Treatment of Delirium During Critical Illness

Acute encephalopathy in the ICU: a practical approach

PURPOSE OF REVIEW

Acute encephalopathy (AE) - which frequently develops in critically ill patients with and without primary brain injury - is defined as an acute process that evolves rapidly and leads to changes in baseline cognitive status, ranging from delirium to coma. The diagnosis, monitoring, and management of AE is challenging. Here, we discuss advances in definitions, diagnostic approaches, therapeutic options, and implications to outcomes of the clinical spectrum of AE in ICU patients without primary brain injury.

RECENT FINDINGS

Understanding and definitions of delirium and coma have evolved. Delirium is a neurocognitive disorder involving impairment of attention and cognition, usually fluctuating, and developing over hours to days. Coma is a state of unresponsiveness, with absence of command following, intelligible speech, or visual pursuit, with no imaging or neurophysiological evidence of cognitive motor dissociation. The CAM-ICU(-7) and the ICDSC are validated, guideline-recommended tools for clinical delirium assessment, with identification of clinical subtypes and stratification of severity. In comatose patients, the roles of continuous EEG monitoring and neuroimaging have grown for the early detection of secondary brain injury and treatment of reversible causes.

SUMMARY

Evidence-based pharmacologic treatments for delirium are limited. Dexmedetomidine is effective for mechanically ventilated patients with delirium, while haloperidol has minimal effect of delirium but may have other benefits. Specific treatments for coma in nonprimary brain injury are still lacking.

Anticholinergic Burden and Xerostomia in Critical Care Settings

BACKGROUND

Although previous studies have established the association of medications with anticholinergic adverse effects and xerostomia, anticholinergic burden and xerostomia in critical care settings are poorly characterized. The objective of this study was to determine the impact of medication burdens associated with anticholinergic adverse effects, particularly the occurrence of xerostomia (dry mouth) in a critical care setting. In addition, this study explored the correlation between the timing of the first instance of xerostomia and the administration timing of medication known to have anticholinergic adverse effects.

METHODS

A retrospective case-control study was used with the MIMIC (Medical Information Mart for Intensive Care) III database. The MIMIC-III clinical database is a publicly available, deidentified, health-related database with more than 40 000 patients in critical care units from 2001 to 2012. Cases of xerostomia (n = 1344) were selected from clinical notes reporting "dry mouth," "xerostomia," or evidence of pharmacological treatment for xerostomia; control (n = 4032) was selected using the propensity analysis with 1:3 matching on covariates (eg, age, sex, race, ethnicity, and length of stay). The anticholinergic burden was quantified as the cumulative effect of anticholinergic activities using the Anticholinergic Burden Scale.

RESULTS

Anticholinergic burden significantly differed between xerostomia patients and control subjects (P = .04). The length of stay was a statistically significant factor in xerostomia. The probability of developing the symptom of xerostomia within 24 hours was .95 (95%) for patients of xerostomia.

CONCLUSIONS

Anticholinergic Burden Scale is associated with xerostomia in the critical care setting, particularly within 24 hours after admission. It is crucial to carefully evaluate alternative options for medications that may have potential anticholinergic adverse effects. This evaluation should include assessing the balance between the benefits and harms, considering the probability of withdrawal reactions, and prioritizing deprescribing whenever feasible within the initial 24-hour period.

Incidence of adverse cardiovascular events in patients with insomnia: A systematic review and meta-analysis of real-world data

Insomnia is a prevalent sleeping disorder associated with increasing cardiovascular (CV) mortality and morbidity. However, data incorporating recent clinical studies evaluating these outcomes is scarce. Hence, we aimed to investigate the association of insomnia with CV mortality, myocardial infarction (MI), all-cause mortality, and incidence of CV disease by conducting the first-ever meta-analysis of real-world data evaluating these CV outcomes. MEDLINE and Scopus databases were queried till August 2022 to identify studies comparing prespecified outcomes in patients with and without insomnia. The primary outcomes were CV mortality and myocardial infarction, while secondary outcomes included all-cause mortality, and CV-disease incidence. All data were pooled using an inverse-variance weighted random-effects model, and results were reported as relative risks (RRs) and p-values. 21 studies were analyzed. Risks for CV mortality and MI were significantly higher in patients with insomnia (RR 1.53, p<0.01, and RR 1.48, p = 0.03, respectively). The risk for all-cause mortality and CV disease incidence was also significantly higher in insomnia patients (RR 1.14, p = 0.03, and RR 1.31, p<0.01, respectively). Individuals with insomnia experience a higher risk of long-term mortality, MI, and incidence of CV disease.

Automated phenotyping of postoperative delirium-like behaviour in mice reveals the therapeutic efficacy of dexmedetomidine

Postoperative delirium (POD) is a complicated and harmful clinical syndrome. Traditional behaviour analysis mostly focuses on static parameters. However, animal behaviour is a bottom-up and hierarchical organizational structure composed of time-varying posture dynamics. Spontaneous and task-driven behaviours are used to conduct comprehensive profiling of behavioural data of various aspects of model animals. A machine-learning based method is used to assess the effect of dexmedetomidine. Fourteen statistically different spontaneous behaviours are used to distinguish the non-POD group from the POD group. In the task-driven behaviour, the non-POD group has greater deep versus shallow investigation preference, with no significant preference in the POD group. Hyperactive and hypoactive subtypes can be distinguished through pose evaluation. Dexmedetomidine at a dose of 25 μg kg-1 reduces the severity and incidence of POD. Here we propose a multi-scaled clustering analysis framework that includes pose, behaviour and action sequence evaluation. This may represent the hierarchical dynamics of delirium-like behaviours.

Agitation is a Common Barrier to Recovery of ICU Patients

Importance: Agitation is common in mechanically ventilated ICU patients, but little is known about physician attitudes regarding agitation in this setting. Objectives: To characterize physician attitudes regarding agitation in mechanically ventilated ICU patients. Design, Setting, and Participants: We surveyed critical care physicians within a multicenter health system in Western Pennsylvania, assessing attitudes regarding agitation during mechanical ventilation and use of and confidence in agitation management options. We used quantitative clinical vignettes to determine whether agitation influences confidence regarding readiness for extubation. We sent our survey to 332 critical care physicians, of whom 80 (24%) responded and 69 were eligible (had cared for a mechanically ventilated patient in the preceding three months). Main Outcomes and Measures: Respondent confidence in patient readiness for extubation (0-100%, continuous) and frequency of use and confidence in management options (1-5, Likert). Results: Of 69 eligible responders, 61 (88%) agreed agitation is common and 49 (71%) agreed agitation is a barrier to extubation, but only 27 (39%) agreed their approach to agitation is evidence-based. Attitudes regarding agitation did not differ much by practice setting or physician demographics, though respondents working in medical ICUs were more likely (P = .04) and respondents trained in surgery or emergency medicine were less likely (P = .03) than others to indicate that agitation is an extubation barrier. Fifty-three (77%) respondents reported they frequently use non-pharmacologic measures to treat agitation, and 42 (70%) of those who reported they used non-pharmacologic measures during the prior 3 months indicated confidence in their effectiveness. In responses to clinical vignettes, confidence in patient's readiness for extubation was significantly lower if the patient was agitated (P < .001) or tachypneic (P < .001), but the presence of both agitation and tachypnea did not reduce confidence compared with tachypnea alone (P = .24). Conclusions and Relevance: Most critical care physicians consider agitation during mechanical ventilation a common problem and agreed that agitation is a barrier to extubation. Treatment practice varies widely.

COVID-19 Critical Illness: A Data-Driven Review

The coronavirus disease 2019 (COVID-19) pandemic has posed unprecedented challenges in critical care medicine, including extreme demand for intensive care unit (ICU) resources and rapidly evolving understanding of a novel disease. Up to one-third of hospitalized patients with COVID-19 experience critical illness. The most common form of organ failure in COVID-19 critical illness is acute hypoxemic respiratory failure, which clinically presents as acute respiratory distress syndrome (ARDS) in three-quarters of ICU patients. Noninvasive respiratory support modalities are being used with increasing frequency given their potential to reduce the need for intubation. Determining optimal patient selection for and timing of intubation remains a challenge. Management of mechanically ventilated patients with COVID-19 largely mirrors that of non-COVID-19 ARDS. Organ failure is common and portends a poor prognosis. Mortality rates have improved over the course of the pandemic, likely owing to increasing disease familiarity, data-driven pharmacologics, and improved adherence to evidence-based critical care.

Bibliometric Analysis of 100 Most-Cited Articles in Delirium

Delirium is a cognitive disorder with complex etiology, which brings a great burden to social health care. Articles with high citation frequency can provide important information about the current research situation in a certain field. Web of Science was used to search the 100 most-cited articles and we extracted key information, such as the authors, countries/regions, institutions, journals, and study types of these articles. CiteSpace was used to visually analyze the keywords. Our bibliometric analysis shows that the attention in this field continues to rise. Authors from the United States published the most articles and Inouye SK is the most influential author in the field. The journals that published these articles have high impact factors. Cohort studies are the main cited articles in this field, and there are a large number of systematic reviews or meta-analyses of cohort studies. Risk factors for delirium, psychometric evaluation, hospital care, and various clinical study design are still the focus of research. In short, we summarized the 100 most-cited articles in the field of delirium to identify the current status and global trends. These results enable researchers to understand the quality and trend of research in the field of delirium and make better use of the classical literature.