Agitation, Confusion and Aggression in Critically Ill trAumatic brain injury patients – a pilot cohort study (ACACIA-PILOT)
CCCF ePoster library. Williamson D. 11/13/19; 283449; EP115 Disclosure(s)(s): David Williamson is supported by an FRQ-S clinician scientist grant
Prof. David Williamson
Prof. David Williamson
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Topic: Retrospective or Prospective Cohort Study or Case Series

David Williamson1,2,3, Sofia Ihsenne Cherifa1,2, Mar Saavedra Mitjans1,2, Anne Julie Frenette1,2,3, Emmanuel Charbonney2,4,5, Gabrielle Cataford1,2, Virginie Williams2,4, Julia Palacios2,4, Lisa Burry6, Caroline Arbour2,7, Nadia Gosselin2,8, Francis Bernard2,4,5.

1 Faculté de pharmacie, Université de Montréal, Montreal, Canada
2 Research center, Hôpital du Sacré-Coeur de Montréal, Montreal, Canada
3 Pharmacy department, Hôpital du Sacré-Coeur de Montréal, Montreal, Canada
4 Critical Care department, Hôpital du Sacré-Coeur de Montréal, Montreal, Canada
5 Faculté de médecine, Université de Montréal, Montreal, Canada
6 Pharmacy department, Mount SInai Hospital, Toronto, Canada
7 Faculté des sciences infirmières, Université de Montréal, Montreal, Canada
8 Départment de psychologie, Université de Montréal, Montreal, Canada

Agitated behaviours (AB) constitute hallmark behaviours of intensive care unit (ICU) patients recovering from traumatic brain injury (TBI). These behaviours create significant challenges for patients and healthcare providers including the need for pharmacologic treatment, delaying mechanical ventilation weaning and mobilization, and complicating bedside care. AB have been reported during the early stage of hospital recovery, but there are no data specific for the ICU setting as well as no clinical definition or assessment tools. In addition, the predictors, clinical phenotypes and impact of AB on clinical outcomes have yet to be described. Before moving towards a multicenter cohort study, we need to assess feasibility and pilot the screening of AB, and confirm study procedures.

The main objective of this pilot study was to evaluate the feasibility of conducting a larger prospective cohort study of AB in critically ill TBI patients.

This was a prospective single center feasibility cohort study. Patients 18 years and older admitted to the ICU of Hôpital du Sacré-Coeur de Montréal with a mild complex, moderate or severe TBI were eligible. Exclusions criteria included: complete spinal cord injury, prior history of TBI, major neurological or psychiatric disease, high risk of short-term mortality, expected stay < 48 hours. Patients or substitute decision maker were approached for consent and study inclusion began within 48 hours of TBI. The primary outcome was feasibilty defined as a recruitment rate greater 2-4 patients per month, more than 90% of AB logs completed and 90% actigraphy adhesion. Secondary outcomes included the incidence of agitation (RASS 2 or more) and characterisation of behaviors using subcategories of the nursing logs during ICU stay. Bedside nurses documented 14 pssible pre-defined components AB with observation logs every 8-hour shift as well as RASS scores. Bedside video recordings were used to validate documentation log comprehension. Sleep-wake cycle monitoring and agitation was measured using wrist actigraphy.
Between September and July 2019, a total of 127 patients were screened for study inclusion. A total of 47 patients were deemed eligible and 30 patients were recruited (64% consent rate and 3 patient/month recruitment rate). In 11 patients, consent was denied whereas in 6 others, no substitute decision maker was available. A total of 80 patients were excluded with the main reasons being: 1) screening beyond 48 hours following TBI (26 patients); 2) expected stay of less than 48 hours (19 patients); 3) imminent withdrawal of life support (13 patients); 4) past history of TBI (7 patients). The median age and APACHE 2 score were 64.5 years (IQR 41.3) and 16.5 (IQR 9.25), and 73% were men. TBI were severe, moderate and mild complex in 30%, 43% and 27% of cases, respectively. Falls (50%) and motor vehicle accidents (43%) were the main causes of TBI. In total, 96% of AB observation logs were completed and 100% of patients were monitored with actigraphs. During the ICU stay, a total of 17 patients developed agitation (57%). Restlessness, disorientation and violent behaviour were reported by nurses in 42.9%, 23.9% and 12.9% of 8-hour shifts.
This study confirmed the feasibility of a larger cohort study. Enabling inclusion within 72 hours of TBI and exploring a differed consent could increase recruitment rates. Preliminary analysis suggests AB are frequent and problematic.   

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