1
|
Kiko T, Aoki T. The relationship between duration of delirium and clinical outcomes in patients with acute heart failure. Int J Cardiol 2024; 405:131902. [PMID: 38403202 DOI: 10.1016/j.ijcard.2024.131902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 02/21/2024] [Indexed: 02/27/2024]
Affiliation(s)
- Takatoyo Kiko
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Centre, Japan
| | - Tatsuo Aoki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Centre, Japan.
| |
Collapse
|
2
|
Dimitriadou I, Fradelos EC, Skoularigis J, Toska A, Vogiatzis I, Papagiannis D, Saridi M. The impact of delirium on clinical and functional outcomes in hospitalized patients with acute coronary syndrome. Nurs Crit Care 2024. [PMID: 38602059 DOI: 10.1111/nicc.13079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 03/14/2024] [Accepted: 04/02/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Delirium, which is prevalent in critical care settings, remains underexplored in acute coronary syndrome (ACS) patients in the cardiac intensive care unit (CICU). AIMS To investigate the prevalence and clinical significance of delirium in patients with ACS admitted to the CICU. STUDY DESIGN A prospective study (n = 106, mean age 74.2 ± 5.7 years) assessed delirium using the confusion assessment method-intensive care unit (CAM-ICU) tool in 21.7% of ACS patients during their CICU stay. Baseline characteristics, geriatric conditions and clinical procedures were compared between delirious and nondelirious patients. The outcomes included in-hospital mortality, 30-day and 6-month mortality, acute adverse events and length of CICU stay and hospital stay (LOS). RESULTS Delirious patients who were older and had a higher incidence of coronary artery disease underwent more complex procedures (e.g., pacemaker placement). Multivariate analysis identified central venous catheter insertion, urinary catheterization and benzodiazepine use as independent predictors of delirium. Delirium was correlated with prolonged LOS (p < .001) and increased in-hospital, 30-day and 6-month mortality (p < .001). CONCLUSIONS Delirium in ACS patients in the CICU extends hospitalization and increases in-hospital, 30-day and 6-month mortality. Early recognition and targeted interventions are crucial for mitigating adverse outcomes in this high-risk population. RELEVANCE TO CLINICAL PRACTICE This study highlights the critical impact of delirium on outcomes in hospitalized patients with ACS in the CICU. Delirium, often overlooked in ACS management, significantly extends hospitalization and increases mortality rates. Nurses and physicians must be vigilant in identifying delirium early, particularly in older ACS patients or those with comorbidities. Recognizing independent predictors such as catheterization and benzodiazepine use allows for targeted interventions to reduce delirium incidence. Integrating routine delirium assessments and preventive strategies into ACS management protocols can improve outcomes, optimize resource utilization and enhance overall patient care in the CICU setting.
Collapse
Affiliation(s)
- Ioanna Dimitriadou
- Laboratory of Clinical Nursing, Department of Nursing, University of Thessaly, Larissa, Greece
| | - Evangelos C Fradelos
- Laboratory of Clinical Nursing, Department of Nursing, University of Thessaly, Larissa, Greece
| | - John Skoularigis
- Cardiology Department, General University Hospital of Larissa, Larissa, Greece
| | - Aikaterini Toska
- Laboratory of Clinical Nursing, Department of Nursing, University of Thessaly, Larissa, Greece
| | | | - Dimitrios Papagiannis
- Laboratory of Clinical Nursing, Department of Nursing, University of Thessaly, Larissa, Greece
| | - Maria Saridi
- Laboratory of Clinical Nursing, Department of Nursing, University of Thessaly, Larissa, Greece
| |
Collapse
|
3
|
Ko RE, Lee J, Kim S, Ahn JH, Na SJ, Yang JH. Machine learning methods for developing a predictive model of the incidence of delirium in cardiac intensive care units. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024:S1885-5857(24)00021-5. [PMID: 38237663 DOI: 10.1016/j.rec.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 12/20/2023] [Indexed: 02/10/2024]
Abstract
INTRODUCTION AND OBJECTIVES Delirium, recognized as a crucial prognostic factor in the cardiac intensive care unit (CICU), has evolved in response to the changing demographics among critically ill cardiac patients. This study aimed to create a predictive model for delirium for patients in the CICU. METHODS This study included consecutive patients admitted to the CICU of the Samsung Medical Center. To assess the candidate variables for the model: we applied the following machine learning methods: random forest, extreme gradient boosting, partial least squares, and Plmnet-elastic.net. After selecting relevant variables, we performed a logistic regression analysis to derive the model formula. Internal validation was conducted using 100-repeated hold-out validation. RESULTS We analyzed 2774 patients, 677 (24.4%) of whom developed delirium in the CICU. Machine learning-based models showed good predictive performance. Clinically significant and frequently important predictors were selected to construct a delirium prediction scoring model for CICU patients. The model included albumin level, international normalized ratio, blood urea nitrogen, white blood cell count, C-reactive protein level, age, heart rate, and mechanical ventilation. The model had an area under the receiver operating characteristics curve (AUROC) of 0.861 (95%CI, 0.843-0.879). Similar results were obtained in internal validation with 100-repeated cross-validation (AUROC, 0.854; 95%CI, 0.826-0.883). CONCLUSIONS Using variables frequently ranked as highly important in four machine learning methods, we created a novel delirium prediction model. This model could serve as a useful and simple tool for risk stratification for the occurrence of delirium at the patient's bedside in the CICU.
Collapse
Affiliation(s)
- Ryoung-Eun Ko
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jihye Lee
- Division of Pulmonology and Allergy, Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Republic of Korea
| | - Sungeun Kim
- Division of Cardiology, Department of Internal Medicine, Inje University College of Medicine, Ilsan Paik Hospital, Goyang, Republic of Korea
| | - Joong Hyun Ahn
- Biostatics and Clinical Epidemiology Center, Samsung Medical Center, Seoul, Republic of Korea
| | - Soo Jin Na
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jeong Hoon Yang
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| |
Collapse
|
4
|
Skidmore KL, Rajabi A, Nguyen A, Imani F, Kaye AD. Veno-venous Extracorporeal Membrane Oxygenation: Anesthetic Considerations in Clinical Practice. Anesth Pain Med 2023; 13:e136524. [PMID: 38021335 PMCID: PMC10664155 DOI: 10.5812/aapm-136524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 05/28/2023] [Accepted: 06/04/2023] [Indexed: 12/01/2023] Open
Abstract
Context After the COVID-19 pandemic, multiple reviews have documented the success of veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Patients who experience hypoxemia but have normal contractility may be switched to veno-venous-ECMO (VV-ECMO). Purpose In this review, we present three protocols for anesthesiologists. Firstly, transesophageal echocardiography (TEE) aids in cannulation and weaning off inotropes and fluids. Our main objective is to assist in patient selection for the Avalon Elite single catheter, which is inserted into the right internal jugular vein and terminates in the right atrium. Secondly, we propose appropriate anticoagulant doses. We outline day-to-day monitoring protocols to prevent heparin-induced thrombocytopenia (HIT) or resistance. Once the effects of neuromuscular paralysis subside, sedation should be reduced. Therefore, we describe techniques that may prevent delirium from progressing into permanent cognitive decline. Methods We conducted a PubMed search using the keywords VV-ECMO, TEE, Avalon Elite (Maquet, Germany), and quetiapine. We combined these findings with interviews conducted with nurses and anesthesiologists from two academic ECMO centers, focusing on anticoagulation and sedation. Results Our qualitative evidence synthesis reveals how TEE confirms cannulation while avoiding right atrial rupture or low flows. Additionally, we discovered that typically, after initial heparinization, activated partial thromboplastin time (PTT) is drawn every 1 to 2 hours or every 6 to 8 hours once stable. Daily thromboelastograms, along with platelet counts and antithrombin III levels, may detect HIT or resistance, respectively. These side effects can be prevented by discontinuing heparin on day two and initiating argatroban at a dose of 1 μg/kg/min while maintaining PTT between 61 - 80 seconds. The argatroban dose is adjusted by 10 - 20% if PTT is between 40 - 60 or 80 - 90 seconds. Perfusionists assist in establishing protocols following manufacturer guidelines. Lastly, we describe the replacement of narcotics and benzodiazepines with dexmedetomidine at a dose of 0.5 to 1 μg/kg/hour, limited by bradycardia, and the use of quetiapine starting at 25 mg per day and gradually increasing up to 200 mg twice a day, limited by prolonged QT interval. Conclusions The limitation of this review is that it necessarily covers a broad range of ECMO decisions faced by an anesthesiologist. However, its main advantage lies in the identification of straightforward argatroban protocols through interviews, as well as the discovery, via PubMed, of the usefulness of TEE in determining cannula position and contractility estimates for transitioning from VA-ECMO to VV-ECMO. Additionally, we emphasize the benefits in terms of morbidity and mortality of a seldom-discussed sedation supplement, quetiapine, to dexmedetomidine.
Collapse
Affiliation(s)
- Kimberly L. Skidmore
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, USA
| | - Alireza Rajabi
- Department of Anesthesiology and Critical Care, Iran University of Medical Sciences, Tehran, Iran
| | - Angela Nguyen
- School of Medicine, Louisiana State University Health Sciences Center at Shreveport, Shreveport, USA
| | - Farnad Imani
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Alan D. Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, USA
| |
Collapse
|
5
|
Clinical phenotypes of delirium in patients admitted to the cardiac intensive care unit. PLoS One 2022; 17:e0273965. [PMID: 36054128 PMCID: PMC9439246 DOI: 10.1371/journal.pone.0273965] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 08/18/2022] [Indexed: 11/19/2022] Open
Abstract
Background Limited data are available on clinical phenotype for delirium that occurs frequently among patients admitted to the cardiac intensive care unit (CICU). The objective of this study was to investigate the clinical pictures of delirium, and their association with clinical outcomes in CICU patients. Methods A total of 4,261 patients who were admitted to the CICU between September 1 2012 to December 31 2018 were retrospectively registered. Patients were excluded if they were admitted to the CICU for less than 24 hours or had missed data. Ultimately, 2,783 patients were included in the analysis. A day of delirium was defined as any day during which at least one CAM-ICU assessment was positive. The clinical risk factors of delirium were classified by the delirium phenotype, as follows; hypoxic, septic, sedative-associated, and metabolic delirium. Results The incidence of delirium was 24.4% at the index hospitalization in all CICU patients, and 22.6% within 7 days after CICU admission. The most common delirium phenotype was septic delirium (17.2%), followed by hypoxic delirium (16.8%). Multiple phenotypes were observed during most delirium days. Delirium most frequently occurred in patients with heart failure. Of all patients affected by delirium within 7 days, both ICU and hospital mortality significantly increased according to the combined number of delirium phenotypes. Conclusions Delirium occurred in a quarter of patients admitted to the modern CICU and was associated with increased in-hospital mortality. Therefore, more efforts are needed to reduce the clinical risk factors of delirium, and to prevent it in order to improve clinical outcomes in the CICU.
Collapse
|
6
|
Kim SE, Ko RE, Na SJ, Chung CR, Choi KH, Kim D, Park TK, Lee JM, Song YB, Choi JO, Hahn JY, Choi SH, Gwon HC, Yang JH. External validation and comparison of two delirium prediction models in patients admitted to the cardiac intensive care unit. Front Cardiovasc Med 2022; 9:947149. [PMID: 35990989 PMCID: PMC9382019 DOI: 10.3389/fcvm.2022.947149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 07/18/2022] [Indexed: 11/16/2022] Open
Abstract
Background No data is available on delirium prediction models in the cardiac intensive care unit (CICU), although preexisting delirium prediction models [PREdiction of DELIRium in ICu patients (PRE-DELIRIC) and Early PREdiction of DELIRium in ICu patients (E-PRE-DELIRIC)] were developed and validated based on a population admitted to the general intensive care unit (ICU). Therefore, we externally validated the usefulness of the PRE-DELIRIC and E-PRE-DELIRIC models and compared their predictive performance in patients admitted to the CICU. Methods A total of 2,724 patients admitted to the CICU were enrolled between September 2012 and December 2018. Delirium was defined as at least one positive Confusion Assessment Method for the ICU (CAM-ICU) which was screened at least once every 8 h. The PRE-DELIRIC value was calculated within 24 h of CICU admission, and the E-PRE-DELIRIC value was calculated at CICU admission. The predictive performance of the models was evaluated by using the area under the receiver operating characteristic (AUROC) curve, and the calibration slope was assessed graphically by plotting. Results Delirium occurred in 677 patients (24.8%) when the patients were assessed thrice daily until 7 days of the CICU stay. The AUROC curve for the prediction of delirium was significantly greater for PRE-DELIRIC values [0.84, 95% confidence interval (CI): 0.82–0.86] than for E-PRE-DELIRIC values (0.79, 95% CI: 0.77–0.80) [z score of −6.24 (p < 0.001)]. Net reclassification improvement for the prediction of delirium increased by 0.27 (95% CI: 0.21–0.32, p < 0.001). Calibration was acceptable in the PRE-DELIRIC model (Hosmer-Lemeshow p = 0.170) but not in the E-PRE-DELIRIC model (Hosmer-Lemeshow p < 0.001). Conclusion Although both models have good predictive performance for the development of delirium, even in critically ill cardiac patients, the performance of the PRE-DELIRIC model might be superior to that of the E-PRE-DELIRIC model. Further studies are required to confirm our results and design a specific delirium prediction model for CICU patients.
Collapse
Affiliation(s)
- Sung Eun Kim
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Heart Vascular Stroke Institute, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Ryoung-Eun Ko
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Soo Jin Na
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Chi Ryang Chung
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Ki Hong Choi
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Heart Vascular Stroke Institute, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Darae Kim
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Heart Vascular Stroke Institute, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Taek Kyu Park
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Heart Vascular Stroke Institute, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Joo Myung Lee
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Heart Vascular Stroke Institute, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Young Bin Song
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Heart Vascular Stroke Institute, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jin-Oh Choi
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Heart Vascular Stroke Institute, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Joo-Yong Hahn
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Heart Vascular Stroke Institute, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Seung-Hyuk Choi
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Heart Vascular Stroke Institute, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hyeon-Cheol Gwon
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Heart Vascular Stroke Institute, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jeong Hoon Yang
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Heart Vascular Stroke Institute, Sungkyunkwan University School of Medicine, Seoul, South Korea
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
- *Correspondence: Jeong Hoon Yang
| |
Collapse
|
7
|
Maximiliano B, Sebastian B, Estefania A, Irma C, Gutierrez P, Daniela P PDLV, Roberta C, Eduardo T, Jose M, Felipe S. Epidemiology of delirium in hospitalized patients in Latin America: A systematic review. Acta Psychiatr Scand 2022; 147:420-429. [PMID: 35791060 DOI: 10.1111/acps.13468] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 05/29/2022] [Accepted: 06/25/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Accurate epidemiological data are essential for the planning of policies aimed at the identification, prevention, and management of delirium. The reported occurrence of delirium in hospitalized patients varies widely among studies, ranging between 5% to more than 80% in the international literature. The exact occurrence in Latin America is not well described. OBJECTIVE The aim of this study is to conduct a systematic analysis of the published data on the epidemiology of delirium in hospitalized patients in Latin America. METHODS We conducted a systematic review following PRISMA guidelines. Both MEDLINE and LILACS databases were searched for original research articles reporting the occurrence of delirium among adult hospitalized patients in Latin American countries. Studies including pediatric populations were excluded from this analysis. Two authors independently applied eligibility criteria, assessed quality, and extracted data. The corresponding authors of the original articles were contacted to obtain relevant information about the study when this was not present in the published manuscripts. RESULTS Seven hundred and eighteen original articles were identified. After screening titles and abstracts, 149 studies were included in the final analysis. The occurrence of delirium varied depending on the clinical scenario: (1) in the general medico-surgical wards, it ranged from 2.1% to 60.4%, (2) in the Intensive Care Units (ICUs), from 9.6% to 94.8%, (3) in the post-operatory population, from 5.45% and 52.3%, and (4) it was found to be between 10.7% and 62% in the emergency department setting. The most used delirium assessment tools were the "Confusion Assessment Method" (CAM; in the general population), and the "Confusion Assessment Method for the ICU" (CAM-ICU). Fourteen out of 149 studies were conducted in clinical settings who actively implemented some form of non-pharmacological delirium prevention bundles, most of them as part of ICU sedation-analgesia protocols. CONCLUSION Delirium occurs frequently in hospitalized patients in Latin America throughout a variety of clinical scenarios, including ICU, general wards, post-operatory populations, and among the emergency department setting. The CAM and the CAM-ICU are the most used delirium assessment tools. Bundles of non-pharmacological interventions to prevent delirium are not universally implemented.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Castro Roberta
- Universidad del Estado de Río de Janeiro, Rio de Janeiro, Brazil.,Latin America Delirium Special Interest Group (LADIG), part of the American Delirium Society (ADS)
| | - Tobar Eduardo
- Latin America Delirium Special Interest Group (LADIG), part of the American Delirium Society (ADS).,Unidad de Pacientes Críticos Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Maldonado Jose
- Latin America Delirium Special Interest Group (LADIG), part of the American Delirium Society (ADS).,Stanford University, Palo Alto, California, USA
| | - Salech Felipe
- Sección Geriatría HCUCH, Santiago, Chile.,Facultad de Medicina Universidad de, Santiago, Chile.,Hospital Clínico Universidad de Chile, Santiago, Chile.,Latin America Delirium Special Interest Group (LADIG), part of the American Delirium Society (ADS).,Centro de gerociencia, Salud Mental y Metabolismo, Santiago, Chile
| |
Collapse
|
8
|
Ritchie C, Walters RW, Ramaswamy S, Alla VM. Impact of delirium on mortality in patients hospitalized for heart failure. Int J Psychiatry Med 2022; 57:212-225. [PMID: 34176306 DOI: 10.1177/00912174211028019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Heart Failure (HF) is one of the leading causes of hospitalization in the United States accounting for ≈800,000 hospital discharges and $11 billion in annual costs. Delirium occurs in approximately 30% of elderly hospitalized patients and its incidence is significantly higher among those admitted to the critical care units. Despite this, there has been limited exploration of the clinical and economic impact of delirium in patients hospitalized with acute HF. We hypothesized that delirium in HF is associated with excess mortality and hospital costs. METHODS We queried the 2001-2014 Nationwide Inpatient Sample to identify hospitalizations that included a primary discharge diagnosis of HF (ICD-9-CM: 428.xx) and stratified them by presence or absence of delirium (ICD-9-CM: 239.0, 290.41, 293.0, 293.1, 348.31). Differences in in-hospital mortality, length of stay (LOS), and hospital costs were assessed using propensity-score matched cohorts. RESULTS Major predictors of delirium included advanced age, Caucasian race, underlying dementia or psychiatric diagnoses, higher Elixhauser Comorbidity Index, renal failure, cardiogenic shock, and coronary artery bypass surgery. In the propensity-score matched analysis of 76,411 hospitalization with delirium compared to 76,612 without delirium, in-hospital mortality (odds ratio: 1.67, 95% CI: 1.51-1.77), LOS (rate ratio [RR]: 1.47, 95% CI: 1.45-1.51), and hospital costs (RR: 1.44, 95% CI: 1.41-1.48) were all statistically higher in the presence of delirium (all p < 0.001). CONCLUSION In patients hospitalized with HF, delirium is an independent predictor of increased in-hospital mortality, longer LOS, and excess hospital costs despite adjustment for baseline characteristics.
Collapse
Affiliation(s)
| | - Ryan W Walters
- Division of Clinical Research and Evaluative Sciences, 12282Creighton University School of Medicine, Department of Medicine, Creighton University School of Medicine, Omaha, NE, USA
| | - Sriram Ramaswamy
- Department of Psychiatry, Creighton University School of Medicine, Creighton University School of Medicine, Omaha, NE, USA
| | - Venkata M Alla
- Division of Cardiology, Department of Medicine, Creighton University School of Medicine, Omaha, NE, USA
| |
Collapse
|
9
|
Breit H, Bleck TP, Koffman L. Delirium in Cardiac and Cardiovascular Surgical Intensive Care Units. Semin Neurol 2021; 41:453-462. [PMID: 33851391 DOI: 10.1055/s-0041-1726283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Delirium is a common occurrence in cardiac and cardiovascular surgical intensive care units. Due to multiple confounding factors, this diagnosis remains challenging for medical professionals. Multiple theories exist regarding the pathophysiology of delirium, which include disruption of neurotransmitters as well as inflammation. Delirium has been associated with prolonged hospitalizations and an increase in mortality. Although there are widely used screening tools for delirium, none have been validated in this particular patient population. Limited treatments exist for delirium, so: both pharmacologic and nonpharmacologic preventative measures should be employed in this patient population.
Collapse
Affiliation(s)
- Hannah Breit
- Section of Neurocritical Care, Rush University Medical Center, Chicago, Illinois
| | - Thomas P Bleck
- Department of Neurology, Northwestern Memorial Hospital, Chicago, Illinois
| | - Lauren Koffman
- Section of Neurocritical Care, Rush University Medical Center, Chicago, Illinois
| |
Collapse
|
10
|
Fordyce CB, Katz JN, Alviar CL, Arslanian-Engoren C, Bohula EA, Geller BJ, Hollenberg SM, Jentzer JC, Sims DB, Washam JB, van Diepen S. Prevention of Complications in the Cardiac Intensive Care Unit: A Scientific Statement From the American Heart Association. Circulation 2020; 142:e379-e406. [DOI: 10.1161/cir.0000000000000909] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Contemporary cardiac intensive care units (CICUs) have an increasing prevalence of noncardiovascular comorbidities and multisystem organ dysfunction. However, little guidance exists to support the development of best-practice principles specific to the CICU. This scientific statement evaluates strategies to avoid the potentially preventable complications encountered within contemporary CICUs, focusing on those that are most applicable to the CICU environment. This scientific statement reviews evidence-based practices derived in non–CICU populations, assesses their relevance to CICU practice, and highlights key knowledge gaps warranting further investigation to attenuate patient risk.
Collapse
|
11
|
Quetiapine therapy in critically injured trauma patients is associated with an increased risk of pulmonary complications. Am J Surg 2020; 219:804-809. [PMID: 32102757 DOI: 10.1016/j.amjsurg.2020.02.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 02/14/2020] [Accepted: 02/14/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND The aim of this study was to evaluate quetiapine-associated pulmonary complications (PC) in critically injured trauma patients. METHODS Injured adults admitted during 2016 to the ICU at a Level I trauma center were analyzed. Outcomes were evaluated by competing risks survival analysis. RESULTS Of 254 admissions, 40 (15.7%) had PC and 214 (84.3%) were non-events. PC patients were more severely injured, had longer hospital stays and were more likely to die. Patients administered quetiapine were more likely to develop PC and acquire PC earlier than those without quetiapine. Quetiapine was a positive risk factor for PC (sHR 2.24, p = 0.013). Stratification by ventilator use revealed non-ventilated patients administered quetiapine had the highest risk for PC (sHR 4.66, p = 0.099). CONCLUSIONS Quetiapine exposure in critically injured trauma patients was associated with increased risk of PC. Guidelines for treatment of delirium with quetiapine in critically injured trauma patients should account for this risk.
Collapse
|
12
|
ter Bekke RM, Volders PG. Haloperidol and sudden death in first acute myocardial infarction. IJC HEART & VASCULATURE 2020; 26:100482. [PMID: 32142077 PMCID: PMC7046527 DOI: 10.1016/j.ijcha.2020.100482] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 02/03/2020] [Indexed: 12/03/2022]
Affiliation(s)
- Rachel M.A. ter Bekke
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, the Netherlands
| | | |
Collapse
|
13
|
Nikooie R, Neufeld KJ, Oh ES, Wilson LM, Zhang A, Robinson KA, Needham DM. Antipsychotics for Treating Delirium in Hospitalized Adults: A Systematic Review. Ann Intern Med 2019; 171:485-495. [PMID: 31476770 DOI: 10.7326/m19-1860] [Citation(s) in RCA: 118] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Delirium is common in hospitalized patients and is associated with worse outcomes. Antipsychotics are commonly used; however, the associated benefits and harms are unclear. PURPOSE To conduct a systematic review evaluating the benefits and harms of antipsychotics to treat delirium in adults. DATA SOURCES PubMed, Embase, CENTRAL, CINAHL, and PsycINFO from inception to July 2019 without language restrictions. STUDY SELECTION Randomized controlled trials (RCTs) of antipsychotic versus placebo or another antipsychotic, and prospective observational studies reporting harms. DATA EXTRACTION One reviewer extracted data and assessed strength of evidence (SOE) for critical outcomes, with confirmation by another reviewer. Risk of bias was assessed independently by 2 reviewers. DATA SYNTHESIS Across 16 RCTs and 10 observational studies of hospitalized adults, there was no difference in sedation status (low and moderate SOE), delirium duration, hospital length of stay (moderate SOE), or mortality between haloperidol and second-generation antipsychotics versus placebo. There was no difference in delirium severity (moderate SOE) and cognitive functioning (low SOE) for haloperidol versus second-generation antipsychotics, with insufficient or no evidence for antipsychotics versus placebo. For direct comparisons of different second-generation antipsychotics, there was no difference in mortality and insufficient or no evidence for multiple other outcomes. There was little evidence demonstrating neurologic harms associated with short-term use of antipsychotics for treating delirium in adult inpatients, but potentially harmful cardiac effects tended to occur more frequently. LIMITATIONS Heterogeneity was present in terms of dose and administration route of antipsychotics, outcomes, and measurement instruments. There was insufficient or no evidence regarding multiple clinically important outcomes. CONCLUSION Current evidence does not support routine use of haloperidol or second-generation antipsychotics to treat delirium in adult inpatients. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality. (PROSPERO: CRD42018109552).
Collapse
Affiliation(s)
- Roozbeh Nikooie
- Johns Hopkins University School of Medicine, Baltimore, Maryland (R.N., K.J.N., E.S.O., K.A.R., D.M.N.)
| | - Karin J Neufeld
- Johns Hopkins University School of Medicine, Baltimore, Maryland (R.N., K.J.N., E.S.O., K.A.R., D.M.N.)
| | - Esther S Oh
- Johns Hopkins University School of Medicine, Baltimore, Maryland (R.N., K.J.N., E.S.O., K.A.R., D.M.N.)
| | - Lisa M Wilson
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (L.M.W., A.Z.)
| | - Allen Zhang
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (L.M.W., A.Z.)
| | - Karen A Robinson
- Johns Hopkins University School of Medicine, Baltimore, Maryland (R.N., K.J.N., E.S.O., K.A.R., D.M.N.)
| | - Dale M Needham
- Johns Hopkins University School of Medicine, Baltimore, Maryland (R.N., K.J.N., E.S.O., K.A.R., D.M.N.)
| |
Collapse
|
14
|
Park Y, Bateman BT, Kim DH, Hernandez-Diaz S, Patorno E, Glynn RJ, Mogun H, Huybrechts KF. Use of haloperidol versus atypical antipsychotics and risk of in-hospital death in patients with acute myocardial infarction: cohort study. BMJ 2018; 360:k1218. [PMID: 29592958 PMCID: PMC5871903 DOI: 10.1136/bmj.k1218] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To compare the risk of in-hospital mortality associated with haloperidol compared with atypical antipsychotics in patients admitted to hospital with acute myocardial infarction. DESIGN Cohort study using a healthcare database. SETTING Nationwide sample of patient data from more than 700 hospitals across the United States. PARTICIPANTS 6578 medical patients aged more than 18 years who initiated oral haloperidol or oral atypical antipsychotics (olanzapine, quetiapine, risperidone) during a hospital admission with a primary diagnosis of acute myocardial infarction between 2003 and 2014. MAIN OUTCOME MEASURE In-hospital mortality during seven days of follow-up from treatment initiation. RESULTS Among 6578 patients (mean age 75.2 years) treated with an oral antipsychotic drug, 1668 (25.4%) initiated haloperidol and 4910 (74.6%) initiated atypical antipsychotics. The mean time from admission to start of treatment (5.3 v 5.6 days) and length of stay (12.5 v 13.6 days) were similar, but the mean treatment duration was shorter in patients using haloperidol compared with those using atypical antipsychotics (2.4 v 3.9 days). 1:1 propensity score matching was used to adjust for confounding. In intention to treat analyses with the matched cohort, the absolute rate of death per 100 person days was 1.7 for haloperidol (129 deaths) and 1.1 for atypical antipsychotics (92 deaths) during seven days of follow-up from treatment initiation. The survival probability was 0.93 in patients using haloperidol and 0.94 in those using atypical antipsychotics at day 7, accounting for the loss of follow-up due to hospital discharge. The unadjusted and adjusted hazard ratios of death were 1.51 (95% confidence interval 1.22 to 1.85) and 1.50 (1.14 to 1.96), respectively. The association was strongest during the first four days of follow-up and decreased over time. By day 5, the increased risk was no longer evident (1.12, 0.79 to 1.59). In the as-treated analyses, the unadjusted and adjusted hazard ratios were 1.90 (1.43 to 2.53) and 1.93 (1.34 to 2.76), respectively. CONCLUSION The results suggest a small increased risk of death within seven days of initiating haloperidol compared with initiating an atypical antipsychotic in patients with acute myocardial infarction. Although residual confounding cannot be excluded, this finding deserves consideration when haloperidol is used for patients admitted to hospital with cardiac morbidity.
Collapse
Affiliation(s)
- Yoonyoung Park
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street, Boston, MA, 02120, USA
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Brian T Bateman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street, Boston, MA, 02120, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Dae Hyun Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street, Boston, MA, 02120, USA
| | - Sonia Hernandez-Diaz
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street, Boston, MA, 02120, USA
| | - Robert J Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street, Boston, MA, 02120, USA
| | - Helen Mogun
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street, Boston, MA, 02120, USA
| | - Krista F Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street, Boston, MA, 02120, USA
| |
Collapse
|
15
|
Ibrahim K, McCarthy CP, McCarthy KJ, Brown CH, Needham DM, Januzzi JL, McEvoy JW. Delirium in the Cardiac Intensive Care Unit. J Am Heart Assoc 2018; 7:JAHA.118.008568. [PMID: 29453307 PMCID: PMC5850211 DOI: 10.1161/jaha.118.008568] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Khalil Ibrahim
- Division of CardiologyDepartment of MedicineJohns Hopkins University School of MedicineBaltimoreMD
| | | | | | - Charles H. Brown
- Department of Anesthesiology and Critical Care MedicineJohns Hopkins University School of MedicineBaltimoreMD
| | - Dale M. Needham
- Department of Physical Medicine and RehabilitationJohns Hopkins University School of MedicineBaltimoreMD,Outcomes After Critical Illness and Surgery (OACIS) GroupDivision of Pulmonary and Critical Care MedicineJohns Hopkins University School of MedicineBaltimoreMD
| | - James L. Januzzi
- Division of CardiologyDepartment of MedicineMassachusetts General HospitalBaim Institute for Clinical ResearchBostonMA,Cardiometabolic TrialsBaim Institute for Clinical ResearchBostonMA
| | - John W. McEvoy
- Division of CardiologyDepartment of MedicineJohns Hopkins University School of MedicineBaltimoreMD
| |
Collapse
|
16
|
Maldonado JR. Acute Brain Failure: Pathophysiology, Diagnosis, Management, and Sequelae of Delirium. Crit Care Clin 2017; 33:461-519. [PMID: 28601132 DOI: 10.1016/j.ccc.2017.03.013] [Citation(s) in RCA: 172] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Delirium is the most common psychiatric syndrome found in the general hospital setting, with an incidence as high as 87% in the acute care setting. Delirium is a neurobehavioral syndrome caused by the transient disruption of normal neuronal activity secondary to systemic disturbances. The development of delirium is associated with increased morbidity, mortality, cost of care, hospital-acquired complications, placement in specialized intermediate and long-term care facilities, slower rate of recovery, poor functional and cognitive recovery, decreased quality of life, and prolonged hospital stays. This article discusses the epidemiology, known etiological factors, presentation and characteristics, prevention, management, and impact of delirium.
Collapse
Affiliation(s)
- José R Maldonado
- Psychosomatic Medicine Service, Emergency Psychiatry Service, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Suite 2317, Stanford, CA 94305-5718, USA.
| |
Collapse
|
17
|
Vrints CJ. Non-ST elevation acute coronary syndromes: timing and selection of early invasive management, ECG monitoring need, DAPT duration, pathogenesis of recurrence and beware of delirium in the intensive/acute cardiac care unit! EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2017; 6:475-476. [PMID: 28933208 DOI: 10.1177/2048872617734983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
|
18
|
Kim DH, Huybrechts KF, Patorno E, Marcantonio ER, Park Y, Levin R, Abdurrob A, Bateman BT. Adverse Events Associated with Antipsychotic Use in Hospitalized Older Adults After Cardiac Surgery. J Am Geriatr Soc 2017; 65:1229-1237. [PMID: 28186624 DOI: 10.1111/jgs.14768] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To evaluate in-hospital adverse events associated with typical and atypical antipsychotic medications (APMs) after cardiac surgery. DESIGN Retrospective cohort study. SETTING Nationwide inpatient database, 2003 to 14. PARTICIPANTS Individuals (mean age 70) newly treated with oral atypical (n = 2,580) or typical (n = 1,126 APMs) after coronary artery bypass grafting or valve surgery (N = 3,706). MEASUREMENTS In-hospital mortality, arrhythmia, pneumonia, use of brain imaging (surrogate for oversedation and neurological events), and length of stay after drug initiation RESULTS: In the propensity score-matched cohort, median treatment duration was 3 days (interquartile range (IQR) 1-6 days) for atypical APMs and 2 days (IQR 1-3 days) for typical APMs. There were no large differences in in-hospital mortality (atypical 5.4%, typical 5.3%; risk difference (RD) = 0.1%, 95% confidence interval (CI) = -2.1 to 2.3%), arrhythmia (2.0% vs 2.2%; RD = 0.0%; 95% CI = -1.4 to 1.4%), pneumonia (16.1% vs 14.5%; RD = 1.6%, 95% CI = -1.9 to 5.0%), and length of stay (9.9 days vs 9.3 days; mean difference = 0.5 days, 95% CI = -1.2 to 2.2). Use of brain imaging was more common after initiating atypical APMs (17.3%) than after typical APMs (12.4%; RD = 4.9%, 95% CI = 1.4-8.4). CONCLUSION In hospitalized individuals who underwent cardiac surgery, short-term use of typical APMs was associated with risks of adverse events similar to those with atypical APMs. Moreover, greater use of brain imaging associated with atypical APMs suggests that these drugs may cause oversedation or adverse neurological events. Because of the low event rates, the analysis could not exclude modest differences in adverse events between atypical and typical APMs.
Collapse
Affiliation(s)
- Dae H Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Krista F Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Edward R Marcantonio
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Yoonyoung Park
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Raisa Levin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Abdurrahman Abdurrob
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Brian T Bateman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| |
Collapse
|
19
|
Montilla Padilla I, Martín-Asenjo R, Bueno H. Management of Acute Coronary Syndromes in Geriatric Patients. Heart Lung Circ 2017; 26:107-113. [DOI: 10.1016/j.hlc.2016.07.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 07/20/2016] [Indexed: 11/26/2022]
|