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Relieving Thirst in ICU A Randomized Clinical Trial Kathleen Puntillo RN, PhD, FAAN, FCCM “Water, water, everywhere, nor any drop to drink” Coleridge
Relieving Thirst in ICU A Randomized Clinical Trial
Kathleen Puntillo RN, PhD, FAAN, FCCM
“Water, water, everywhere, nor any drop to drink”
Coleridge
Thirst: Important Points
• One of the most pervasive, intense, unrecognized, and under-treated symptoms in ICU patients (Ballard, 1981; Novaes et al, 1999; Nelson et al, 2001; Nelson et al, 2004; Puntillo et al, 2010, 2012)
• Many biological, clinical, and treatment-related factors can influence thirst
• Treating thirst and doing mouth care are not the same thing
Palliation of Thirst in ICU Patients
• Single-blinded randomized clinical trial
• 3 Adult ICUs (Medical-Surgical, Cardiac, Neuro) in tertiary care center.
• Hypothesis: Thirst intensity and thirst distress will decrease significantly more over time in ICU patients who receive a thirst intervention bundle compared to those who receive usual care.the bundle.
NIH- NINR Grant 1NR011825-03 K. Puntillo, Principal Investigator
Inclusion Criteria
• Age >18 years
• ICU stay ≥ 24 hours
• English proficient
• Oriented to name, date of birth, and location
• RASS score of -1 to +1
• Either a thirst intensity or thirst distress score of > 3 on a 0 – 10 numeric rating scale (NRS)
Patient Flow Diagram of Screening,* Recruitment, and Randomization
Patients with Eligible Thirst Scores (n – 950)
Not Enrolled (n = 698) • Cognitive impairment (n = 29) • Too tired or in pain (n = 113) • Other limitations (n = 30) • Declined (n = 526)
• Most gave no reason for refusal
Consented & Randomized
(n = 252)
Intervention Group
(n = 129)
Usual Care Group
(n = 123)
* 1417 patients were screened
Thirst Relief Bundle
Oral Swabs
sterile ice
cold water
sprays
Mentholated
Moisturizer
Research-based Thirst Bundle
Thirst Bundle Testing Usual Care Group Intervention Group
1. RTN #1: Pre-intervention NRS thirst scores 2. Thirst Bundle 3. RTN #2: Post-intervention
NRS thirst scores
1. RTN #1: Pre-observation NRS thirst scores 2. Observation 3. RTN #2: Post-observation
NRS thirst scores
Thirst Bundle Testing Usual Care Group Intervention Group
Intervention repeated twice on day #1 and 3 times on day #2
Observation time repeated twice on day #1 and 3 times on day #2
Statistical Analyses
• Multilevel regression analysis with random intercepts – whether the decrease in TI and TD over time was
greater in the thirst intervention versus the usual care patients.
Three within-subjects factors:
– pre-post scores for each session
– three sessions each day
– two days
for the intervention group (p < 0.05).
Patient Sample Intervention Usual Care
Age (mean + SD) 54.5 ± 14.0 55.5 ± 15.0
Male Gender (%) 53.5 56
Race (%) - White 64.6 68.8
APACHE II (mean + SD) 20.5 ± 8 20.2 ± 8.2
Total days in ICU (mean + SD) 9.5 ± 12.2 9.5 ± 9.8
ICU day of enrollment (mean
+ SD)
5.2 ± 5.8 5.6 ± 6.5
Mechanically ventilated (%) 7.1 4.8
Died in ICU (%) 3.9 2.4
Sessions completed** (mean
+ SD)
3.1 ± 1.5 3.6 ± 1.7
** P = .02
Statistical Results
• The average differences due to days and sessions not significant.
• Examining average changes in scores from pre-session to post-session, without regard to individual session or day:
decreases in TI and TD scores were greater in intervention group.
Estimated Mean Thirst Intensity Scores (0 – 10 NRS) (per multilevel regression analysis with random intercepts)
Observations by Group Estimated
Means (SE)
95% Confidence
Intervals lower
limit
upper
limit
No Intervention
n = 450
Pre-thirst
5.3 (.22)
4.9
5.8
n = 442 Post-thirst 4.7 (.22) 4.3 5.1
Intervention
n = 399
Pre-thirst
5.9 (.22)
5.4
6.3
n = 396 Post thirst 3.6 (.22) 3.1 4.0
Estimated Mean Thirst Intensity Scores (0 – 10 NRS)
Observations by Group Estimated
Means (SE)
95% Confidence
Intervals lower
limit
upper
limit
No Intervention
n = 450
Pre-thirst
5.3 (.22)
4.9
5.8
n = 442 Post-thirst 4.7 (.22) 4.3 5.1
Intervention
n = 399
Pre-thirst
5.9 (.22)
5.4
6.3
n = 396 Post thirst 3.6 (.22) 3.1 4.0 - 2.3
- 0.7
Thirst Intensity
Usual Care Intervention
Estimated Mean Thirst Distress Scores (0 – 10 NRS)
Observations by Group Estimated
Means (SE)
95% Confidence
Intervals lower
limit
upper
limit
No Intervention
n = 447
Pre-thirst
4.1 (.25)
3.6
4.6
n = 439 Post thirst 3.7 (.25) 3.2 4.2
Intervention
n = 395
Pre-thirst
5.0 (.25)
4.5
5.5
n = 392 Post thirst 3.2 (.25) 2.7 3.6
Estimated Mean Thirst Distress Scores (0 – 10 NRS)
Observations by
Group
Estimated
Means (SE)
95%
Confidence
Intervals lower
limit
upper
limit
No
Intervention
n = 447
Pre-thirst
4.1 (.25)
3.6
4.6
n = 439 Post thirst 3.7 (.25) 3.2 4.2
Intervention
n = 395
Pre-thirst
5.0 (.25)
4.5
5.5
n = 392 Post thirst 3.2 (.25) 2.7 3.6
- 0.4
- 1.8
Thirst Distress
Usual Care Intervention
Limitations
• High refusal rate
• Small number of MV patients
• Some patients received fluids, but more in no intervention group
• Effects of individual parts of bundle not analyzed
• Exact duration of effect unknown
Conclusion
This simple bundle of thirst relief measures significantly decreased ICU patients’ thirst intensity and distress and should be considered as a practice intervention.
Thank You
And thanks to my team at UCSF:
• Shoshana Arai RN, PhD
• Meghan Saito RN, MS
• Waiyee Kwong RN, MS
• Michelle Truong RN, MS
• Jennifer Saaty RN, MS
• Charlene Bugais RN, MS
• Marianna Kiranou RN, PhD
And thanks to my co-investigators: • Nancy Stotts RN, EdD
• Bruce Cooper PhD
• Judity Nelson MD, JD
