Evidence-Based Review and Discussion Points By Ronald L. Hickman, RN, PhD, ACNP-BC Evidence-Based Review (EBR) is the journal club feature in the American Journal of Critical Care. In a journal club, attendees review and critique published research articles: an important first step toward integrating evidence-based practice into patient care. General and specific questions such as those outlined in the “Discussion Points” box aid journal club participants in probing the quality of the research study, the appropriateness of the study design and methods, the validity of the conclusions, and the implications of the article for clinical practice. When critically appraising this issue’s EBR article, found on pp 49-57, consider the questions and discussion points outlined in the “Discussion Points” box. Visit www.ajcconline.org to discuss the article online.
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elirium affects more than two-thirds of critically ill patients. Despite the incidence of delirium among those who are critically ill, the clinical manifestations of delirium often go unrecognized and undertreated by critical care practitioners. This study reports on the role of biologic
factors, such as serum interleukins and apolipoprotein E, in the response and recovery from delirium among critically ill patients. A total of 77 critically ill patients who required 24 to 96 hours of mechanical ventilation and who were without preexisting cognitive deficits were recruited to participate in this study. Participants had daily assessments for delirium, as well as blood draws Investigator Spotlight to measure their levels of interleukins, which are a group of cytokines that This feature briefly describes the personal journey and background story of the EBR article’s lead investigators, discussing the circumstances that mediate the inflammatory response, led them to undertake the line of inquiry represented in the research and serum apolipoprotein E. article featured in this issue. This study confirmed that serum apolipoprotein E was associated with heila Alexander, RN, PhD, is an assistant interleukin expression (IL-8 and IL-10) professor at the University of Pittsburgh and patients with the genetic variant, School of Nursing. She and her coauthors apolipoprotein E 4 allele carriers, were took a multidisciplinary approach to investigate the relationship between apoplipoprotein likely to experience shorter periods of E and the occurrence of impaired cognition delirium and lower rates of mortality. among critically ill patients. Alexander’s priIn contrast, patients with the genetic mary research interest involves identifying variant, apolipoprotein E 3 allele, were genetic and cerebrospinal fluid markers of clinically more likely to have longer Sheila Alexander recovery in patients who have been acutely intensive care unit stays, higher disneurologically injured. charge needs, and increased rates of “Coinvestigator selection is really about finding people who mortality. The results of this study have the knowledge and skill set you need for your study, and they highlight how genetic variations in find it interesting,” says Alexander. “As the findings began to come apolipoprotein E and serum levels of in, it was clear that an expert in neuroinflammation was needed, this protein can contribute to the likeleading me to Dr Patrick Kochanek. Finally, when all of the subjects with an apolipoprotein E 4 allele survived, we knew we needed lihood of a patient’s recovery from someone with more experience in that particular area, so we sought delirium during critical illness.
S
out the scientific expertise of Dr Milos Ikonomovic,” explains Alexander, discussing her journey to find coinvestigators with the knowledge and skill set she needed. Little is known about the genetic variations in apolipoprotein E and its role in the recovery from a state of delirium. Alexander and coauthors note that the preliminary findings from their study establish relationships between apolipoprotein E protein and proinflammatory interleukins, as well as between apolipoprotein E genotype and the duration of an episode of delirium among the critically ill. Despite the exploratory nature of this study, this research serves as the foundation for further investigation into the contributory role of apolipoprotein E in the pathogenesis of delirium and illness recovery.
Information From the Authors Sheila Alexander, RN, PhD, lead author of the article, says the study was designed to identify information about the role of apolipoprotein E in an effort to one day develop a laboratory test that will help critical care clinicians identify patients who are at risk for delirium. According to Alexander, this study was a new scientific direction from her previous work, which focused on
©2014 American Association of Critical-Care Nurses, doi: http://dx.doi.org/10.4037/ajcc2014113
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AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2014, Volume 23, No. 1 Downloaded from ajcc.aacnjournals.org by guest on June 3, 2015
www.ajcconline.org
genomics and clinical outcomes of patients with acute brain injury. “My previous work in subarachnoid hemorrhage and traumatic brain injury gave me knowledge about the role of apolipoprotein E in the body and the genetic variants that can influence brain recovery,” she says. Although initially hesitant about investigating the linkages between apolipoprotein E and delirium, Alexander points out that the more she learned about intensive care unit (ICU) delirium, the more interesting the idea became, eventually leading her to seek funding for this work. A central component of this investigation was the engagement of bedside nurses. The identification and recruitment of patients who met the eligibility criteria for the study was a challenge for Alexander and her team. “I don’t think I fully appreciated the time and persistence it takes to recruit from this population, which was a little different from that of my previous work,” notes Alexander. “It was the bedside nurses who were the most vital to recruitment.”
Implications for Practice The study findings confirm that a significant proportion of critically ill patients may acquire delirium and that apolipoprotein E may have a role in their recovery. Alexander explains that the study results have several implications for critical care practitioners. She says the study “helps explain that concept a little more, contributing to our understanding of ICU delirium and the pathology driving it as well as the poor outcomes we see in these patients.” Alexander suspects that her research will contribute to the identification of a genetic or other biomarker panel that will inform critical care practitioners about which patients will develop delirium as well as how to individualize care plans to optimize patient outcomes. Alexander encourages critical care professionals to practice vigilance in the assessment of delirium and to support research that aims to help us better understand the biology of delirium. “The key is to About the Author Ronald L. Hickman is an assistant professor, Case Western Reserve University, and an acute care nurse practitioner at University Hospitals Case Medical Center, Cleveland, Ohio.
www.ajcconline.org
build the evidence base on how genetics influences an individual’s response to delirium. Hopefully, this will inform us on effective strategies to prevent delirium or offer insights on how to personalize care plans to accelerate a patient’s recovery from delirium,” she concludes. eLetters Now that you’ve read the EBR article and accompanying features, discuss them with colleagues. To begin an online discussion using eLetters, just visit www.ajcconline.org and click “Responses” in the second column of either the full-text or PDF view of the article. All eLetters must be approved by the journal’s coeditors prior to publication.
Discussion Points A. Description of the Study ❑ Why does delirium disproportionately affect critically ill patients? ❑ Why is delirium a significant problem for those who are critically ill? B. Literature Evaluation ❑ What has been cited in the literature about the relationship between apolipoprotein E and cognitive impairment? ❑ What previous research on genetic variants of apolipoprotein E has been conducted? C. Sample ❑ What patients were eligible to participate in this study? ❑ How did the investigators classify the patients’ cognitive status? D. Methods and Design ❑ How did the investigators assess for delirium? ❑ What was the purpose of daily blood draws? E. Results ❑ What were the findings of the study? ❑ What genetic variation in apolipoprotein E may help patients recover from a state of delirium? F. Clinical Significance ❑ What are the implications of this study for clinical practice? ❑ What strategies can be used to reduce the chance of delirium among critically ill patients?
AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2014, Volume 23, No. 1 Downloaded from ajcc.aacnjournals.org by guest on June 3, 2015
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Evidence-Based Review and Discussion Points Ronald L. Hickman Am J Crit Care 2014;23:58-59 doi: 10.4037/ajcc2014113 © 2014 American Association of Critical-Care Nurses Published online http://www.ajcconline.org Personal use only. For copyright permission information: http://ajcc.aacnjournals.org/cgi/external_ref?link_type=PERMISSIONDIRECT
Subscription Information http://ajcc.aacnjournals.org/subscriptions/ Information for authors http://ajcc.aacnjournals.org/misc/ifora.xhtml Submit a manuscript http://www.editorialmanager.com/ajcc Email alerts http://ajcc.aacnjournals.org/subscriptions/etoc.xhtml
AJCC, the American Journal of Critical Care, is the official peer-reviewed research journal of the American Association of Critical-Care Nurses (AACN), published bimonthly by The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Telephone: (800) 899-1712, (949) 362-2050, ext. 532. Fax: (949) 362-2049. Copyright © 2014 by AACN. All rights reserved.
Downloaded from ajcc.aacnjournals.org by guest on June 3, 2015
D
elirium affects more than two-thirds of critically ill patients. Despite the incidence of delirium among those who are critically ill, the clinical manifestations of delirium often go unrecognized and undertreated by critical care practitioners. This study reports on the role of biologic
factors, such as serum interleukins and apolipoprotein E, in the response and recovery from delirium among critically ill patients. A total of 77 critically ill patients who required 24 to 96 hours of mechanical ventilation and who were without preexisting cognitive deficits were recruited to participate in this study. Participants had daily assessments for delirium, as well as blood draws Investigator Spotlight to measure their levels of interleukins, which are a group of cytokines that This feature briefly describes the personal journey and background story of the EBR article’s lead investigators, discussing the circumstances that mediate the inflammatory response, led them to undertake the line of inquiry represented in the research and serum apolipoprotein E. article featured in this issue. This study confirmed that serum apolipoprotein E was associated with heila Alexander, RN, PhD, is an assistant interleukin expression (IL-8 and IL-10) professor at the University of Pittsburgh and patients with the genetic variant, School of Nursing. She and her coauthors apolipoprotein E 4 allele carriers, were took a multidisciplinary approach to investigate the relationship between apoplipoprotein likely to experience shorter periods of E and the occurrence of impaired cognition delirium and lower rates of mortality. among critically ill patients. Alexander’s priIn contrast, patients with the genetic mary research interest involves identifying variant, apolipoprotein E 3 allele, were genetic and cerebrospinal fluid markers of clinically more likely to have longer Sheila Alexander recovery in patients who have been acutely intensive care unit stays, higher disneurologically injured. charge needs, and increased rates of “Coinvestigator selection is really about finding people who mortality. The results of this study have the knowledge and skill set you need for your study, and they highlight how genetic variations in find it interesting,” says Alexander. “As the findings began to come apolipoprotein E and serum levels of in, it was clear that an expert in neuroinflammation was needed, this protein can contribute to the likeleading me to Dr Patrick Kochanek. Finally, when all of the subjects with an apolipoprotein E 4 allele survived, we knew we needed lihood of a patient’s recovery from someone with more experience in that particular area, so we sought delirium during critical illness.
S
out the scientific expertise of Dr Milos Ikonomovic,” explains Alexander, discussing her journey to find coinvestigators with the knowledge and skill set she needed. Little is known about the genetic variations in apolipoprotein E and its role in the recovery from a state of delirium. Alexander and coauthors note that the preliminary findings from their study establish relationships between apolipoprotein E protein and proinflammatory interleukins, as well as between apolipoprotein E genotype and the duration of an episode of delirium among the critically ill. Despite the exploratory nature of this study, this research serves as the foundation for further investigation into the contributory role of apolipoprotein E in the pathogenesis of delirium and illness recovery.
Information From the Authors Sheila Alexander, RN, PhD, lead author of the article, says the study was designed to identify information about the role of apolipoprotein E in an effort to one day develop a laboratory test that will help critical care clinicians identify patients who are at risk for delirium. According to Alexander, this study was a new scientific direction from her previous work, which focused on
©2014 American Association of Critical-Care Nurses, doi: http://dx.doi.org/10.4037/ajcc2014113
58
AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2014, Volume 23, No. 1 Downloaded from ajcc.aacnjournals.org by guest on June 3, 2015
www.ajcconline.org
genomics and clinical outcomes of patients with acute brain injury. “My previous work in subarachnoid hemorrhage and traumatic brain injury gave me knowledge about the role of apolipoprotein E in the body and the genetic variants that can influence brain recovery,” she says. Although initially hesitant about investigating the linkages between apolipoprotein E and delirium, Alexander points out that the more she learned about intensive care unit (ICU) delirium, the more interesting the idea became, eventually leading her to seek funding for this work. A central component of this investigation was the engagement of bedside nurses. The identification and recruitment of patients who met the eligibility criteria for the study was a challenge for Alexander and her team. “I don’t think I fully appreciated the time and persistence it takes to recruit from this population, which was a little different from that of my previous work,” notes Alexander. “It was the bedside nurses who were the most vital to recruitment.”
Implications for Practice The study findings confirm that a significant proportion of critically ill patients may acquire delirium and that apolipoprotein E may have a role in their recovery. Alexander explains that the study results have several implications for critical care practitioners. She says the study “helps explain that concept a little more, contributing to our understanding of ICU delirium and the pathology driving it as well as the poor outcomes we see in these patients.” Alexander suspects that her research will contribute to the identification of a genetic or other biomarker panel that will inform critical care practitioners about which patients will develop delirium as well as how to individualize care plans to optimize patient outcomes. Alexander encourages critical care professionals to practice vigilance in the assessment of delirium and to support research that aims to help us better understand the biology of delirium. “The key is to About the Author Ronald L. Hickman is an assistant professor, Case Western Reserve University, and an acute care nurse practitioner at University Hospitals Case Medical Center, Cleveland, Ohio.
www.ajcconline.org
build the evidence base on how genetics influences an individual’s response to delirium. Hopefully, this will inform us on effective strategies to prevent delirium or offer insights on how to personalize care plans to accelerate a patient’s recovery from delirium,” she concludes. eLetters Now that you’ve read the EBR article and accompanying features, discuss them with colleagues. To begin an online discussion using eLetters, just visit www.ajcconline.org and click “Responses” in the second column of either the full-text or PDF view of the article. All eLetters must be approved by the journal’s coeditors prior to publication.
Discussion Points A. Description of the Study ❑ Why does delirium disproportionately affect critically ill patients? ❑ Why is delirium a significant problem for those who are critically ill? B. Literature Evaluation ❑ What has been cited in the literature about the relationship between apolipoprotein E and cognitive impairment? ❑ What previous research on genetic variants of apolipoprotein E has been conducted? C. Sample ❑ What patients were eligible to participate in this study? ❑ How did the investigators classify the patients’ cognitive status? D. Methods and Design ❑ How did the investigators assess for delirium? ❑ What was the purpose of daily blood draws? E. Results ❑ What were the findings of the study? ❑ What genetic variation in apolipoprotein E may help patients recover from a state of delirium? F. Clinical Significance ❑ What are the implications of this study for clinical practice? ❑ What strategies can be used to reduce the chance of delirium among critically ill patients?
AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2014, Volume 23, No. 1 Downloaded from ajcc.aacnjournals.org by guest on June 3, 2015
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Evidence-Based Review and Discussion Points Ronald L. Hickman Am J Crit Care 2014;23:58-59 doi: 10.4037/ajcc2014113 © 2014 American Association of Critical-Care Nurses Published online http://www.ajcconline.org Personal use only. For copyright permission information: http://ajcc.aacnjournals.org/cgi/external_ref?link_type=PERMISSIONDIRECT
Subscription Information http://ajcc.aacnjournals.org/subscriptions/ Information for authors http://ajcc.aacnjournals.org/misc/ifora.xhtml Submit a manuscript http://www.editorialmanager.com/ajcc Email alerts http://ajcc.aacnjournals.org/subscriptions/etoc.xhtml
AJCC, the American Journal of Critical Care, is the official peer-reviewed research journal of the American Association of Critical-Care Nurses (AACN), published bimonthly by The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Telephone: (800) 899-1712, (949) 362-2050, ext. 532. Fax: (949) 362-2049. Copyright © 2014 by AACN. All rights reserved.
Downloaded from ajcc.aacnjournals.org by guest on June 3, 2015
