir koje ukazuju na ucinkovitost kvalitetnih instrumenata u onim situacijama u kojima je njihovo koristenje potkrijepljeno validacijskim podacima.
Abstract: Pedagosko i psiholosko testiranje i procjenjivanje spadaju među najvažnije doprinose znanosti o ponasanju nasem drustvu i pružaju temeljna i znacajna poboljsanja u odnosu na ranije postupke. Iako se ne može ustvrditi da su svi testovi dovoljno usavrseni niti da su sva testiranja razborita i korisna, postoji velika kolicina informacija koje ukazuju na ucinkovitost kvalitetnih instrumenata u onim situacijama u kojima je njihovo koristenje potkrijepljeno validacijskim podacima. Pravilna upotreba testova može dovesti do boljih odluka o pojedincima i programima nego sto bi to bio slucaj bez njihovog koristenja, a također i ukazati na put za siri i pravedniji pristup obrazovanju i zaposljavanju. Međutim, losa upotreba testova može dovesti do zamjetne stete nanesene ispitanicima i drugim sudionicima u procesu donosenja odluka na temelju testovnih podataka. Cilj Standarda je promoviranje kvalitetne i eticne upotrebe testova te uspostavljanje osnovice za ocjenu kvalitete postupaka testiranja. Svrha objavljivanja Standarda je uspostavljanje kriterija za evaluaciju testova, provedbe testiranja i posljedica upotrebe testova. Iako bi evaluacija prikladnosti testa ili njegove primjene trebala ovisiti prvenstveno o strucnim misljenjima, Standardi pružaju okvir koji osigurava obuhvacanje svih relevantnih pitanja. Bilo bi poželjno da svi autori, sponzori, nakladnici i korisnici profesionalnih testova usvoje Standarde te da poticu druge da ih također prihvate.
3,905 citations
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Stanford University1, Maine Medical Center2, University of California, San Francisco3, Veterans Health Administration4, McGill University5, University of Texas at Austin6, Scripps Health7, Northeastern University8, University of Chicago9, University of Washington10, University of Wisconsin-Madison11, University of Maryland, Baltimore12, University of Cincinnati13, University of Virginia14, Baylor University Medical Center15, Virginia Commonwealth University16, Université de Montréal17, McMaster University18
TL;DR: These guidelines provide a roadmap for developing integrated, evidence-based, and patient-centered protocols for preventing and treating pain, agitation, and delirium in critically ill patients.
Abstract: Objective:To revise the “Clinical Practice Guidelines for the Sustained Use of Sedatives and Analgesics in the Critically Ill Adult” published in Critical Care Medicine in 2002.Methods:The American College of Critical Care Medicine assembled a 20-person, multidisciplinary, multi-institutional task f
3,005 citations
••
St George’s University Hospitals NHS Foundation Trust1, New York University2, McMaster University3, Brown University4, Catholic University of the Sacred Heart5, Autonomous University of Barcelona6, University of Manitoba7, Emory University8, Hebrew University of Jerusalem9, University of Toronto10, University of Pittsburgh11, St Thomas' Hospital12, University College London13, Vanderbilt University14, Keio University15, Memorial Hospital of South Bend16, Rowan University17, University of Mississippi18, Rush University Medical Center19, University of Ulsan20, Universidade Federal do Rio Grande do Sul21, Federal University of São Paulo22, Regions Hospital23, Washington University in St. Louis24, University of Ottawa25, University of Sydney26, University of New South Wales27, Fujita Health University28, University of Copenhagen29, Sapienza University of Rome30, Christiana Care Health System31, Stanford University32, King Abdullah University of Science and Technology33, University of Kansas34, Harvard University35, California Pacific Medical Center36, University of Amsterdam37, Université libre de Bruxelles38, Houston Methodist Hospital39
TL;DR: A consensus committee of 55 international experts representing 25 international organizations was assembled at key international meetings (forSurviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012 as discussed by the authors ).
Abstract: Objective:To provide an update to “Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012.”Design:A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for
2,414 citations
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TL;DR: In view of the complex multifactorial causes of delirium, multicomponent non-pharmacological risk factor approaches are the most effective strategy for prevention and no convincing evidence shows that pharmacological prevention or treatment is effective.
2,359 citations