In this episode I’ll:

1. Share an article about using earplugs to reduce ICU delirium.

2. Answer the drug information question: “Should dextrose containing solutions be avoided in ischemic stroke patients?”

3. Share the resource I used to answer the drug information question.

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Article

The Efficacy of Earplugs as a Sleep Hygiene Strategy for Reducing Delirium in the ICU: A Systematic Review and Meta-Analysis

Lead author: Edward Litton

Published in Critical Care Medicine May 2016

Background

In a world of fancy & expensive medications and procedures, I enjoy seeing a simple & cheap intervention performing well. Aspirin & crystalloid fluids are two examples – perhaps after this article we can add earplugs to that list.

Objective

The authors conducted a systematic review and meta-analysis to assess the efficacy of earplugs as an ICU strategy for reducing delirium.

Methods

Intervention studies (randomized or nonrandomized) assessing the efficacy of earplugs as a sleep hygiene strategy in patients admitted to a critical care environment were included.

Nine studies published between 2009 and 2015, including 1,455 participants, fulfilled the eligibility criteria and were included in the systematic review. Three studies included earplugs as an isolated intervention, two as part of a bundle with eye shades, and four studies looked at earplugs, eye shades, and additional sleep noise abatement strategies.

Results

Five studies comprising 832 participants reported incident delirium. Earplug placement was associated with a relative risk of delirium of 0.59 (95% CI, 0.44–0.78). Hospital mortality was reported in four studies and was associated with a relative risk of 0.77 (95% CI, 0.54–1.11). Compliance with the placement of earplugs was reported in six studies. The mean per-patient noncompliance was 13.1% of those assigned to receive earplugs.

Conclusion

The authors concluded:

Placement of earplugs in patients admitted to the ICU, either in isolation or as part of a bundle of sleep hygiene improvement, is associated with a significant reduction in risk of delirium. The potential effect of cointerventions and the optimal strategy for improving sleep hygiene and associated effect on patient-centered outcomes remains uncertain.

Discussion

You can bet that an ICU patient will have their normal sleep-wake cycle disrupted. Although the meta-analysis did not find a mortality benefit with the use of earplugs, the number of study patients who died was small, and a benefit on mortality cannot be excluded. All of the studies in the meta-analysis were single center studies with a high risk of bias. With earplugs being such a safe, cheap & simple strategy I don’t see a downside to offering them to all ICU patients. After all, earplug use has better data for the prevention of delirium than drugs like quetiapine do!

Drug information question

Q: Should dextrose containing solutions be avoided in ischemic stroke patients?

A: Yes.

I was asked this question recently by “Pulmonology Tony” & “Pulmonology Zoi”. They had heard this statement by “Neurology Refat” and asked me to look into it. I was stumped, so I turned to the Pharmacy Nation Slack group for help answering the question. I promptly got three replies. Thank you to “Pharmacy Courtney”, “Pharmacy Justin” & “Pharmacy Mike”!

It turns out the neurologist and the pulmonologists were each right. There is no direct evidence that dextrose containing solutions should be avoided in ischemic stroke patients.

However, one of the most significant acute complications of ischemic stroke is cerebral edema, and a hypotonic solution such as dextrose 5% might increase the risk or severity of cerebral edema. “Pharmacy Mike” was kind enough to link a document explaining the rationale and I’ve posted that document here (read the end of page 7 into page 8).

Resource

And that makes the resource for this episode…The Pharmacy Nation Slack Group! As of this recording there are 243 members of this group spread across 15 time zones communicating about professional issues using real-time messaging. You can sign up at pharmacynation.org

Slack is a popular team communication app that works on mobile and desktop devices.

After signing up be sure to download the Slack app from your google play or apple app store.

Once you have signed into the app, you’ll notice that conversations can take place in different “channels”. Each channel is devoted to a topic, and you can join as many or as few channels as you would like. The most popular channels are general “Pharmacy”, “Infectious Disease”, “Cardiology”, and “Critical Care & Emergency Medicine”.

One of the things I enjoy most about hospital pharmacy is that you’re seldom alone in trying to solve a problem. There are usually other pharmacists or professionals that you can reach out to for advice. With the Pharmacy Nation Slack Group, you can communicate and collaborate with a much greater number of professionals at once. I like to think of it as a modern and more convenient version of an email list-serv.

The group is free, the slack app is free, and the community is great – I hope to see you on the inside – sign up at pharmacynation.org!!!

If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.

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