Delirium duration and mortality in lightly sedated, mechanically ventilated intensive care patients*:

Haloperidol in treating delirium, reducing mortality, and preventing delirium occurrence: Bayesian and frequentist meta-analyses

BACKGROUND

Although haloperidol is commonly used to treat or prevent delirium in intensive care unit (ICU) patients, the evidence remains inconclusive. This study aimed to comprehensively evaluate the efficacy and safety of haloperidol for delirium treatment and prevention in ICU patients.

METHODS

We searched MEDLINE, the cochrane central register of controlled trials, EMBASE, ClinicalTrial.gov, and PubMed without language restrictions from database inception to June 27, 2024. We included double-blind randomized controlled trials (RCTs) on haloperidol versus placebo for treating and preventing delirium in adult ICU patients. In addition to frequentist analyses, Bayesian analysis was used to calculate the posterior probabilities of any benefit/harm and clinically important benefit/harm (CIB/CIH). The primary outcomes for delirium treatment were all-cause mortality and serious adverse events (SAEs). For delirium prevention, the primary outcomes included incident delirium, all-cause mortality, and SAEs. The secondary outcomes for efficacy were delirium-or coma-free days, ventilator-free days, length of stay in ICU, length of stay in hospital, and rescue benzodiazepine use. The secondary outcomes for safety were QTc prolongation and extrapyramidal syndrome.

RESULTS

We included seven RCTs on delirium treatment (n = 1767) and five on delirium prevention (n = 2509). The Bayesian analysis showed that, compared to placebo for delirium treatment, haloperidol had a 68% probability of achieving CIB (defined as risk difference [RD] < -0.02) in reducing all-cause mortality, a 2% probability of achieving CIH (RD > 0.02) in causing SAEs, and a 78% probability of achieving CIB (RD < -0.02) in reducing the need for rescue benzodiazepine use. The probabilities of haloperidol causing CIH (RD > 0.02) across all other safety outcomes were low (all < 50%). In frequentist analysis on delirium treatment, the pooled estimated RD for haloperidol compared to placebo was -0.05 (-0.09, -0.00; I2 = 0%) for rescue benzodiazepine use. In Bayesian analysis on delirium prevention, haloperidol had a 12% probability of achieving CIB in all-cause mortality, a 34% probability of achieving CIB in delirium incidence, and a 0% probability of achieving CIB in SAEs. Importantly, haloperidol had a 65% probability of causing CIH (risk ratio > 1.1) for QTc prolongation, while the posterior probabilities of achieving CIB across all efficacy outcomes were low (all < 50%). In frequentist analysis on delirium prevention, all primary and secondary outcomes were not statistically significant in frequentist analysis.

CONCLUSION

Our study supported the use of haloperidol for delirium treatment in adult ICU patients, but not for delirium prevention.

A bibliometric analysis on delirium in intensive care unit from 2013-2023

Background

Delirium is a common manifestation of acute brain dysfunction among patients in the Intensive Care Unit (ICU), afflicting an estimated 30-35% of this vulnerable population. The prevalence of delirium in ICU settings has catalyzed a surge in academic interest, as evidenced by a growing body of literature on the subject. This study seeks to synthesize the progress in understanding ICU delirium through a bibliometric analysis.

Methods

We conducted a comprehensive search of the Web of Science Core (WOS) Collection database for literature on ICU delirium, focusing on studies published between 2013 and 2023. Our analysis utilized two bibliometric software tools, Citespace and VOSviewer, to scrutinize the data across various dimensions, including country contributions, authorship patterns, publishing journals, key thematic terms, and other pertinent metrics, with the aim of identifying emerging trends in the field.

Results

Our search yielded a total of 1,178 publications on ICU delirium within the WOS database from January 2013 to June 2023. The United States emerged as the leading contributor in terms of published articles, with Ely, E. Wesley being the most prolific author, having published 85 articles, and "Critical Care Medicine" as the journal with the highest number of publications, totaling 105. The application of literature clustering and keyword analysis revealed that future research is poised to delve deeper into areas such as pediatric delirium, risk factors, and the development of preventive and therapeutic strategies.

Conclusion

This study employs bibliometric analysis to provide a multifaceted overview of the ICU delirium research landscape over the past decade. By examining the topic from various perspectives, we have not only mapped the current state of ICU delirium research but also illuminated potential avenues for future inquiry and areas of emphasis.

Is there a place for natural agents with anti-inflammatory and antioxidative properties in critically ill patients? Potential usefulness of Xanthohumol

Multi-organ dysfunction is a major issue in critically ill patients, where a significant inflammatory response appears to be the primary factor driving the degree of organ impairment, which correlates with the extent of organ injury. The management of inflammation requires a multidisciplinary approach, including antibiotics for infection control, circulatory and respiratory support, and correction of coagulation abnormalities. However, the use of anti-inflammatory treatments is typically restricted to a selected group of medications, with their effectiveness remaining the subject of extensive debate. Xanthohumol (Xn), a natural compound extracted from hops, possesses strong anti-inflammatory and antioxidative properties, with a mild anti-coagulation effect. Its biological activity is related to the inhibition of different inflammatory pathways, reduction in cytokine production and secretion, and an increase in antioxidative enzyme activity. This review examined the potential use of Xn as an adjuvant in the treatment of various pathologies in critically ill patients.

A nomogram for predicting the risk of postoperative delirium in individuals undergoing cardiovascular surgery

BACKGROUND AND PURPOSE

Delirium is a common mental disorder after adult cardiovascular surgery. Fifteen to 23% of patients undergoing cardiovascular surgery and cardiomyopathy experience delirium, and the efficacy of treatment interventions for delirium has been consistently unsatisfactory.

METHODS

A total of 729 patients who underwent cardiovascular surgery were randomly allocated into a training set and a validation set. A nomogram was developed using a logistic regression model to predict the incidence of delirium following cardiovascular surgery. The validity of the model was assessed by determining the receiver operating characteristic (ROC) curve, calculating the area under the ROC curve (AUROC), performing a calibration plot, and executing a decision curve analysis. This model was internally validated using the bootstrap method.

RESULTS

Postoperative delirium (POD) occurred in 165 cases (22.6%) among the 729 patients. Predictors included age, transient ischemic attack, length of preoperative stay, preoperative left ventricular injection fraction and N-terminal pro-B-type natriuretic peptide level, and intraoperative infusion of dexmedetomidine and human fibrinogen. The nomogram showed sufficient differentiation and calibration (AUROC = 0.754, 95% confidence interval = 0.703-0.804). The calibration graphs showed that the predictive values of the nomogram were in agreement with the actual values. The analysis of the training and validation sets suggested that the model possessed specific clinical significance.

CONCLUSIONS

In summary, the predictive model consists of seven factors that can roughly predict the occurrence of POD in patients who undergo cardiovascular surgery.

Effect of different durations of preoperative computerised cognitive training on postoperative delirium in older patients undergoing cardiac surgery: a study protocol for a prospective, randomised controlled trial

INTRODUCTION

Postoperative delirium (POD) is a common neurological complication after surgery among older patients, characterised by acute disturbances in consciousness, attention and cognition, usually occurring within 24-72 hours after surgery. POD has a significant impact on the prognosis of older patients undergoing major cardiovascular surgery, including increased length of hospital stay, hospital costs and readmission rates, with an incidence rate as high as 26%-52%. Computerised cognitive training (CCT) refers to difficulty-adaptive training in cognitive domains such as attention, memory and logical reasoning, using systematically designed tasks. Existing studies have shown that CCT has reduced the risk of delirium in non-cardiac surgery patients with at least minimal compliance. The purpose of this study is to investigate the effects of preoperative CCT on the incidence of POD in older patients undergoing elective cardiac surgery, to clarify the dose-effect relationship between different training time of preoperative CCT and POD and to explore the minimum effective time target that can significantly lower the incidence of POD.

METHODS AND ANALYSIS

This is a prospective, single-blind, randomised controlled trial that aims to enrol 261 older patients scheduled for elective cardiac surgery at the Affiliated Hospital of Xuzhou Medical University. The patients will be randomised into three groups: group C will be the routine care group (no CCT prior to surgery); group L will be the low-dose time group (with a total of 5 hours of CCT prior to surgery) and group H will be the high-dose time group (with a total of 10 hours of CCT prior to surgery). The primary outcome is the incidence of delirium within 7 days after surgery. Secondary outcomes include postoperative mild neurocognitive disorder (NCD) and postoperative major NCD (30 days up to 1 year), time of onset and duration and severity of delirium, and all-cause mortality within 1 year after surgery. The results of this study are of significant importance for establishing effective, patient-centred and low-risk prevention strategies for POD/postoperative NCD.

ETHICS AND DISSEMINATION

This study protocol has been approved by the Ethics Committee of the Affiliated Hospital of Xuzhou Medical University (Ethics Number: XYFY2023-KL149-01). All participants will provide written informed consent, and the results of the study will be published in international peer-reviewed academic journals and presented at academic conferences.

TRIAL REGISTRATION NUMBER

ChiCTR2300072806.

Mortality-related factors in older adults with delirium: A prospective observational study

BACKGROUND

Delirium is a common and serious neuropsychiatric syndrome characterized by acute changes in attention, cognition, and consciousness. It is frequently encountered in various clinical settings, including critical care units and postoperative care, and is associated with significant morbidity and mortality. Understanding the factors contributing to delirium-related mortality is crucial for improving patient outcomes and healthcare practices. However, the factors associated with mortality in delirium have not been well-defined in the literature.

OBJECTIVES

This study aimed to identify factors influencing 3-month mortality in older adults with delirium presenting to the emergency department (ED).

METHODS

The study was conducted prospectively and delirium was screened using the brief Confusion Assesment Method (bCAM). The primary outcome was 3-month mortality. Mann-Whitney U and Chi-square tests compared groups, Spearman correlation analyzed correlations, and multivariate logistic regression identified risk factors.

RESULTS

Among 243 patients, 29.6% experienced in-hospital mortality, and 56.4% had 3-month mortality. Factors associated with increased mortality risk included prior delirium history (3.32-fold increase, 95%CI: 1.51-7.30), active malignancy (3.49-fold increase, 95%CI: 1.61-7.56) and increased respiratory rate (1.18-fold increase, 95%CI: 1.08-1.29). An increase in mean arterial pressure (MAP) was associated with a 0.98-fold decrease in mortality risk (95%CI: 0.96-0.99), increase in body temperature was associated with a 0.48-fold decrease in mortality risk (95%CI:0.31-0.76).

CONCLUSION

In delirious older adults at the ED, higher respiratory rate, lower MAP, lower body temperature, active malignancy and prior delirium history signal elevated mortality risk.

Early processed electroencephalography for the monitoring of deeply sedated mechanically ventilated critically ill patients

BACKGROUND

Deep sedation may be indicated in the intensive care unit (ICU) for the management of acute organ failure, but leads to sedative-induced delirium. Whether processed electroencephalography (p-EEG) is useful in this setting is unclear.

AIM

To describe the PSI index in deeply sedated critically ill patients with acute organ failure, and to examine a potential association between low PSI values and ICU delirium. [Correction added on 16 October 2024, after first online publication: Aim subsection in Abstract has been added on this version.] METHODS: We conducted a single-centre observational study of non-neurological ICU patients sedated according to a standardized guideline of deep sedation (Richmond Agitation Sedation Scale [RASS] between -5 and -4) during the acute phase of respiratory and/or cardio-circulatory failure. The SedLine (Masimo Incorporated, Irvine, California) was used to monitor the Patient State Index (PSI) (ranging from 0 to 100, <25 = very deep sedation and >50 = light sedation to full awareness) during the first 72 h of care. Delirium was assessed with the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU).

RESULTS

The median duration of PSI monitoring was 43 h. Patients spent 49% in median of the total PSI monitoring duration with a PSI <25. Patients with delirium (n = 41/97, 42%) spent a higher percentage of total monitored time with PSI <25 (median 67% [19-91] vs. 47% [12.2-78.9]) in non-delirious patients (p .047). After adjusting for the cumulative dose of analgesia and sedation, increased time spent with PSI <25 was associated with higher delirium (odds ratio 1.014; 95% CI 1.001-1.027, p = .036).

CONCLUSIONS

A clinical protocol of deep sedation targeted to RASS at the acute ICU phase may be associated with prolonged EEG suppression and increased delirium. Whether PSI-targeted sedation may help reducing sedative dose and delirium deserves further clinical investigation.

RELEVANCE TO CLINICAL PRACTICE

Patients requiring deep sedation are at high risk of being over-sedated and developing delirium despite the application of an evidence-based sedation guideline. Development of early objective measures are essential to improve sedation management in these critically ill patients.

Delirium care in hospitals in Ireland on World Delirium Awareness Day 2023

BACKGROUND

Acute, transient, but sometimes persistent, delirium is characterized by a sharp disruption in attention, consciousness, and cognitive function, and can be caused by many medications and disorders. Delirium occurrence and negative consequences, such as falls and functional decline, can be decreased with multifactorial prevention and timely detection.

AIMS

To describe current clinical practice in relation to the prevention, assessment, and management of delirium in Irish hospitals; awareness-raising and educational activities; and barriers to good practice.

METHODS

On World Delirium Awareness Day (15th March 2023), a global survey was conducted of delirium prevalence and care. A senior clinical staff member on each participating ward reported on delirium prevalence at 8AM and 8PM, and on usual ward practice; this data was entered into an online survey by a data collector (typically a clinician from the site, visiting several wards to record data). This study reports data from Irish hospitals.

RESULTS

In total, 132 wards from 15 hospitals across Ireland participated. Almost 60% of wards used 'personal judgment' for delirium assessment. Having at least one delirium training session in the preceding year was associated with greater use of a formal assessment tool (60.3% versus 18.8%; p < 0.001). Wards reported staff training/education as the main priority to improve care, but 72.7% of wards identified insufficient time to train staff as a key barrier.

CONCLUSIONS

Clinical practice related to delirium care requires improvement. Awareness raising and staff training require more focus and time in busy clinical settings.

Impact of Delirium Onset and Duration on Mortality in Patients With Cancer Admitted to the ICU

BACKGROUND

Little is known on the effects of delirium onset and duration on outcome in critically ill patients with cancer.

OBJECTIVES

To determine the impact of delirium onset and duration on intensive care unit (ICU) and hospital mortality and length of stay (LOS) in patients with cancer.

METHODS

Of the 915 ICU patients admitted in 2018, 371 were included for analysis after excluding for terminal disease, <24-h ICU stay, lack of active cancer and delirium. Delirium was defined as early if onset was within 2 days of ICU admission, late if onset was on day 3 or later, short if duration was 2 days or less, and long if duration was 3 days or longer. Patients were placed into 4 combination groups: early-short, early-long, late-short, and late-long delirium. Multivariate analysis controlling for sex, age, metastatic disease, and predelirium hospital LOS was performed to determine ICU and hospital mortality and LOS. Exploratory analysis of long-term survival was also performed. Restricted cubic splines were performed to confirm the use of 2 days to distinguish between early versus late onset and short versus long duration.

RESULTS

A total of 32.9% (n = 122) patients had early-short, 39.1% (n = 145) early-long, 16.2% (n = 60) late-short, and 11.9% (n = 44) late-long delirium. Late-long delirium was independently associated with increased ICU (OR 4.45, CI 1.92-10.30; P < .001) and hospital (OR 2.91, CI 1.37-6.19; P = .005) mortality and longer ICU (OR 1.97, CI 1.58-2.47; P < .001) LOS compared to early-short delirium. Early delirium had better overall survival at 18 months than late delirium. Long-term survival further improved when delirium duration was 2 days or less. Prediction heatmaps confirm the use of a 2-day cutoff.

CONCLUSION

Late delirium, especially with long duration, significantly worsens outcome in ICU patients with cancer and should be considered a harbinger of poor overall condition.

Effect of intra-operative Magnesium sulphate on the occurrence of post-operative delirium and insomnia in patients undergoing lumbar fixation: a randomized controlled trial

BACKGROUND

Over the last two decades, a large body of literature has focused on studying the prevalence and outcome of the postoperative delirium and sleep disturbance. The aim of this work was to evaluate the effect of intraoperative administration of Magnesium sulphate on the occurrence of post-operative delirium and insomnia in patients undergoing lumbar fixation.

METHODS

This prospective randomized controlled trial was carried out on 80 patients indicated for lumbar fixation; 40 of them received conventional general anesthesia with extra administration of intraoperative magnesium sulphate (Mg sulphate group), and the other 40 received conventional general anesthesia only (control group). Both groups were submitted to pre-operative assessment of depression using Beck Depression inventory (BDI) scale, pre-operative assessment of fatigue using a fatigue questionnaire, pre- and post-operative assessment of insomnia using Insomnia severity index (ISI), post-operative assessment of delirium using Memorial delirium assessment scale (MDAS), post-operative assessment of pain using Visual Analogue Scale (VAS), and pre- and post-operative Quantitative electroencephalography (QEEG).

RESULTS

Mg sulphate administration, age, pre-operative BDI, pre-operative ISI, and post-operative VAS were independent predictors of post-operative ISI (P-value < 0.001, 0.047, 0.021, < 0.001, and < 0.001 respectively). Age and post-operative VAS were independent predictors of post-operative MDAS (P-value = 0.008, 0.013 respectively). Mg sulphate administration and pre-operative ISI were independent predictors of post-operative VAS (P-value = 0.010, 0.006 respectively).

CONCLUSION

There was a significant relationship between intraoperative Mg sulphate administration and both post-operative insomnia and pain in unadjusted and adjusted analysis.

Long-term outcomes after treatment of delirium during critical illness with antipsychotics (MIND-USA): a randomised, placebo-controlled, phase 3 trial

BACKGROUND

Delirium is common during critical illness and is associated with long-term cognitive impairment and disability. Antipsychotics are frequently used to treat delirium, but their effects on long-term outcomes are unknown. We aimed to investigate the effects of antipsychotic treatment of delirious, critically ill patients on long-term cognitive, functional, psychological, and quality-of-life outcomes.

METHODS

This prespecified, long-term follow-up to the randomised, double-blind, placebo-controlled phase 3 MIND-USA Study was conducted in 16 hospitals throughout the USA. Adults (aged ≥18 years) who had been admitted to an intensive care unit with respiratory failure or septic or cardiogenic shock were eligible for inclusion in the study if they had delirium. Participants were randomly assigned-using a computer-generated, permuted-block randomisation scheme with stratification by trial site and age-in a 1:1:1 ratio to receive intravenous placebo, haloperidol, or ziprasidone for up to 14 days. Investigators and participants were masked to treatment group assignment. 3 months and 12 months after randomisation, we assessed survivors' cognitive, functional, psychological, quality-of-life, and employment outcomes using validated telephone-administered tests and questionnaires. This trial was registered with ClinicalTrials.gov, NCT01211522, and is complete.

FINDINGS

Between Dec 7, 2011, and Aug 12, 2017, we screened 20 914 individuals, of whom 566 were eligible and consented or had consent provided to participate. Of these 566 patients, 184 were assigned to the placebo group, 192 to the haloperidol group, and 190 to the ziprasidone group. 1-year survival and follow-up rates were similar between groups. Cognitive impairment was common in all three treatment groups, with a third of survivors impaired at both 3-month and 12-month follow-up in all groups. More than half of the surveyed survivors in each group had cognitive or physical limitations (or both) that precluded employment at both 3-month and 12-month follow-up. At both 3 months and 12 months, neither haloperidol (adjusted odds ratio 1·22 [95% CI 0·73-2.04] at 3 months and 1·12 [0·60-2·11] at 12 months) nor ziprasidone (1·07 [0·59-1·96] at 3 months and 0·94 [0·62-1·44] at 12 months) significantly altered cognitive outcomes, as measured by the Telephone Interview for Cognitive Status T score, compared with placebo. We also found no evidence that functional, psychological, quality-of-life, or employment outcomes improved with haloperidol or ziprasidone compared with placebo.

INTERPRETATION

In delirious, critically ill patients, neither haloperidol nor ziprasidone had a significant effect on cognitive, functional, psychological, or quality-of-life outcomes among survivors. Our findings, along with insufficient evidence of short-term benefit and frequent inappropriate continuation of antipsychotics at hospital discharge, indicate that antipsychotics should not be used routinely to treat delirium in critically ill adults.

FUNDING

National Institutes of Health and the US Department of Veterans Affairs.

Reporting on Neurological Decline as Identified by Hourly Neuroassessments

ABSTRACT

BACKGROUND: Hourly neurological examinations (neuro exam) have been widely used to monitor for a decline in neurological status, allowing for timely intervention. There are, however, limited data behind this common practice. The objective of this study was to identify how frequently neurological decline occurred across various diagnoses and whether that decline (1) was identified by a scheduled neurocheck and (2) altered management. METHODS: A cross-sectional survey was performed in a neurological intensive care unit at a tertiary care academic medical center. Clinical neuroscience nurses caring for patients with hourly neurological assessments completed a brief survey at 12-hour shift completion. RESULTS: Data were collected from 212 nurse's shifts. Neurological changes were identified by nurses in 14% (n = 30) of shifts. The neurological change was identified during a scheduled neurocheck 67% of the time, with the detection of changes more likely to occur during a scheduled neuro exam than at other times ( P < .05). There was no change to the care plan in 55% of the cases of neurological decline. Patients with subarachnoid hemorrhage were more likely to have a decline detected. CONCLUSION: Findings suggest that many patients undergo hourly neurological exams without ever identifying a neurological deterioration. In many instances of neurodeterioration, there was no change to the treatment plan pursued. Primary diagnoses and neurological changes may not be entirely independent, and therefore, hourly neuro exams may have greater yield in some diagnoses than others. Replication is warranted with a larger sample to evaluate the risks and benefits of neuroassessments.

Incidence and Risk Factors of Developing Post-operative Delirium Among Elderly Patients in a Tertiary Care Hospital: A Retrospective Chart Review

Introduction Delirium is an acute and fluctuating decline in attention and cognition caused by reversible neural disruption. Post-operative delirium (POD) may happen 10 minutes after anesthesia administration up to discharge. POD has been associated with increased days of mechanical ventilation, increased patients' functional decline, prolonged intensive care unit (ICU) stay, and prolonged hospital length of stay, which can lead to nosocomial complications, further investigations, and increased treatment costs. In this study, we aim to determine the prevalence of POD and identify demographic or surgical variables associated with POD. Materials and methods This retrospective cross-sectional study was conducted at the National Guard Health Affairs Hospital (NGHA), a teaching tertiary care center in Riyadh, Kingdom of Saudi Arabia. The study included all patients older than 65 who developed POD from January 2017 to January 2023 and a control group of the same time window. The data were analyzed using custom Python code. Results The study included 108 patients, 72 of whom were male patients. General anesthesia was most used compared to other anesthesia techniques (79.630%). Patients with hypertension (HTN) and diabetes mellitus (DM) each account for 75 cases. Elective surgeries account for 86.111% of cases. Our analysis showed a significant association between POD and advanced age, male gender, DM, HTN, congestive heart failure (CHF), and chronic kidney disease (CKD).  Conclusion With our study, we hope to aid the process of better understanding POD to help healthcare providers identify high-risk patients, implement preventative measures, and enhance patient safety and satisfaction.

Platelet Bioenergetics and Associations With Delirium and Coma in Patients With Sepsis: A Prospective Cohort Study

BACKGROUND

Acute brain dysfunction during sepsis, which manifests as delirium or coma, is common and is associated with multiple adverse outcomes, including longer periods of mechanical ventilation, prolonged hospital stays, and increased mortality. Delirium and coma during sepsis may be manifestations of alteration in systemic metabolism. Because access to brain mitochondria is a limiting factor, measurement of peripheral platelet bioenergetics offers a potential opportunity to understand metabolic changes associated with acute brain dysfunction during sepsis.

RESEARCH QUESTION

Are altered platelet mitochondrial bioenergetics associated with acute brain dysfunction during sepsis?

STUDY DESIGN AND METHODS

We assessed participants with critical illness in the ICU for the presence of delirium or coma via validated assessment measures. Blood samples were collected and processed to isolate and measure platelet mitochondrial oxygen consumption. We used Seahorse extracellular flux to measure directly baseline, proton leak, maximal oxygen consumption rate, and extracellular acidification rate. We calculated adenosine triphosphate-linked, spare respiratory capacity, and nonmitochondrial oxygen consumption rate from the measured values.

RESULTS

Maximum oxygen consumption was highest in patients with coma, as was spare respiratory capacity and extracellular acidification rate in unadjusted analysis. After adjusting for age, sedation, modified Sequential Organ Failure Assessment score without the neurologic component, and preexisting cognitive function, increased spare respiratory capacity remained associated with coma. Delirium was not associated with any platelet mitochondrial bioenergetics.

INTERPRETATION

In this single-center exploratory prospective cohort study, we found that increased platelet mitochondrial spare respiratory capacity was associated with coma in patients with sepsis. Future studies powered to determine any relationship between delirium and mitochondrial respiration bioenergetics are needed.

Association between body mass index and delirium incidence in critically ill patients: a retrospective cohort study based on the MIMIC-IV Database

OBJECTIVES

Delirium is a form of brain dysfunction with high incidence and is associated with many negative outcomes in the intensive care unit. However, few studies have been large enough to reliably examine the associations between body mass index (BMI) and delirium, especially in critically ill patients. The objective of this study was to investigate the association between BMI and delirium incidence in critically ill patients.

DESIGN

A retrospective cohort study.

SETTING

Data were collected from the Medical Information Mart for Intensive Care-IV V2.0 Database consisting of critically ill participants between 2008 and 2019 at the Beth Israel Deaconess Medical Center in Boston.

PARTICIPANTS

A total of 20 193 patients with BMI and delirium records were enrolled in this study and were divided into six groups.

PRIMARY OUTCOME MEASURE

Delirium incidence.

RESULTS

Generalised linear models and restricted cubic spline analysis were used to estimate the associations between BMI and delirium incidence. A total of 30.81% of the patients (6222 of 20 193) developed delirium in the total cohort. Compared with those in the healthy weight group, the patients in the different groups (underweight, overweight, obesity grade 1, obesity grade 2, obesity grade 3) had different relative risks (RRs): RR=1.10, 95% CI=1.02 to 1.19, p=0.011; RR=0.93, 95% CI=0.88 to 0.97, p=0.003; RR=0.88, 95% CI=0.83 to 0.94, p<0.001; RR=0.94, 95% CI=0.86 to 1.03, p=0.193; RR=1.14, 95% CI=1.03 to 1.25, p=0.010, respectively. For patients with or without adjustment variables, there was an obvious U-shaped relationship between BMI as a continuous variable and delirium incidence.

CONCLUSION

BMI was associated with the incidence of delirium. Our results suggested that a BMI higher or lower than obesity grade 1 rather than the healthy weight in critically ill patients increases the risk of delirium incidence.

Data-derived subtypes of delirium during critical illness

BACKGROUND

To understand delirium heterogeneity, prior work relied on psychomotor symptoms or risk factors to identify subtypes. Data-driven approaches have used machine learning to identify biologically plausible, treatment-responsive subtypes of other acute illnesses but have not been used to examine delirium.

METHODS

We conducted a secondary analysis of a large, multicenter prospective cohort study involving adults in medical or surgical ICUs with respiratory failure or shock who experienced delirium per the Confusion Assessment Method for the ICU. We used data collected before delirium diagnosis in an unsupervised latent class model to identify delirium subtypes and then compared demographics, clinical characteristics, and outcomes between subtypes in the final model.

FINDINGS

The 731 patients who developed delirium during critical illness had a median age of 63 [IQR, 54-72] years, a median Sequential Organ Failure Assessment score of 8.0 [6.0-11.0] and 613 [83.4%] were mechanically ventilated at delirium identification. A four-class model best fit the data with 50% of patients in subtype (ST) 1, 18% in subtype 2, 17% in subtype 3, and 14% in subtype 4. Subtype 2-which had more shock and kidney impairment-had the highest mortality (33% [ST2] vs. 17% [ST1], 25% [ST3], and 17% [ST4], p = 0.003). Subtype 4-which received more benzodiazepines and opioids-had the longest duration of delirium (6 days [ST4] vs. 3 [ST1], 4 [ST2], and 3 days [ST3], p < 0.001) and coma (4 days [ST4] vs. 2 [ST1], 1 [ST2], and 2 days [ST3], p < 0.001). Each of the four data-derived delirium subtypes was observed within previously identified psychomotor and risk factor-based delirium subtypes. Clinically significant cognitive impairment affected all subtypes at follow-up, but its severity did not differ by subtype (3-month, p = 0.26; 12-month, p = 0.80).

INTERPRETATION

The four data-derived delirium subtypes identified in this study should now be validated in independent cohorts, examined for differential treatment effects in trials, and inform mechanistic work evaluating treatment targets.

FUNDING

National Institutes of Health (T32HL007820, R01AG027472).

Recurrent delirium episodes within the intensive care unit: Incidence and associated factors

PURPOSE

Describe the incidence and factors associated with recurrent delirium in the intensive care unit (ICU).

MATERIALS AND METHODS

Retrospective study of ICU patients diagnosed with delirium. Delirium clearance defined as 48 h of negative delirium assessments following initial episode and recurrent delirium as any positive delirium assessment following clearance. Multivariable logistic regression model assessed independent association of patient and hospital factors on development of recurrent delirium, adjusting for pre-defined covariates.

RESULTS

Among 8591 ICU admissions identified with delirium, 1067 (12.4%) had recurrent symptoms. Factors associated with increased odds of recurrent delirium were age (nonlinear; p = 0.02), shock (OR 1.45, 95% CI [1.20, 1.75]), admission to medical (OR 3.25, 95% CI [2.42, 4.37]), surgical (OR 3.00, 95% CI [2.21, 4.06]), or trauma (OR 2.17, 95% CI [1.58, 3.00]) ICU vs. cardiovascular ICU, increased duration of mechanical ventilation (OR 2.43, 95% CI [2.22, 2.65]), propofol use (OR 1.35, 95% CI [1.02, 1.80]), and antipsychotic medications (haloperidol OR 1.53, 95% CI [1.26, 1.86]; quetiapine OR 2.45, 95% CI [1.98, 3.02]; and olanzapine OR 1.54, 95% CI [1.25, 1.88]).

CONCLUSIONS

Over 10% of delirious ICU patients had recurrent symptoms. Factors associated with recurrence included age, duration of mechanical ventilation and medication exposure.

CLINICAL TRIAL NUMBER

Not applicable.

Associations of Race With Sedation Depth Among Mechanically Ventilated Adults: A Retrospective Cohort Study

OBJECTIVES

To evaluate the association of race with proportion of time in deep sedation among mechanically ventilated adults.

DESIGN

Retrospective cohort study from October 2017 to December 2019.

SETTING

Five hospitals within a single health system.

PATIENTS

Adult patients who identified race as Black or White who were mechanically ventilated for greater than or equal to 24 hours in one of 12 medical, surgical, cardiovascular, cardiothoracic, or mixed ICUs.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The exposure was White compared with Black race. The primary outcome was the proportion of time in deep sedation during the first 48 hours of mechanical ventilation, defined as Richmond Agitation-Sedation Scale values of -3 to -5. For the primary analysis, we performed mixed-effects linear regression models including ICU as a random effect, and adjusting for age, sex, English as preferred language, body mass index, Elixhauser comorbidity index, Laboratory-based Acute Physiology Score, Version 2, ICU admission source, admission for a major surgical procedure, and the presence of septic shock. Of the 3337 included patients, 1242 (37%) identified as Black, 1367 (41%) were female, and 1002 (30%) were admitted to a medical ICU. Black patients spent 48% of the first 48 hours of mechanical ventilation in deep sedation, compared with 43% among White patients in unadjusted analysis. After risk adjustment, Black race was significantly associated with more time in early deep sedation (mean difference, 5%; 95% CI, 2-7%; p < 0.01).

CONCLUSIONS

There are disparities in sedation during the first 48 hours of mechanical ventilation between Black and White patients across a diverse set of ICUs. Future work is needed to determine the clinical significance of these findings, given the known poorer outcomes for patients who experience early deep sedation.

Blood-brain barrier dysfunction in intensive care unit

The central nervous system is characterized by a peculiar vascularization termed blood-brain barrier (BBB), which regulates the exchange of cells and molecules between the cerebral tissue and the whole body. BBB dysfunction is a life-threatening condition since its presence corresponds to a marker of severity in most diseases encountered in the intensive care unit (ICU). During critical illness, inflammatory response, cytokine release, and other phenomena activating the brain endothelium contribute to alterations in the BBB and increase its permeability to solutes, cells, nutrients, and xenobiotics. Moreover, patients in the ICU are often old, with underlying acute or chronic diseases, and overly medicated due to their critical condition; these factors could also contribute to the development of BBB dysfunction. An accurate diagnostic approach is critical for the identification of the mechanisms underlying BBB alterations, which should be rapidly managed by intensivists. Several methods were developed to investigate the BBB and assess its permeability. Nevertheless, in humans, exploration of the BBB requires the use of indirect methods. Imaging and biochemical methods can be used to study the abnormal passage of molecules through the BBB. In this review, we describe the structural and functional characteristics of the BBB, present tools and methods for probing this interface, and provide examples of the main diseases managed in the ICU that are related to BBB dysfunction.

Association between Change in the peripheral biomarkers of inflammation, astrocyte activation, and neuroprotection at one week of critical illness and hospital mortality in patients with delirium: A prospective cohort study

OBJECTIVE

In critically ill adults with delirium, biomarkers of systemic inflammation, astrocyte activation, neuroprotection, and systemic inflammation measured at one week of critical illness may be associated with mortality.

DESIGN

Prospective observational study.

SETTING

Intensive care unit (ICU).

PATIENTS

178 ICU patients with delirium, alive and remaining in ICU at one week.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Blood samples collected for a pair of previously published, negative, clinical trials were utilized. Samples were collected at study enrollment/ICU admission (Day 1 sample) and one week later (Day 8 sample), and analyzed for interleukins (IL)-6, 8, 10, Insulin-like Growth Factor (IGF), S100 Binding Protein (S100B), Tumor Necrosis Factor Alpha (TNF-A) and C-Reactive Protein (CRP). Delirium, delirium severity, and coma were assessed twice daily using Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), CAM-ICU-7, and Richmond Agitation-Sedation Scale (RASS), respectively. Mortality was assessed until discharge using the electronic medical record. Logistic regression models adjusting for age, sex, severity of illness, comorbidities, sepsis, and randomization status, were used to assess the relationship among biomarkers and mortality. Higher IL-10 quartiles at day 8 were associated with increased odds of hospital mortality (IL-10: OR 2.00 95%CI: 1.1-3.65, p = 0.023). There was a significant interaction between day 1 and day 8 biomarker quartiles only for IL-6. Patients with IL-6 values in the first three quartiles on admission to the ICU that transitioned to higher IL-6 quartiles at day 8 had increased probability of hospital mortality.

CONCLUSION

In this hypothesis-generating study, higher IL-6 and IL-10 quartiles at one week, and increase in IL-6 from day 1 to day 8 were associated with increased hospital mortality. Studies with larger sample sizes are needed to confirm the mechanisms for these observations.

Incidence of Delirium in Critically Ill Patients With and Without COVID-19

BACKGROUND

It is known that patients with COVID-19 are at high risk of developing delirium. The aim of the study was to compare the incidence of delirium between critically ill patients with and without a diagnosis of COVID-19.

METHODS

This is a retrospective study conducted in a southern Brazilian hospital from March 2020 to January 2021. Patients were divided into two groups: the COVID-19 group consisted of patients with a diagnosis of COVID-19 confirmed by reverse transcription-polymerase chain reaction (RT-PCR) or serological tests who were admitted to specific ICUs. The non-COVID-19 group consisted of patients with other surgical and medical diagnoses who were admitted to non-COVID ICUs. All patients were evaluated daily using the Intensive Care Delirium Screening Checklist (ICDSC). The two cohorts were compared in terms of the diagnosis of delirium.

RESULTS

Of the 649 patients who remained more than 48 h in the ICU, 523 were eligible for the study (COVID-19 group: 292, non-COVID-19 group: 231). There were 119 (22.7%) patients who had at least one episode of delirium, including 96 (32.9%) in the COVID-19 group and 23 (10.0%) in the non-COVID-19 group (odds ratio [OR] 4.42; 95% confidence interval [CI], 2.69 to 7.26; p < 0.001). Among patients mechanically ventilated for two days or more, the incidence of delirium did not differ between groups (COVID-19: 89/211, 42.1% vs non-COVID-19: 19/47, 40.4%; p  =  0.82). Logistic regression showed that the duration of mechanical ventilation was the only independent factor associated with delirium (p  =  0.001).

CONCLUSION

COVID-19 can be associated with a higher incidence of delirium among critically ill patients, but there was no difference in this incidence between groups when mechanical ventilation lasted two days or more.

Delirium as a Risk Factor for Mortality in Critically Ill Patients With Cancer

PURPOSE

Although delirium is known to negatively affect critically ill patients, little data exist on delirium in critically ill patients with cancer.

METHODS

We analyzed 915 critically ill patients with cancer between January and December 2018. Delirium screening was performed using the Confusion Assessment Method for the intensive care unit (ICU), performed twice daily. Confusion Assessment Method-ICU incorporates four features of delirium: acute fluctuations in mental status, inattention, disorganized thinking, and altered levels of consciousness. Multivariable analysis controlling for admitting service, pre-ICU hospital length of stay (LOS), metastatic disease, CNS involvement, Mortality Probability Model II score on ICU admission, mechanical ventilation, and others was performed to determine precipitating factors for delirium, ICU, and hospital mortality and LOS.

RESULTS

Delirium occurred in 40.5% (n = 317) of patients; 43.8% (n = 401) were female; the median age was 64.9 (interquartile range, 54.6-73.2) years; 70.8% (n = 647) were White, 9.3% (n = 85) were Black, and 8.9% (n = 81) were Asian. The most common cancer types were hematologic (25.7%, n = 244) and gastrointestinal (20.9%, n = 191). Delirium was independently associated with age (OR, 1.01; 95% CI, 1.00 to 1.02; P = .038), longer pre-ICU hospital LOS (OR, 1.04; 95% CI, 1.02 to 1.06; P < .001), not resuscitating on admission (OR, 2.18; 95% CI, 1.07 to 4.44; P = .032), CNS involvement (OR, 2.25; 95% CI, 1.20 to 4.20; P = .011), higher Mortality Probability Model II score (OR, 1.02; 95% CI, 1.01 to 1.02; P < .001), mechanical ventilation (OR, 2.67; 95% CI, 1.84 to 3.87; P < .001), and sepsis diagnosis (OR, 0.65; 95% CI, 0.43 to 0.99; P = .046). Delirium was also independently associated with higher ICU mortality (OR, 10.75; 95% CI, 5.91 to 19.55; P < .001), hospital mortality (OR, 5.84; 95% CI, 4.03 to 8.46; P < .001), and ICU LOS (estimate, 1.67; 95% CI, 1.54 to 1.81; P < .001).

CONCLUSION

Delirium significantly worsens outcome in critically ill patients with cancer. Delirium screening and management should be integrated into the care of this patient subgroup.

Neurocheck Frequency: Determining Perceptions and Barriers to Implementation of Evidence-Based Practice

BACKGROUND

Following acute brain injury, patients in the intensive care unit often undergo hourly or every-other-hour exams ("neurochecks") to monitor for neurodeterioration. We assessed health care provider attitudes towards neurocheck frequency and evaluated providers' ideal neurocheck frequency.

METHODS

This was a cross-sectional, online survey distributed in Spring 2021 at a tertiary care academic medical center. Providers from multiple intensive care unit and neuroscience clinical specialties including attending faculty, medical trainees, advanced practice providers, and bedside nurses were invited to participate.

RESULTS

Among 177 participants, 61 (34%) and 116 (66%) were self-identified as ordering and performing providers, respectively. The survey response rate was 58% among physicians and 51% among bedside nurses with neurological expertise. The most common medical and non-medical reasons for ordering hourly neurochecks were "a specific diagnosis with anticipated course" and "standard of care," respectively. Compared with ordering providers, performing providers felt guidelines regarding neurocheck frequency ( P <0.01) and duration ( P <0.01) should be proscriptive. Conversely, ordering providers felt hourly neurochecks were detrimental to patients with acute brain injury ( P =0.02) and believed they would not utilize hourly neurochecks if there was another mode of monitoring available ( P =0.03). Performing providers identified multiple patient-related factors impacting the difficulty of and their willingness to perform frequent neurochecks, and only 70% of neurochecks were perceived to be performed as ordered. Both ordering and performing providers preferred every-other-hour neurochecks following acute brain injury.

CONCLUSIONS

This survey revealed clinically relevant differences in ordering versus performing provider attitudes about frequent neurochecks. Providers preferred every-other-hour rather than hourly neurochecks.

Dexmedetomidine for the prevention of delirium in adults admitted to the intensive care unit or post-operative care unit: A systematic review of randomised clinical trials with meta-analysis and Trial Sequential Analysis

OBJECTIVES

To assess any benefit or harm, we conducted a systematic review of randomised clinical trials (RCTs) allocating adults to dexmedetomidine versus placebo/no intervention for the prevention of delirium in intensive care or post-operative care units.

DATA SOURCES

We searched Medline, Embase, CENTRAL and other databases. The last search was 9 April 2022.

DATA EXTRACTION

Literature screening, data extraction and risk of bias volume 2 assessments were performed independently and in duplicate. Primary outcomes were occurrences of serious adverse events (SAEs), delirium and all-cause mortality. We used meta-analysis, Trial Sequential Analysis, and GRADE (Grading Recommendations Assessment, Development and Evaluation).

DATA SYNTHESIS

Eighty-one RCTs (15,745 patients) provided data for our primary outcomes. Results from trials at low risk of bias showed that dexmedetomidine may reduce the occurrence of the most frequently reported SAEs (relative risk [RR] 0.69; 95% CI 0.43-1.09), cumulated SAEs (RR 0.70; 95% CI 0.52-0.95) and the occurrence of delirium (RR 0.62; 95% CI 0.43-0.89). The certainty of evidence was very low for delirium. Mortality was very low in trials at low risk of bias (0.4% in the dexmedetomidine groups and 1.0% in the control groups) and meta-analysis did not provide conclusive evidence that dexmedetomidine may result in lower or higher all-cause mortality (RR 0.47; 95% CI 0.18-1.21). There was a lack of information from trial results at low risk of bias for all primary outcomes.

CONCLUSIONS

Trial results at low risk of bias showed that dexmedetomidine might reduce occurrences of SAEs and delirium, while no conclusive evidence was found for effects on all-cause mortality. The certainty of evidence ranged from very low for occurrence of delirium to low for the remaining outcomes.

Evaluation of the delirium preventive effect of dual orexin receptor antagonist (DORA) in critically ill adult patients requiring ventilation with tracheal intubation at an advanced emergency center: A single-center, retrospective, observational study

OBJECTIVE

ICU delirium reportedly contributes to increased mortality attributed to underlying diseases, long-term cognitive decline, and increased healthcare costs. Dual orexin receptor antagonists (DORAs), suvorexant and lemborexant, have been suggested for preventing ICU delirium. Although ventilator management is a risk factor for delirium, no study has examined the efficacy of suvorexant and lemborexant in preventing delirium in critically ill patients requiring ventilation. Thus, we retrospectively evaluated the efficacy of DORA in preventing delirium in critically ill adult patients requiring ventilatory management in the emergency room.

METHOD

This retrospective study included patients aged ≥18 years who were admitted to the emergency room and received ventilator support between January 2015 and April 2022. The HR (95% CI) for delirium development in patients taking DORA was estimated using a Cox proportional hazards model, which was adjusted for the patient background and concomitant medications. HRs were calculated for patients taking suvorexant and those taking lemborexant using a stratified analysis.

RESULTS

Of the 297 patients included in the study, 67 were in the DORA group; 50 were on suvorexant and 17 were on lemborexant. The DORA group had a lower incidence of delirium than the control group (p < 0.0001). The risk of delirium was lower in the DORA group compared the control group (HR, 0.22; 95% CI 0.12-0.40).The risk of developing delirium was lower with suvorexant (HR 0.22; 95% CI 0.11-0.41) and lemborexant (HR 0.25; 95% CI 0.08-0.81).

CONCLUSION

DORA is a promising drug that could have the potential to prevent delirium, and its efficacy in preventing delirium should be tested in randomized controlled trials in the future.

Analysis of delirium prediction in the ICU based on the hybrid SGDCS-ANFIS approach

In recent years, intensive care unit (ICU) doctors have paid more attention to delirium. ICU patients have a high risk of delirium. Delirium can lead to serious adverse outcomes, but early diagnosis and prediction of delirium are very difficult and lack effective assessment tools. The causes of delirium are many and complex, and there is no definite prediction model. To solve this problem, this paper proposes a delirium prediction model based on a hybrid cuckoo search algorithm with stochastic gradient descent-the adaptive-network-based fuzzy inference system (SGDCS-ANFIS) approach. Thirty-five relevant indicators of 1072 ICU cases (536 delirium cases and 536 nondelirium cases) were selected to establish a delirium prediction model to judge whether patients tended to experience delirium. The experiments show that the delirium prediction model based on the hybrid SGDCS-ANFIS approach has better performance than traditional classification and prediction machine learning approaches, and the accuracy is improved to 73.02%. It can provide some reference for the prediction of delirium, promote early diagnosis, and provide knowledge for early intervention to improve the prognosis of ICU patients. Adding this delirium prediction model to the ICU protocol will potentially improve the treatment outcome, quality, and cost. Doctors can manage sudden symptoms more calmly, and patients will also benefit. By collecting the real-time data commonly used in electronic medical records of ICUs, the proposed delirium prediction model can be easily applied in hospitals. Delirium can lead to serious adverse outcomes, but early diagnosis and prediction of delirium are very difficult and lack effective assessment tools. We propose a hybrid SGDCS-ANFIS approach to establish delirium prediction model to judge whether ICU patients tend to experience delirium. It can provide some reference for the prediction of delirium, promote early diagnosis, and provide knowledge for early intervention to improve the prognosis of ICU patients. By collecting the real-time data commonly used in electronic medical records of ICUs, the proposed delirium prediction model can be easily applied in hospitals. Fig. Development flow from raw data to the building of the delirium prediction model and model comparison.

A randomised controlled trial of dexmedetomidine for delirium in adults undergoing heart valve surgery

Dexmedetomidine might reduce delirium after cardiac surgery. We allocated 326 participants to an infusion of dexmedetomidine at a rate of 0.6 μg kg^-1 for 10 min and then at 0.4 μg.kg^-1 .h^-1 until the end of surgery; 326 control participants received comparable volumes of saline. We detected delirium in 98/652 (15%) participants during the first seven postoperative days: 47/326 after dexmedetomidine vs. 51/326 after placebo, p = 0.62, adjusted relative risk (95%CI) 0.86 (0.56-1.33), p = 0.51. Postoperative renal impairment (Kidney Disease Improving Global Outcomes stages 1, 2 and 3) was detected in 46, 9 and 2 participants after dexmedetomidine and 25, 7 and 4 control participants, p = 0.040. Intra-operative dexmedetomidine infusion did not reduce the incidence of delirium after cardiac valve surgery but might impair renal function.

Incidence, characteristics and risk factors of delirium in the intensive care unit: An observational study

AIMS AND OBJECTIVE

To investigate the incidence, characteristics and risk factors of delirium in the ICU.

BACKGROUND

Identifying the risk factors of delirium is important for early detection and to prevent adverse consequences.

DESIGN

An observational cohort study conducted according to STROBE Guidelines.

METHOD

The study was conducted with patients who stayed in ICU ≥24 h and were older than 18 years. Patients were assessed twice daily using the RASS and CAM-ICU until either discharge or death. Cumulative incidence was calculated. Demographic/clinical characteristics, length of stay and mortality were compared between patients with and without delirium. A logistic regression model was used to investigate risk factors.

RESULTS

The incidence of delirium was 31.8% and hypoactive type was the most frequent (41.5%). The median onset of delirium was 3 days (IQR = 2) with a mean duration of 5.27 ± 2.32 days. Patients with delirium were significantly older, had higher APACHE-II, SOFA and CPOT scores, higher blood urea levels, higher requirements for mechanical ventilation, sedation and physical restraints, longer stays in the ICU and higher mortality than those without delirium. The logistic regression analysis results revealed that a CPOT score ≥3 points (OR = 4.70, 95% CI: 1.05-20.93; p = .042), physical restraint (OR = 10.40, 95% CI: 2.75-39.27; p = .001) and ICU stay ≥7 days (OR = 7.26, 95% CI: 1.60-32.84; p = .010) were independent risk factors of delirium.

CONCLUSIONS

In this study, the incidence of delirium was high and associated with several factors. It is critical that delirium is considered by all members of the healthcare team, especially nurses, and that protocols are established for improvements.

RELEVANCE TO THE CLINICAL PRACTICE

Based on the results of this study, delirium could be decreased by preventing the presence of pain, prudent use of physical restraints and shortening the ICU stay.

Sleep quality and quantity determined by polysomnography in mechanically ventilated critically ill patients randomized to dexmedetomidine or placebo

BACKGROUND

Abnormal sleep is commonly observed in the ICU and is associated with delirium and increased mortality. If sedation is necessary, it is often performed with gamma-aminobutyric acid agonists such as propofol or midazolam leading to an absence of restorative sleep. We aim to evaluate the effect of dexmedetomidine on sleep quality and quantity.

METHODS

Thirty consecutive patients were included. The study was conducted as a double-blinded, randomized, placebo-controlled trial with two parallel groups: 20 patients were treated with dexmedetomidine, and 10 with placebo. Two 16 h of polysomnography recordings were done for each patient on two consecutive nights. Patients were randomized to dexmedetomidine or placebo after the first recording, thus providing a control recording for all patients. Dexmedetomidine was administered during the second recording (6 p.m.-6 a.m.).

OBJECTIVE

To compare the effect of dexmedetomidine versus. placebo on sleep - quality and quantity.

PRIMARY OUTCOME

Sleep quality, total sleep time (TST), Sleep efficiency (SE), and Rapid Eye Movement (REM) sleep determined by Polysomnography (PSG).

SECONDARY OUTCOME

Delirium and daytime function determined by Confusion Assessment Method of the Intensive Care Unit and physical activity. Alertness and wakefulness were determined by RASS (Richmond Agitation and Sedation Scale).

RESULTS

SE were increased in the dexmedetomidine group by; 37.6% (29.7;45.6 95% CI) versus 3.7% (-11.4;18.8 95% CI) (p < .001) and TST were prolonged by 271 min. (210;324 95% CI) versus 27 min. (-82;135 95% CI), (p < .001). No significant difference in REM sleep, delirium physical activity, or RASS score was found except for RASS night two.

CONCLUSION

Total sleep time and sleep efficiency were significantly increased, without elimination of REM sleep, in mechanically ventilated ICU patients randomized to dexmedetomidine, when compared to a control PSG recording performed during non-sedation/standard care.

What Is Known about Midazolam? A Bibliometric Approach of the Literature

Midazolam is a drug with actions towards the central nervous system producing sedative and anticonvulsants effects, used for sedation and seizures treatments. A better understanding about its effects in the different scenarios presented in the literature could be helpful to gather information regarding its clinical indications, pharmacological interactions, and adverse events. From this perspective, the aim of this study was to analyze the global research about midazolam mapping, specifically the knowledge of the 100 most-cited papers about this research field. For this, a search was executed on the Web of Science-Core Collection database using bibliometric methodological tools. The search strategy retrieved 34,799 articles. A total of 170 articles were evaluated, with 70 articles being excluded for not meeting the inclusion criteria. The 100 most-cited articles rendered 42,480 citations on WoS-CC, ranging from 253 to 1744. Non-systematic review was the most published study type, mainly from North America, during the period of 1992 to 2002. The most frequent keywords were midazolam and pharmacokinetics. Regarding the authors, Thummel and Kunze were the ones with the greatest number of papers included. Our findings showed the global research trends about midazolam, mainly related to its different effects and uses throughout the time.

Using a real-time ABCDEF compliance tool to understand the role of bundle elements in mortality and delirium

BACKGROUND

ABC-123, a novel Epic electronic medical record real-time score, assigns 0 to 3 points per bundle element to assess ABCDEF bundle compliance. We sought to determine if maximum daily ABC-123 score (ABC-MAX), individual bundle elements, and mobility were associated with mortality and delirium-free/coma-free intensive care unit (DF/CF-ICU) days in critically injured patients.

METHODS

We reviewed 6 months of single-center data (demographics, Injury Severity Score [ISS], Abbreviated Injury Scale of the head [AIS-Head] score, ventilator and restraint use, Richmond Agitation Sedation Score, Confusion Assessment Method for the ICU, ABC-MAX, ABC-123 subscores, and mobility level). Hospital mortality and likelihood of DF/CF-ICU days were endpoints for logistic regression with ISS, AIS-Head, surgery, penetrating trauma, sex, age, restraint and ventilator use, ABC-MAX or individual ABC-123 subscores, and mobility level or a binary variable representing any improvement in mobility during admission.

RESULTS

We reviewed 172 patients (69.8% male; 16.3% penetrating; median age, 50.0 years [IQR, 32.0-64.8 years]; ISS, 17.0 [11.0-26.0]; AIS-Head, 2.0 [0.0-3.0]). Of all patients, 66.9% had delirium, 48.8% were restrained, 51.7% were ventilated, and 11.0% died. Age, ISS, AIS-Head, and penetrating mechanism were associated with increased mortality. Restraints were associated with more than 70% reduction in odds of DF/CF-ICU days. Maximum daily ABC-123 score and mobility level were associated with decreased odds of death and increased odds of DF/CF-ICU days. Any improvement in mobility during hospitalization was associated with an 83% reduction in mortality odds. A and C subscores were associated with increased mortality, and A was also associated with decreased DF/CF-ICU days. B and D subscores were associated with increased DF/CF-ICU days. D and E subscores were associated with decreased mortality.

CONCLUSION

Maximum daily ABC-123 score is associated with reduced mortality and delirium in critically injured patients, while mobility is associated with dramatic reduction in mortality. B and D subscores have the strongest positive effects on both mortality and delirium.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

The effects of anesthesia methods and anesthetics on postoperative delirium in the elderly patients: A systematic review and network meta-analysis

STUDY OBJECTIVE

Postoperative delirium (POD) is one of the serious postoperative complications in elderly patients, which is always related to long-term mortality. Anesthesia is often considered a risk factor for POD. This systematic review and network meta-analysis (NMA) aimed to assess the impact of different anesthesia methods and anesthetics on POD.

MEASUREMENTS

We searched for studies published in PubMed, Embase, Web of Science, Scopus, and Cochrane Library (CENTRAL) from inception to 18 March 2022. RevMan 5.3 and CINeMA 2.0.0 were used to assess the risk of bias and confidence. Data analysis using STATA 17.0 and R 4.1.2. STATA 17.0 was used to calculate the surface under the cumulative ranking curve (SUCRA) and provide network plots with CINeMA 2.0.0. NMA was performed with R 4.1.2 software gemtc packages in RStudio.

MAIN RESULTS

This NMA included 19 RCTs with 5,406 patients. In the pairwise meta-analysis results, only regional anesthesia (RA) with general anesthesia (GA) vs. GA (Log OR: -1.08; 95% CI: -1.54, -0.63) were statistically different in POD incidence. In the NMA results, there was no statistical difference between anesthesia methods, and psoas compartment block (PCB) with bupivacaine was superior to the desflurane, propofol, sevoflurane, and spinal anesthesia with bupivacaine of POD occurrence.

CONCLUSION

Our study indicated that RA and GA had no significant effect on POD, and there was no difference between anesthesia methods. Pairwise meta-analysis showed that, except for RA with GA vs. GA, the rest of the results were not statistically different. Besides, PCB with bupivacaine may benefit to reduce POD incidence.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/dis play_record.php?ID=CRD42022319499, identifier PROSPERO 2022 CRD42022319499.

Nurses' assessment of subsyndromal delirium and barriers to assessment: A cross-sectional survey in the intensive care unit

AIMS

The aims of the study are to investigate the current status of nurses' assessment of subsyndromal delirium (SSD) in the intensive care unit (ICU) and explore possible barriers to assessment.

BACKGROUND

SSD is a dynamic, recognizable disorder commonly seen in the ICU that can lead to poor patient outcomes. Timely recognition and management can prevent its progression.

METHODS

A cross-sectional survey design was used to collect data from ICU registered nurses in southwest China. The online survey containing an analysis of the current status of SSD assessment and barriers was completed by 237 nurses.

RESULTS

A total of 51.5% of nurses chose to assess SSD using an assessment tool, the most commonly used being the Confusion Assessment Method for the Intensive Care Unit; the frequency of assessment was mostly once a day (66, 41.0%) and often at shift change (178, 87.3%). There were statistically significant differences in the barrier factor scores by assessment frequency, assessment method, status of training in SSD, ability of SSD-related knowledge to meet clinical needs and willingness to receive SSD training.

CONCLUSION

Our study confirms that the current state of assessment of SSD in the ICU is unsatisfactory, with nurses' lack of assessment knowledge and skills, poor organization and management, and the complexity of patients' conditions being barriers.

IMPLICATIONS FOR NURSING MANAGEMENT

Nursing managers should systematically conduct training programmes on effective SSD assessment knowledge and skills, incorporate SSD assessment into the daily workflow, have standardized assessment tools, develop standardized processes and assign dedicated staff to monitor, audit and provide feedback on SSD assessments.

Association of Incident Delirium With Short-term Mortality in Adults With Critical Illness Receiving Mechanical Ventilation

IMPORTANCE

Intensive care unit (ICU)-acquired delirium and/or coma have consequences for patient outcomes. However, contradictory findings exist, especially when considering short-term (ie, in-hospital) mortality and length of stay (LOS).

OBJECTIVE

To assess whether incident delirium, days of delirium, days of coma, and delirium- and coma-free days (DCFDs) are associated with 14-day mortality, in-hospital mortality, and hospital LOS among patients with critical illness receiving mechanical ventilation.

DESIGN, SETTING, AND PARTICIPANTS

This single-center prospective cohort study was conducted in 6 ICUs of a university-affiliated tertiary hospital in Taiwan. A total of 267 delirium-free patients (aged ≥20 years) with critical illness receiving mechanical ventilation were consecutively enrolled from August 14, 2018, to October 1, 2020.

EXPOSURES

Participants were assessed daily for the development of delirium and coma status over 14 days (or until death or ICU discharge) using the Confusion Assessment Method for the Intensive Care Unit and the Richmond Agitation-Sedation Scale, respectively.

MAIN OUTCOMES AND MEASURES

Mortality rates (14-day and in-hospital) and hospital LOS using electronic health records.

RESULTS

Of 267 participants (median [IQR] age, 65.9 [57.4-75.1] years; 171 men [64.0%]; all of Taiwanese ethnicity), 149 patients (55.8%) developed delirium for a median (IQR) of 3.0 (1.0-5.0) days at some point during their first 14 days of ICU stay, and 105 patients (39.3%) had coma episodes also lasting for a median (IQR) of 3.0 (1.0-5.0) days. The 14-day and in-hospital mortality rates were 18.0% (48 patients) and 42.1% (112 of 266 patients [1 patient withdrew from the study]), respectively. The incidence and days of delirium were not associated with either 14-day mortality (incident delirium: adjusted hazard ratio [aHR], 1.37; 95% CI, 0.69-2.72; delirium by day: aHR, 1.00; 95% CI, 0.91-1.10) or in-hospital mortality (incident delirium: aHR, 1.00; 95% CI, 0.64-1.55; delirium by day: aHR, 1.02; 95% CI, 0.97-1.07), whereas days spent in coma were associated with an increased hazard of dying during a given 14-day period (aHR, 1.16; 95% CI, 1.10-1.22) and during hospitalization (aHR, 1.10; 95% CI, 1.06-1.14). The number of DCFDs was a protective factor; for each additional DCFD, the risk of dying during the 14-day period was reduced by 11% (aHR, 0.89; 95% CI, 0.84-0.94), and the risk of dying during hospitalization was reduced by 7% (aHR, 0.93; 95% CI, 0.90-0.97). Incident delirium was associated with longer hospital stays (adjusted β = 10.80; 95% CI, 0.53-21.08) when compared with no incident delirium.

CONCLUSIONS AND RELEVANCE

In this study, despite prolonged LOS, ICU delirium was not associated with short-term mortality. However, DCFDs were associated with a lower risk of dying, suggesting that future research and intervention implementation should refocus on maximizing DCFDs to potentially improve the survival of patients receiving mechanical ventilation.

Incidence and interaction factors of delirium as an independent risk of mortality in elderly patients in the intensive units: a retrospective analysis from MIMIC-IV database

BACKGROUND

As delirium is a common problem in critcal elderly patients, the aim of the study was to investigate the interaction factors of delirium as an independent risk of mortality in elderly patients in the intensive care unit (ICU).

PATIENTS AND METHODS

Elderly patients (age ≥ 65) were selected from Medical Information Mart for Intensive Care (MIMIC)-IV database. Demographics data were collected on the 1st day of admission to ICU. The main outcome is in-hospital mortality. Propensity score matching analysis (PSMA) was used to remove the influence of comfounding factors between survival and nonsurvival groups. Chi-square test and logistic regression analysis was used to identify the association between delirium and in-hospital death. Stratified analysis and interaction analysis was used to evaluate the interaction factors of delirium as a risk of in-hospital mortality.

RESULTS

22,361 patients were selected, and in which 2809 patients died. 5453 patients had delirium (about 24.4%). There is a significant difference in delirium between the survival and nonsurvival groups before and after PSMA (p = 0.000 and p = 0.030). Logistic regression showed delirium, sequential organ failure assessment (SOFA), and hemoglobin were all significantly related to in-hospital death (p = 0.000). SOFA score and hemoglobin concentration were proved to be remarkable interaction factors of delirium (p = 0.000, and p = 0.041). Significant correlation between delirium and hospital mortality was inhibited when SOFA was more than 12 or hemoglobin was higher than 15 g/dL. In-hospital mortality (49.1% vs. 10.5%, p = 0.000) and shock incidence (87.9% vs. 15.8%, p = 0.000) of the patients with SOFA ≥ 12 was much higher than that of the patients with SOFA ≤ 11.

CONCLUSION

SOFA and hemoglobin are interaction factors of delirium as an independent risk of in-hospital mortality in elderly patients in the intensive care unit.

GOODNIGHT, SLEEP TIGHT, DON'T LET THE MICROBES BITE: A REVIEW OF SLEEP AND ITS EFFECTS ON SEPSIS AND INFLAMMATION

ABSTRACT

Sleep is a restorative biological process that is crucial for health and homeostasis. However, patient sleep is frequently interrupted in the hospital environment, particularly within the intensive care unit. Suboptimal sleep may alter the immune response and make patients more vulnerable to infection and sepsis. In addition, hospitalized patients with sepsis experience altered sleep relative to patients without infectious disease, suggesting a bidirectional interplay. Preclinical studies have generated complementary findings, and together, these studies have expanded our mechanistic understanding. This review article summarizes clinical and preclinical studies describing how sleep affects inflammation and the host's susceptibility to infection. We also highlight potential strategies to reverse the detrimental effects of sleep interruption in the intensive care unit.

Non-pharmacological delirium prevention practices among critical care nurses: a qualitative study

Background

Delirium is common among critically ill patients, leading to increased mortality, physical dependence, and cognitive impairment. Evidence suggests non-pharmacological delirium prevention practices are effective in preventing delirium. However, only a few studies explore the actual implementation and its associated challenges among critical care nurses.

Aim

To explore critical care nurses’ perceptions of current non-pharmacological delirium prevention practices in adult intensive care settings, including delirium screening, early mobilisation, sleep promotion, family engagement, and sensory stimulation.

Methods

A qualitative design adopting a thematic analysis approach. Semi-structured interviews with 20 critical care nurses were conducted in ten acute hospitals in mainland China.

Results

Three themes emerged: (a) importance of family engagement; (b) influence of organisational factors, and (c) suggestions on implementation. The implementation of non-pharmacological delirium prevention practices was limited by a strict ICU visitation policy, lack of routine delirium screening and delirium training, light and noise disturbances during nighttime hours, frequent resuscitation and new admissions and strict visitation policy. Case-based training, adopting a sensory stimulation protocol, and family engagement may be enablers.

Conclusion

ICU care routine that lacks delirium assessment and the strict family visitation policy made it challenging to implement the complete bundle of non-pharmacological practices. Resource deficiency (understaffing, lack of training) and ICU environment (frequent resuscitation) also limited the implementation of non-pharmacological practices. Clinicians could implement case-based training and sensory-stimulation programs and improve communication with family caregivers by instructing family caregivers to recognise delirium symptoms and delirium prevention strategies.

Evaluating the Medication Regimen Complexity Score as a Predictor of Clinical Outcomes in the Critically Ill

Background: Medication Regimen Complexity (MRC) refers to the combination of medication classes, dosages, and frequencies. The objective of this study was to examine the relationship between the scores of different MRC tools and the clinical outcomes. Methods: We conducted a retrospective cohort study at Roger William Medical Center, Providence, Rhode Island, which included 317 adult patients admitted to the intensive care unit (ICU) between 1 February 2020 and 30 August 2020. MRC was assessed using the MRC Index (MRCI) and MRC for the Intensive Care Unit (MRC-ICU). A multivariable logistic regression model was used to identify associations among MRC scores, clinical outcomes, and a logistic classifier to predict clinical outcomes. Results: Higher MRC scores were associated with increased mortality, a longer ICU length of stay (LOS), and the need for mechanical ventilation (MV). MRC-ICU scores at 24 h were significantly (p < 0.001) associated with increased ICU mortality, LOS, and MV, with ORs of 1.12 (95% CI: 1.06−1.19), 1.17 (1.1−1.24), and 1.21 (1.14−1.29), respectively. Mortality prediction was similar using both scoring tools (AUC: 0.88 [0.75−0.97] vs. 0.88 [0.76−0.97]. The model with 15 medication classes outperformed others in predicting the ICU LOS and the need for MV with AUCs of 0.82 (0.71−0.93) and 0.87 (0.77−0.96), respectively. Conclusion: Our results demonstrated that both MRC scores were associated with poorer clinical outcomes. The incorporation of MRC scores in real-time therapeutic decision making can aid clinicians to prescribe safer alternatives.

The predictors of postoperative delirium at surgical units in Sudan: A multicenter, cross-sectional, prospective study

Background

Knowledge of potential and amenable risk factors involved in the development of postoperative delirium (POD) is imperative for successful prevention and subsequent management.

Objective

The current study objective was to delineate the risk factors associated with the occurrence of POD among patients undergoing surgical procedures.

Methods

This multi-center (6 hospitals), cross-sectional prospective hospital-based study recruited 415 subjects aged ≥50 years who were scheduled to undergo different types of surgery. Delirium Observational Screening Scale used for the diagnosis of POD. Short Nutritional Assessment Questionnaire used for assessing the nutritional and the hydration status of patients. Pre and postoperative risk factors analyzed by univariate (chi square) and then multivariate analyses and the incidence rate of POD, was reported.

Results

The main outcome measure was the development of POD. Out of the 385, only 43 subjects (11.2%) developed POD. High American Society of Anesthesiologists score (OR: 10.76, 95% CI: 1.379-83.99, P =0.023), duration of surgery (OR: 5.426, 95% CI: [2.249-13.092]; P =0.0001), were the strongest independent risk factors for the development of POD. Katz Index of Independence in Activities of Daily Living score (OR: 3.227, 95% CI: [1.177-8.844], P =0.023), and age ≥ 70 years (OR: 1.174, 95% CI: [1.015-1.359]; P =0.027) were additional strongest independent risk factors for the development of POD.

Conclusion

Based on analysis or study, we found High American Society of Anesthesiologist sore, Katz-ADL, duration of surgery, and advanced age were predictors of POD. Our findings suggest preventive measures initiated in subjects identified at risk of developing POD. These results support the healthcare providers in the early prevention, diagnosis, and timely management of POD.

Melatonin and Its Analogs for Prevention of Post-cardiac Surgery Delirium: A Systematic Review and Meta-Analysis

Background

The effectiveness of melatonin and its analogs in preventing postoperative delirium (POD) following cardiac surgery is controversial. The purpose of this systematic review and meta-analysis was to confirm the benefits of melatonin and its analogs on delirium prevention in adults who underwent cardiac surgery.

Methods

We systematically searched the PubMed, Cochrane Library, Web of Science, Embase, and EBSCOhost databases, the last search was performed in October 2021 and repeated before publication. The controlled studies were included if investigated the impact of melatonin and its analogs on POD in adults who underwent cardiac surgery. The primary outcome was the incidence of delirium. The Stata statistical software 17.0 was used to perform this study.

Results

This meta-analysis included eight randomized controlled trials (RCTs) and two cohort studies with a total of 1,714 patients. The results showed that melatonin and ramelteon administration were associated with a significantly lower incidence of POD in adults who underwent cardiac surgery (odds ratio [OR], 0.46; 95% confidence interval [CI], 0.29–0.74; P = 0.001). The subgroup analyses confirmed that melatonin 3 mg (OR, 0.37; 95% CI, 0.18–0.76; P = 0.007) and 5 mg (OR, 0.34; 95% CI, 0.21–0.56; P < 0.001) significantly reduced the incidence of POD.

Conclusion

Melatonin at dosages of 5 and 3 mg considerably decreased the risk of delirium in adults who underwent cardiac surgery, according to our results. Cautious interpretation of our results is important owing to the modest number of studies included in this meta-analysis and the heterogeneity among them.

Systematic Review Registration

PROSPERO registration number: CRD42021246984.

Development of a scale measuring the difficulties faced by nurses who care for patients with delirium in intensive care units

BACKGROUND

Delirium in patients in the intensive care unit is associated with adverse outcomes. Nurses experience many difficulties in caring for those with delirium, which can lead to nurse burnout, prevent effective care for patients, and negatively impact the patient. The identification of factors creating challenges for nurses is, therefore, important to enable intervention.

OBJECTIVES

The aim of this study was to develop a new scale to assess the difficulties faced by nurses caring for patients with delirium in the intensive care unit and to examine its reliability and validity.

METHODS

We based our draft scale items on literature reviews and interviews. Four experts evaluated the collected items. After a pilot study, 211 nurses working in intensive care units in Japan completed the questionnaire. Subsequent statistical analysis of results included factor validity, construct validity, known-group validity, internal consistency, and test-retest reliability.

RESULTS

Exploratory factor analysis extracted a scale of 33 items with eight factors and an additional scale of four items with one factor. The analysis of construct validity suggested a possible association with the Strain of Care for Delirium Index. In the known-group validity, a comparison with two groups based on experience in the intensive care unit found significant differences among the five factors. Internal consistency (Cronbach's α = 0.68-.87) and test-retest reliability (intraclass correlation coefficients = .46-.62) were confirmed.

CONCLUSION

We developed a difficulty scale for nurses caring for patients with delirium in the intensive care unit and confirmed its reliability and validity. The difficulty factors were developed with the intention to identify educational interventions for nurses and the introduction of new organisational resources, such as manpower and providing emotional support and feedback to nurses.

Delirium risk in geriatric hip hemi-arthroplasty (DRIGHA): Development and validation of a novel score using a national data

BACKGROUND

In-hospital delirium after hip hemi-arthroplasty results in a prolonged hospital course and an increase in morbidity and mortality. Early identification of high-risk patients and preventive strategies can reduce the occurrence of delirium. The purpose of the study is to identify the risk factors of delirium and create a scoring system for point of care physicians. The risk factors were created and validated in the study.

HYPOTHESIS

Certain factors are associated with in-hospital delirium after hip hemi-arthroplasty in geriatric patients.

METHODS

The National Surgical Quality Improvement Program (NSQIP) database from 2016 to 2019 was accessed for the study. The study included all geriatric patients, ages 65 years and older, who underwent hip hemi-arthroplasty following a hip fracture. A multivariable analysis was performed to identify the risk of delirium using all the available information including patient demography, timing of surgery, comorbidities, and infective complications. Eighty percent of the data were used to develop a risk model, and 20% of the data were used to validate the model. A Receiving Operating Characteristics (ROC) curve was created. The Area Under the Curve (AUC) was calculated with a 95% confidence interval (CI). A Delirium Risk in Geriatric Hip Hemi-Arthroplasty (DRIGHA) score was created.

RESULTS

Out of 13,174 patients who qualified for the study, 3924 (29.8%) patients developed in-hospital delirium. The risk model showed advanced age, male gender, prior history of delirium and dementia, certain comorbidities, and complications were associated with a higher incidence of in-hospital delirium. The AUC was 0.79 (95% CI, 0.78-0.80). The DRIGHA score predicted the risk of delirium from 8 to 99.4%.

CONCLUSION

Certain demography characteristics, comorbidities and infective complications were associated with a higher risk of developing in-hospital delirium. A DRIGHA score can be calculated at the bedside through a web-based calculator. Preventive strategies in high-risk patients will reduce the incidence of delirium.

Dexmedetomidine and sleep quality in mechanically ventilated critically ill patients: study protocol for a randomised placebo-controlled trial

INTRODUCTION

Sleep deprivation, which is a common complication in the intensive care unit (ICU), is associated with delirium and increased mortality. Sedation with gamma-aminobutyric acid agonists (propofol, benzodiazepine) results in significant disturbance of the sleep architecture. Dexmedetomidine is a lipophilic imidazole with an affinity for α2-adrenoceptors and it has sedative and analgesic properties. It has been reported to enhance sleep efficiency, thus sedate while preserving sleep architecture.

METHODS AND ANALYSIS

Thirty consecutive patients are planned to be included, at the Department of Anesthesia and Intensive Care at the Hospital of Southwest Jutland, Denmark. The study is a double-blinded, randomised, controlled trial with two parallel groups (2:1 allocation ratio). Screening and inclusion will be done on day 1 from 8:00 to 16:00. Two 16 hours PSG (polysomnography) recording will be done starting at 16:00 on day 1 and day 2. Randomisation is performed if the first recording is of acceptable quality, otherwise the patient is excluded before randomisation. Dexmedetomidine/placebo will be administered during the second recording from 18:00 on day 2 to 6:00 on day 3.

PRIMARY ENDPOINT

Improvement of total sleep time and sleep quality of clinical significance determined by PSG.

SECONDARY ENDPOINTS

Sleep phases determined by PSG. Daytime function and delirium determined by Confusion Assessment Method-ICU. Alertness and wakefulness determined by Richmonde Agitation Sedation Scale. The objective is to compare the effect of dexmedetomidine versus placebo on sleep quality in critical ill mechanically ventilated patients.

ETHICS AND DISSEMINATION

The trial investigate the potential benefit of dexmedetomidine on clinically relevant endpoints. If a beneficial effect is shown, this would have a large impact on future treatment of mechanically ventilated critically ill patients. Publication in peer-reviewed journal are plannedand the study has been approved by the National Committee on Health Research Ethics (ID:S-20180214).

TRIAL REGISTRATION NUMBER

EudraCT (2017-001612-11DK) and Danish National Committee on Health Research Ethics (ID:S-20180214). The study related to pre-results.

Delirium in the Neonate

Delirium is likely present in the neonatal intensive care unit and has been largely unrecognized. There are several risk factors for delirium including illness severity, neurosedative exposure, and environmental disruptions that put infants at risk for delirium. Regular use of scoring systems should be considered to improve delirium detection. When identified, initial steps in management should include resolving underlying causes and implementation of standard nonpharmacologic measures. Mounting pediatric evidence suggests that the atypical antipsychotics, as well as the α-2 agonists, may be additionally beneficial in treating delirium as well as improving the ability to wean off other neurosedative medications.

Outcomes After Implementation of a Benzodiazepine-Sparing Alcohol Withdrawal Order Set in an Integrated Health Care System

Importance

Alcohol withdrawal syndrome (AWS) is a common inpatient diagnosis managed primarily with benzodiazepines. Concerns about the adverse effects associated with benzodiazepines have spurred interest in using benzodiazepine-sparing treatments.

Objective

To evaluate changes in outcomes after implementation of a benzodiazepine-sparing AWS inpatient order set that included adjunctive therapies (eg, gabapentin, valproic acid, clonidine, and dexmedetomidine).

Design, Setting, and Participants

This difference-in-differences quality improvement study was conducted among 22 899 AWS adult hospitalizations from October 1, 2014, to September 30, 2019, in the Kaiser Permanente Northern California integrated health care delivery system. Data were analyzed from September 2020 through November 2021.

Exposures

Implementation of the benzodiazepine-sparing AWS order set on October 1, 2018.

Main Outcomes and Measures

Adjusted rate ratios for medication use, inpatient mortality, length of stay, intensive care unit admission, and nonelective readmission within 30 days were calculated comparing postimplementation and preimplementation periods among hospitals with and without order set use.

Results

Among 904 540 hospitalizations in the integrated health care delivery system during the study period, AWS was present in 22 899 hospitalizations (2.5%), occurring among 16 323 unique patients (mean [SD] age, 57.1 [14.8] years; 15 764 [68.8%] men). Of these hospitalizations, 12 889 (56.3%) used an order set for alcohol withdrawal. Among hospitalizations with order set use, any benzodiazepine use decreased after implementation from 6431 hospitalizations (78.1%) to 2823 hospitalizations (60.7%) (P < .001), with concomitant decreases in the mean (SD) total dosage of lorazepam before vs after implementation (19.7 [38.3] mg vs 6.0 [9.1] mg; P < .001). There were also significant changes from before to after implementation in the use of adjunctive medications, including gabapentin (2413 hospitalizations [29.3%] vs 2814 hospitalizations [60.5%]; P < .001), clonidine (1476 hospitalizations [17.9%] vs 2208 hospitalizations [47.5%]; P < .001), thiamine (6298 hospitalizations [76.5%] vs 4047 hospitalizations [87.0%]; P < .001), valproic acid (109 hospitalizations [1.3%] vs 256 hospitalizations [5.5%]; P < .001), and phenobarbital (412 hospitalizations [5.0%] vs 292 hospitalizations [6.3%]; P = .003). Compared with AWS hospitalizations without order set use, use of the benzodiazepine-sparing order set was associated with decreases in intensive care unit use (adjusted rate ratio [ARR], 0.71; 95% CI, 0.56-0.89; P = .003) and hospital length of stay (ARR, 0.71; 95% CI, 0.58-0.86; P < .001).

Conclusions and Relevance

This study found that implementation of a benzodiazepine-sparing AWS order set was associated with decreased use of benzodiazepines and favorable trends in outcomes. These findings suggest that further prospective research is needed to identify the most effective treatments regimens for patients hospitalized with alcohol withdrawal.

Animal-Assisted Interventions in Intensive Care Delirium: A Literature Review

Critical illness has lasting consequences on the mind and the body. Acute sequelae include a decline in cognitive function known as delirium. Increased interest in improving outcomes for intensive care unit survivors without a high incidence of delirium has initiated a focus on an array of nonpharmacologic interventions in many countries. One such intervention is animalassisted intervention. As the role of animals in human healing is being recognized by clinicians, need is increasing for formal and professionally directed therapies. This review ascertains the effect of interaction with animals on critically ill patients. Emerging evidence indicates that animal-assisted intervention improves the efficacy of critical care regarding primary symptoms and secondary factors of delirium.

Development of a delirium predictive model for adult trauma patients in an emergency and critical care center: a retrospective study

Background

Delirium has been shown to prolong the length of intensive care unit stay, hospitalization, and duration of ventilatory control, in addition to increasing the use of sedatives and increasing the medical costs. Although there have been a number of reports referring to risk factors for the development of delirium, no model has been developed to predict delirium in trauma patients at the time of admission. This study aimed to create a scoring system that predicts delirium in trauma patients.

Methods

In this single-center, retrospective, observational study, trauma patients aged 18 years and older requiring hospitalization more than 48 hours were included and divided into the development and validation cohorts. Univariate analysis was performed in the development cohort to identify factors significantly associated with prediction of delirium. The final scoring system for predicting delirium was developed using multivariate analysis and internal validation was performed.

Results

Of the 308 patients in the development cohort, 91 developed delirium. Clinical Frailty Score, fibrin/fibrinogen degradation products, low body mass index, lactate level, and Glasgow Coma Scale score were independently associated with the development of delirium. We developed a scoring system using these factors and calculated the delirium predictive score, which had an area under the curve of 0.85. In the validation cohort, 46 of 206 patients developed delirium. The area under the curve for the validation cohort was 0.86, and the calibration plot analysis revealed the scoring system was well calibrated in the validation cohort.

Discussion

This scoring system for predicting delirium in trauma patients consists of only five risk factors. Delirium prediction at the time of admission may be useful in clinical practice.

Level of evidence

Prognostic and epidemiological, level III.

ICU delirium burden predicts functional neurologic outcomes

Background

We investigated the effect of delirium burden in mechanically ventilated patients, beginning in the ICU and continuing throughout hospitalization, on functional neurologic outcomes up to 2.5 years following critical illness.

Methods

Prospective cohort study of enrolling 178 consecutive mechanically ventilated adult medical and surgical ICU patients between October 2013 and May 2016. Altogether, patients were assessed daily for delirium 2941days using the Confusion Assessment Method for the ICU (CAM-ICU). Hospitalization delirium burden (DB) was quantified as number of hospital days with delirium divided by total days at risk. Survival status up to 2.5 years and neurologic outcomes using the Glasgow Outcome Scale were recorded at discharge 3, 6, and 12 months post-discharge.

Results

Of 178 patients, 19 (10.7%) were excluded from outcome analyses due to persistent coma. Among the remaining 159, 123 (77.4%) experienced delirium. DB was independently associated with >4-fold increased mortality at 2.5 years following ICU admission (adjusted hazard ratio [aHR], 4.77; 95% CI, 2.10–10.83; P < .001), and worse neurologic outcome at discharge (adjusted odds ratio [aOR], 0.02; 0.01–0.09; P < .001), 3 (aOR, 0.11; 0.04–0.31; P < .001), 6 (aOR, 0.10; 0.04–0.29; P < .001), and 12 months (aOR, 0.19; 0.07–0.52; P = .001). DB in the ICU alone was not associated with mortality (HR, 1.79; 0.93–3.44; P = .082) and predicted neurologic outcome less strongly than entire hospital stay DB. Similarly, the number of delirium days in the ICU and for whole hospitalization were not associated with mortality (HR, 1.00; 0.93–1.08; P = .917 and HR, 0.98; 0.94–1.03, P = .535) nor with neurological outcomes, except for the association between ICU delirium days and neurological outcome at discharge (OR, 0.90; 0.81–0.99, P = .038).

Conclusions

Delirium burden throughout hospitalization independently predicts long term neurologic outcomes and death up to 2.5 years after critical illness, and is more predictive than delirium burden in the ICU alone and number of delirium days.

Treatment of Delirium During Critical Illness

Delirium, an acute disturbance in mental status due to another medical condition, is common and morbid in the intensive care unit. Despite its clear association with multiple common risk factors and important outcomes, including mortality and long-term cognitive impairment, both the ultimate causes of and ideal treatments for delirium remain unclear. Studies suggest that neuroinflammation, hypoxia, alterations in energy metabolism, and imbalances in multiple neurotransmitter pathways contribute to delirium, but commonly used treatments (e.g., antipsychotic medications) target only one or a few of these potential mechanisms and are not supported by evidence of efficacy. At this time, the optimal treatment for delirium during critical illness remains avoidance of risk factors, though ongoing trials may expand on the promise shown by agents such as melatonin and dexmedetomidine. Expected final online publication date for the Annual Review of Medicine, Volume 73 is January 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Association of Delirium during Critical Illness With Mortality: Multicenter Prospective Cohort Study

BACKGROUND

The temporal association of delirium during critical illness with mortality is unclear, along with the associations of hypoactive and hyperactive motoric subtypes of delirium with mortality. We aimed to evaluate the relationship of delirium during critical illness, including hypoactive and hyperactive motoric subtypes, with mortality in the hospital and after discharge up to 1 year.

METHODS

We analyzed a prospective cohort study of adults with respiratory failure and/or shock admitted to university, community, and Veterans Affairs hospitals. We assessed patients using the Richmond Agitation-Sedation Scale and the Confusion Assessment Method for the intensive care unit (ICU) and defined the motoric subtype according to the corresponding Richmond Agitation-Sedation Scale if delirium was present. We used Cox proportional hazard models, adjusted for baseline characteristics, coma, and daily hospital events, to determine whether delirium on a given day predicted mortality the following day in patients in the hospital and also to determine whether delirium presence and duration predicted mortality after discharge up to 1 year in patients who survived to hospital discharge. We performed similar analyses for hypoactive and hyperactive subtypes of delirium.

RESULTS

Among 1040 critically ill patients, 214 (21%) died in the hospital and 204 (20%) died out-of-hospital by 1 year. Delirium was common, occurring in 740 (71%) patients for a median (interquartile range [IQR]) of 4 (2-7) days. Hypoactive delirium occurred in 733 (70%) patients, and hyperactive occurred in 185 (18%) patients, with a median (IQR) of 3 (2-7) days and 1 (1-2) days, respectively. Delirium on a given day (hazard ratio [HR], 2.87; 95% confidence interval [CI], 1.32-6.21; P = .008), in particular the hypoactive subtype (HR, 3.35; 95% CI, 1.51-7.46; P = .003), was independently associated with an increased risk of death the following day in the hospital. Hyperactive delirium was not associated with an increased risk of death in the hospital (HR, 4.00; 95% CI, 0.49-32.51; P = .19). Among hospital survivors, neither delirium presence (HR, 1.01; 95% CI, 0.82-1.24; P = .95) nor duration (HR, 0.99; 95% CI, 0.97-1.01; P = .56), regardless of motoric subtype, was associated with mortality after hospital discharge up to 1 year.

CONCLUSIONS

Delirium during critical illness is associated with nearly a 3-fold increased risk of death the following day for patients in the hospital but is not associated with mortality after hospital discharge. This finding appears primarily driven by the hypoactive motoric subtype. The independent relationship between delirium and mortality occurs early during critical illness but does not persist after hospital discharge.