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Wu TT, Vernooij LM, Duprey MS, Zaal IJ, Gélinas C, Devlin JW, Slooter AJC. Relationship Between Pain and Delirium in Critically Ill Adults. Crit Care Explor 2023; 5:e1012. [PMID: 38053750 PMCID: PMC10695586 DOI: 10.1097/cce.0000000000001012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023] Open
Abstract
OBJECTIVES Although opioids are frequently used to treat pain, and are an important risk for ICU delirium, the association between ICU pain itself and delirium remains unclear. We sought to evaluate the relationship between ICU pain and delirium. DESIGN Prospective cohort study. SETTING A 32-bed academic medical-surgical ICU. PATIENTS Critically ill adults (n = 4,064) admitted greater than or equal to 24 hours without a condition hampering delirium assessment. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Daily mental status was classified as arousable without delirium, delirium, or unarousable. Pain was assessed six times daily in arousable patients using a 0-10 Numeric Rating Scale (NRS) or the Critical Care Pain Observation Tool (CPOT); daily peak pain score was categorized as no (NRS = 0/CPOT = 0), mild (NRS = 1-3/CPOT = 1-2), moderate (NRS = 4-6/CPOT = 3-4), or severe (NRS = 7-10/CPOT = 5-8) pain. To address missingness, a Multiple Imputation by Chained Equations approach that used available daily pain severity and 19 pain predictors was used to generate 25 complete datasets. Using a first-order Markov model with a multinomial logistic regression analysis, that controlled for 11 baseline/daily delirium risk factors and considered the competing risks of unarousability and ICU discharge/death, the association between peak daily pain and next-day delirium in each complete dataset was evaluated. RESULTS Among 14,013 ICU days (contributed by 4,064 adults), delirium occurred on 2,749 (19.6%). After pain severity imputation on 1,818 ICU days, mild, moderate, and severe pain were detected on 2,712 (34.1%), 1,682 (21.1%), and 894 (11.2%) of the no-delirium days, respectively, and 992 (36.1%), 513 (18.6%), and 27 (10.1%) of delirium days (p = 0.01). The presence of any pain (mild, moderate, or severe) was not associated with a transition from awake without delirium to delirium (aOR 0.96; 95% CI, 0.76-1.21). This association was similar when days with only mild, moderate, or severe pain were considered. All results were stable after controlling for daily opioid dose. CONCLUSIONS After controlling for multiple delirium risk factors, including daily opioid use, pain may not be a risk factor for delirium in the ICU. Future prospective research is required.
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Affiliation(s)
- Ting Ting Wu
- Bouve College of Health Sciences, Northeastern University, Boston, MA
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA
| | - Lisette M Vernooij
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Anesthesiology, Intensive Care and Pain Medicine, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Matthew S Duprey
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY
| | - Irene J Zaal
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
- Department of Intensive Care Medicine, Franciscus Gasthuis and Vlietland, Rotterdam, The Netherlands
| | - Céline Gélinas
- Ingram School of Nursing, McGill University, Montreal, QC, Canada
- Centre for Nursing Research, Jewish General Hospital, Montreal, QC, Canada
| | - John W Devlin
- Bouve College of Health Sciences, Northeastern University, Boston, MA
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA
| | - Arjen J C Slooter
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Psychiatry, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Neurology, UZ Brussel and Vrije Universiteit Brussel, Brussels, Belgium
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Maagaard M, Barbateskovic M, Andersen-Ranberg NC, Kronborg JR, Chen YX, Xi HH, Perner A, Wetterslev J. 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. Acta Anaesthesiol Scand 2023; 67:382-411. [PMID: 36702780 DOI: 10.1111/aas.14208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 01/18/2023] [Accepted: 01/20/2023] [Indexed: 01/28/2023]
Abstract
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.
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Affiliation(s)
- Mathias Maagaard
- Department of Anaesthesiology, Centre for Anaesthesiogical Research, Zealand University Hospital, Køge, Denmark
| | - Marija Barbateskovic
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Nina C Andersen-Ranberg
- Department of Anaesthesiology, Centre for Anaesthesiogical Research, Zealand University Hospital, Køge, Denmark
| | - Jonas R Kronborg
- Department of Thoracic Anaesthesiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Ya-Xin Chen
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, China
| | - Huan-Huan Xi
- Shanxi University of Chinese Medicine, Taiyuan City, China
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
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Zhang Y, Wan D, Chen M, Li Y, Ying H, Yao G, Liu Z, Zhang G. Automated machine learning-based model for the prediction of delirium in patients after surgery for degenerative spinal disease. CNS Neurosci Ther 2022; 29:282-295. [PMID: 36258311 PMCID: PMC9804056 DOI: 10.1111/cns.14002] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 09/25/2022] [Accepted: 10/01/2022] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE This study used machine learning algorithms to identify critical variables and predict postoperative delirium (POD) in patients with degenerative spinal disease. METHODS We included 663 patients who underwent surgery for degenerative spinal disease and received general anesthesia. The LASSO method was used to screen essential features associated with POD. Clinical characteristics, preoperative laboratory parameters, and intraoperative variables were reviewed and were used to construct nine machine learning models including a training set and validation set (80% of participants), and were then evaluated in the rest of the study sample (20% of participants). The area under the receiver-operating characteristic curve (AUROC) and Brier scores were used to compare the prediction performances of different models. The eXtreme Gradient Boosting algorithms (XGBOOST) model was used to predict POD. The SHapley Additive exPlanations (SHAP) package was used to interpret the XGBOOST model. Data of 49 patients were prospectively collected for model validation. RESULTS The XGBOOST model outperformed the other classifier models in the training set (area under the curve [AUC]: 92.8%, 95% confidence interval [CI]: 90.7%-95.0%), validation set (AUC: 87.0%, 95% CI: 80.7%-93.3%). This model also achieved the lowest Brier Score. Twelve vital variables, including age, serum albumin, the admission-to-surgery time interval, C-reactive protein level, hypertension, intraoperative blood loss, intraoperative minimum blood pressure, cardiovascular-cerebrovascular disease, smoking, alcohol consumption, pulmonary disease, and admission-intraoperative maximum blood pressure difference, were selected. The XGBOOST model performed well in the prospective cohort (accuracy: 85.71%). CONCLUSION A machine learning model and a web predictor for delirium after surgery for the degenerative spinal disease were successfully developed to demonstrate the extent of POD risk during the perioperative period, which could guide appropriate preventive measures for high-risk patients.
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Affiliation(s)
- Yu Zhang
- Outpatient DepartmentThe Second Affiliated Hospital of Nanchang UniversityNanchangChina,Medical Innovation Centerthe First Affiliated Hospital of Nanchang UniversityNanchangChina,Institute of Spine and Spinal CordNanchang UniversityNanchangChina
| | - Dong‐Hua Wan
- Department of OrthopedicsThe Second Affiliated Hospital of Nanchang UniversityNanchangChina
| | - Min Chen
- Department of OrthopedicsThe Second Affiliated Hospital of Nanchang UniversityNanchangChina
| | - Yun‐Li Li
- Department of OrthopedicsThe Second Affiliated Hospital of Nanchang UniversityNanchangChina
| | - Hui Ying
- Medical Innovation Centerthe First Affiliated Hospital of Nanchang UniversityNanchangChina,Institute of Spine and Spinal CordNanchang UniversityNanchangChina
| | - Ge‐Liang Yao
- Medical Innovation Centerthe First Affiliated Hospital of Nanchang UniversityNanchangChina,Institute of Spine and Spinal CordNanchang UniversityNanchangChina
| | - Zhi‐Li Liu
- Medical Innovation Centerthe First Affiliated Hospital of Nanchang UniversityNanchangChina,Institute of Spine and Spinal CordNanchang UniversityNanchangChina
| | - Guo‐Mei Zhang
- Outpatient DepartmentThe Second Affiliated Hospital of Nanchang UniversityNanchangChina
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4
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Li N, Liu X, Gao Y, Yin L, Zhao W, Ma R, Ni X. Association of electroencephalogram epileptiform discharges during cardiac surgery with postoperative delirium: An observational study. Front Surg 2022; 9:900122. [PMID: 36147691 PMCID: PMC9485598 DOI: 10.3389/fsurg.2022.900122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 08/15/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundDelirium is a frequent and serious complication following cardiac surgery involving cardiopulmonary bypass (CPB). Electroencephalography reflects the electrical activity of the cerebral cortex. The impact of electroencephalographic epileptiform discharges during cardiac surgery on postoperative delirium remains unclear. This study was designed to investigate the relationship between intraoperative epileptiform discharges and postoperative delirium in patients undergoing cardiac surgery.MethodsA total of 76 patients who underwent cardiac surgery under CPB were included. The baseline cognitive status was measured before surgery. Electroencephalograms were monitored continuously from entry into the operating room to the end of surgery. The presence of delirium was assessed through the Confusion Assessment Method or the Confusion Assessment Method for the Intensive Care Unit on the first 3 days after surgery. Univariate and multivariate logistic regression analyses were performed to evaluate the association between epileptiform discharges and delirium.ResultsDelirium occurred in 31% of patients and epileptiform discharges were present in 26% of patients in the study. Patients with delirium had a higher incidence of epileptiform discharges (52.63% vs. 13.95%, P < 0.001) and longer durations of anesthesia and CPB (P = 0.023 and P = 0.015, respectively). In addition, patients with delirium had a longer length of hospital stay and a higher incidence of postoperative complications. Multivariate logistic regression analysis showed that age and epileptiform discharges were significantly associated with the incidence of postoperative delirium [odds ratio, 4.75 (1.26–17.92), P = 0.022; 5.00 (1.34–18.74), P = 0.017, respectively].ConclusionsPostoperative delirium is significantly related to the occurrence of epileptiform discharges during cardiac surgery.
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Affiliation(s)
- Na Li
- Department of Anaesthesiology, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Xing Liu
- Department of Anaesthesiology, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Yuhua Gao
- Department of Anaesthesiology, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Lingzi Yin
- Department of Anaesthesiology, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Wanli Zhao
- Department of Anaesthesiology, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Rongxing Ma
- Department of Neuroelectrophysiology, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Xinli Ni
- Department of Anaesthesiology, General Hospital of Ningxia Medical University, Yinchuan, China
- Correspondence: XinLi Ni
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Park WR, Kim HR, Park JY, Kim HE, Cho J, Oh J. Potential Usefulness of Blood Urea Nitrogen to Creatinine Ratio in the Prediction and Early Detection of Delirium Motor Subtype in the Intensive Care Unit. J Clin Med 2022; 11:jcm11175073. [PMID: 36078999 PMCID: PMC9457387 DOI: 10.3390/jcm11175073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/21/2022] [Accepted: 08/25/2022] [Indexed: 11/16/2022] Open
Abstract
Prediction and early detection of delirium can improve patient outcomes. A high blood urea nitrogen to creatinine ratio (BCR), which reflects dehydration, has been reported as a risk factor for delirium. Additionally, BCR represents skeletal muscle loss in intensive care unit (ICU) patients, which can have critical implications for clinical outcomes. We investigated whether BCR could be used to predict the occurrence and motor subtype of delirium in ICU patients through a retrospective cohort study that included 7167 patients (50 years or older) admitted to the ICU. Patients were assessed daily using the Richmond Agitation-Sedation Scale and the Confusion Assessment Method for ICU and categorized according to the delirium subtype. Participants were split into 10 groups according to BCR at ICU admission and the prevalence of each delirium subtype was compared. Multivariable logistic regression was then used for analysis. A higher BCR at ICU admission was associated with the development of hypoactive delirium. Moreover, BCR > 24.9 was associated with higher rates of hypoactive delirium. Our findings showed that a high BCR at ICU admission was associated with the development of hypoactive delirium, which suggested that BCR could be a potential biomarker for hypoactive delirium in ICU patients.
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Affiliation(s)
- Woo Rhim Park
- Department of Psychiatry, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Hye Rim Kim
- Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul 06273, Korea
| | - Jin Young Park
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul 03722, Korea
- Department of Psychiatry, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin 16995, Korea
| | - Hesun Erin Kim
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Jaehwa Cho
- Department of Pulmonary and Critical Care Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea
| | - Jooyoung Oh
- Department of Psychiatry, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul 03722, Korea
- Correspondence:
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Okamoto S, Ishizawa M, Inoue S, Sakuramoto H. Use of Automated Infrared Pupillometry to Predict Delirium in the Intensive Care Unit: A Prospective Observational Study. SAGE Open Nurs 2022; 8:23779608221124417. [PMID: 36081493 PMCID: PMC9445463 DOI: 10.1177/23779608221124417] [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: 01/12/2022] [Revised: 08/14/2022] [Accepted: 08/21/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Delirium is an acute state of brain dysfunction prevalent among critically ill patients. Disturbances in the sympathetic neurons, including cholinergic neurons, have been reported to cause delirium by upsetting the balance of neurotransmitter synthesis, release, and inactivation. The cholinergic system mediates pupillary constriction as a response to light stimulation, and this reflex can be measured using automated infrared pupillometry (AIP). The relationship between delirium and AIP parameters has been examined. The Confusion Assessment Method for the Intensive Care Unit (CAM ICU) and the Intensive Care Unit Delirium Screening Checklist (ICDSC) are used for assessing delirium. However, that between the ICDSC score and AIP parameters remains unclear. Objective To examine the relationship between AIP parameters and the various categories of delirium as defined by the ICDSC score (delirium, subsyndromal delirium, no delirium). Methods This prospective observational study included patients aged ≥18 years admitted to the intensive care unit (ICU) from May 2018 to September 2018. ICU patients were classified into delirium, subsyndromal delirium, and no delirium groups according to the ICDSC score during ICU stay. The pupillary light reflex was assessed in both eyes immediately after admission using AIP with a portable infrared pupillometer. Logistic regression analyses were used to estimate the odds ratio to examine the relationship between the severity of delirium as assessed by the ICDSC score and the AIP parameters. Results In total 133 patients were included in the study. Based on the ICDSC scores, 41.4% of patients had no delirium, 40.6% had subsyndromal delirium, and 18% had delirium. Dilation velocity (DV) measured by AIP was significantly different among the delirium, subsyndromal delirium, and no delirium groups. Post-hoc comparisons showed that DV was significantly slower in the delirium group than in the no delirium group but was not significantly different between the subsyndromal delirium and no delirium groups. After adjusting for patients’ sex and age at enrollment, DV was shown to be independently associated with delirium. Conclusion This study suggests that the use of AIP at ICU admission may improve the identification of patients at a high risk of developing delirium.
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Affiliation(s)
- Saiko Okamoto
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Ibaraki, Japan
| | - Mihoko Ishizawa
- Department of Adult Health Nursing, College of Nursing, Nara Medical University, Nara, Japan
| | - Satoki Inoue
- Department of Anesthesiology, Fukushima Medical University Hospital, Fukushima, Japan
| | - Hideaki Sakuramoto
- Department of Critical Care and Disaster Nursing, Japanese Red Cross Kyusyu International College of Nursing, Fukuoka, Japan
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Hu XY, Liu H, Zhao X, Sun X, Zhou J, Gao X, Guan HL, Zhou Y, Zhao Q, Han Y, Cao JL. Automated machine learning-based model predicts postoperative delirium using readily extractable perioperative collected electronic data. CNS Neurosci Ther 2021; 28:608-618. [PMID: 34792857 PMCID: PMC8928919 DOI: 10.1111/cns.13758] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 10/13/2021] [Accepted: 10/16/2021] [Indexed: 12/19/2022] Open
Abstract
Objective Postoperative delirium (POD) is a common postoperative complication that is relevant to poor outcomes. Therefore, it is critical to find effective methods to identify patients with high risk of POD rapidly. Creating a fully automated score based on an automated machine‐learning algorithm may be a method to predict the incidence of POD quickly. Materials and methods This is the secondary analysis of an observational study, including 531 surgical patients who underwent general anesthesia. The least absolute shrinkage and selection operator (LASSO) was used to screen essential features associated with POD. Finally, eight features (age, intraoperative blood loss, anesthesia duration, extubation time, intensive care unit [ICU] admission, mini‐mental state examination score [MMSE], Charlson comorbidity index [CCI], postoperative neutrophil‐to‐lymphocyte ratio [NLR]) were used to established models. Four models, logistic regression, random forest, extreme gradient boosted trees, and support vector machines, were built in a training set (70% of participants) and evaluated in the remaining testing sample (30% of participants). Multivariate logistic regression analysis was used to explore independent risk factors for POD further. Results Model 1 (logistic regression model) was found to outperform other classifier models in testing data (area under the curve [AUC] of 80.44%, 95% confidence interval [CI] 72.24%–88.64%) and achieve the lowest Brier Score as well. These variables including age (OR = 1.054, 95%CI: 1.017~1.093), extubation time (OR = 1.027, 95%CI: 1.012~1.044), ICU admission (OR = 2.238, 95%CI: 1.313~3.793), MMSE (OR = 0.929, 95%CI: 0.876~0.984), CCI (OR = 1.197, 95%CI: 1.038~1.384), and postoperative NLR (OR = 1.029, 95%CI: 1.002~1.057) were independent risk factors for POD in this study. Conclusions We have built and validated a high‐performing algorithm to demonstrate the extent to which patient risk changes of POD during the perioperative period, thus leading to a rational therapeutic choice.
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Affiliation(s)
- Xiao-Yi Hu
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Jiangsu Province, Xuzhou City, China.,Jiangsu Province Key Laboratory of Anesthesiology & NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Jiangsu Province, Xuzhou City, China
| | - He Liu
- Department of Anesthesiology, The Affiliated Huzhou Hospital, Zhejiang University School of Medicine, Huzhou Central Hospital, Zhejiang Province, Huzhou City, China
| | - Xue Zhao
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Jiangsu Province, Xuzhou City, China
| | - Xun Sun
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Jiangsu Province, Xuzhou City, China.,Jiangsu Province Key Laboratory of Anesthesiology & NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Jiangsu Province, Xuzhou City, China
| | - Jian Zhou
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Jiangsu Province, Xuzhou City, China.,Jiangsu Province Key Laboratory of Anesthesiology & NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Jiangsu Province, Xuzhou City, China
| | - Xing Gao
- Jiangsu Province Key Laboratory of Anesthesiology & NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Jiangsu Province, Xuzhou City, China.,Department of Anesthesiology, Changzhou First People's Hospital, Changzhou, Jiangsu, China
| | - Hui-Lian Guan
- Jiangsu Province Key Laboratory of Anesthesiology & NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Jiangsu Province, Xuzhou City, China.,Department of Anesthesiology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
| | - Yang Zhou
- Jiangsu Province Key Laboratory of Anesthesiology & NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Jiangsu Province, Xuzhou City, China
| | - Qiu Zhao
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Jiangsu Province, Xuzhou City, China.,Jiangsu Province Key Laboratory of Anesthesiology & NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Jiangsu Province, Xuzhou City, China
| | - Yuan Han
- Department of Anesthesiology, Eye & ENT Hospital of Fudan University, Shanghai, China
| | - Jun-Li Cao
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Jiangsu Province, Xuzhou City, China.,Jiangsu Province Key Laboratory of Anesthesiology & NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Jiangsu Province, Xuzhou City, China
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Duprey MS, Dijkstra-Kersten SMA, Zaal IJ, Briesacher BA, Saczynski JS, Griffith JL, Devlin JW, Slooter AJC. Opioid Use Increases the Risk of Delirium in Critically Ill Adults Independently of Pain. Am J Respir Crit Care Med 2021; 204:566-572. [PMID: 33835902 PMCID: PMC8491270 DOI: 10.1164/rccm.202010-3794oc] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 04/09/2021] [Indexed: 11/16/2022] Open
Abstract
Rationale: It is unclear whether opioid use increases the risk of ICU delirium. Prior studies have not accounted for confounding, including daily severity of illness, pain, and competing events that may preclude delirium detection.Objectives: To evaluate the association between ICU opioid exposure, opioid dose, and delirium occurrence.Methods: In consecutive adults admitted for more than 24 hours to the ICU, daily mental status was classified as awake without delirium, delirium, or unarousable. A first-order Markov model with multinomial logistic regression analysis considered four possible next-day outcomes (i.e., awake without delirium, delirium, unarousable, and ICU discharge or death) and 11 delirium-related covariables (baseline: admission type, age, sex, Acute Physiology and Chronic Health Evaluation IV score, and Charlson comorbidity score; daily: ICU day, modified Sequential Organ Failure Assessment, ventilation use, benzodiazepine use, and severe pain). This model was used to quantify the association between opioid use, opioid dose, and delirium occurrence the next day.Measurements and Main Results: The 4,075 adults had 26,250 ICU days; an opioid was administered on 57.0% (n = 14,975), severe pain occurred on 7.0% (n = 1,829), and delirium occurred on 23.5% (n = 6,176). Severe pain was inversely associated with a transition to delirium (odds ratio [OR] 0.72; 95% confidence interval [CI], 0.53-0.97). Any opioid administration in awake patients without delirium was associated with an increased risk for delirium the next day [OR, 1.45; 95% CI, 1.24-1.69]. Each daily 10-mg intravenous morphine-equivalent dose was associated with a 2.4% increased risk for delirium the next day.Conclusions: The receipt of an opioid in the ICU increases the odds of transitioning to delirium in a dose-dependent fashion.
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Affiliation(s)
| | - Sandra M. A. Dijkstra-Kersten
- Department of Intensive Care Medicine, and
- Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Irene J. Zaal
- Department of Intensive Care Medicine, and
- Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | | | | | - John L. Griffith
- Department of Health Sciences, Bouve College of Health Sciences, Northeastern University, Boston, Massachusetts
| | - John W. Devlin
- Department of Pharmacy and Health Systems Sciences and
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, Massachusetts; and
| | - Arjen J. C. Slooter
- Department of Intensive Care Medicine, and
- Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Neurology, University Ziekenhuis Brussel and Vrije University, Brussels, Belgium
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Rose L, Burry L, Agar M, Blackwood B, Campbell NL, Clarke M, Devlin JW, Lee J, Marshall JC, Needham DM, Siddiqi N, Page V. A core outcome set for studies evaluating interventions to prevent and/or treat delirium for adults requiring an acute care hospital admission: an international key stakeholder informed consensus study. BMC Med 2021; 19:143. [PMID: 34140006 PMCID: PMC8211534 DOI: 10.1186/s12916-021-02015-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 05/21/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Trials of interventions to prevent or treat delirium in adults in an acute hospital setting report heterogeneous outcomes. Our objective was to develop international consensus among key stakeholders for a core outcome set (COS) for future trials of interventions to prevent and/or treat delirium in adults with an acute care hospital admission and not admitted to an intensive care unit. METHODS A rigorous COS development process was used including a systematic review, qualitative interviews, modified Delphi consensus process, and in-person consensus using nominal group technique (registration http://www.comet - initiative.org/studies/details/796 ). Participants in qualitative interviews were delirium survivors or family members. Participants in consensus methods comprised international representatives from three stakeholder groups: researchers, clinicians, and delirium survivors and family members. RESULTS Item generation identified 8 delirium-specific outcomes and 71 other outcomes from 183 studies, and 30 outcomes from 18 qualitative interviews, including 2 that were not extracted from the systematic review. De-duplication of outcomes and formal consensus processes involving 110 experts including researchers (N = 32), clinicians (N = 63), and delirium survivors and family members (N = 15) resulted in a COS comprising 6 outcomes: delirium occurrence and reoccurrence, delirium severity, delirium duration, cognition, emotional distress, and health-related quality of life. Study limitations included exclusion of non-English studies and stakeholders and small representation of delirium survivors/family at the in-person consensus meeting. CONCLUSIONS This COS, endorsed by the American and Australian Delirium Societies and European Delirium Association, is recommended for future clinical trials evaluating delirium prevention or treatment interventions in adults presenting to an acute care hospital and not admitted to an intensive care unit.
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Affiliation(s)
- Louise Rose
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, Rm 1.13, James Clerk Maxwell Building, 57 Waterloo Rd, London, SE1 8WA, UK.
| | - Lisa Burry
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
- Mount Sinai Hospital, Sinai Health System, Toronto, Canada
| | - Meera Agar
- Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute of Experimental Medicine, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Noll L Campbell
- College of Pharmacy, Purdue University, West Lafayette, IN, USA
| | - Mike Clarke
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, Northern Ireland
| | - John W Devlin
- School of Pharmacy, Northeastern University, Boston, MA, USA
| | - Jacques Lee
- Inaugural Research Chair in Geriatric Emergency Medicine, Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, Ontario, Canada
| | - John C Marshall
- St Michael's Hospital and Li Ka Shing Research Institute, Toronto, Canada
| | - Dale M Needham
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Najma Siddiqi
- Hull York Medical School, University of York, York, UK
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Duprey MS, Devlin JW, Skrobik Y. Is there an association between subjective sleep quality and daily delirium occurrence in critically ill adults? A post hoc analysis of a randomised controlled trial. BMJ Open Respir Res 2021; 7:7/1/e000576. [PMID: 32847946 PMCID: PMC7451265 DOI: 10.1136/bmjresp-2020-000576] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 07/27/2020] [Accepted: 07/30/2020] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVES Whether and how delirium and sleep quality in the intensive care unit (ICU) are linked remains unclear. A recent randomised trial reported nocturnal low-dose dexmedetomidine (DEX) significantly reduces incident ICU delirium. Leeds Sleep Evaluation Questionnaire (LSEQ) scores were similar between intervention (DEX; n=50) and control (placebo (PLA); n=50) groups. We measured the association between morning LSEQ and delirium occurrence in the prior 24 hours (retrospective analysis) and the association between morning LSEQ and delirium occurrence in the following 24 hours (predictive analysis). DESIGN Post hoc analysis of randomised controlled trial data. PARTICIPANTS Adult ICU patients (n=100) underwent delirium screening twice a day using the Intensive Care Delirium Screening Checklist (ICDSC) if Richmond Agitation Sedation Scale (RASS) was ≥-3 and patient-reported sleep quality evaluations at 09:00 daily with the LSEQ if RASS was ≥-1. OUTCOMES The analysis included all 24-hour study periods with LSEQ documentation and matched delirium screening in coma-free patients. Separate logistic regression models controlling for age, baseline Acute Physiology and Chronic Health Evaluation II score and DEX/PLA allocation evaluated the association between morning LSEQ and delirium occurrence for both retrospective and predictive analyses. RESULTS The 100 patients spent 1115 24-hour periods in the ICU. Coma, delirium and no delirium occurred in 130 (11.7%), 114 (10.2%) and 871 (78.1%), respectively. In the retrospective analysis, when an LSEQ result was preceded by an ICDSC result (439/985 (44.6%) 24-hour periods), delirium occurred during 41/439 (9.3%) periods. On regression analysis, the LSEQ score had no relationship to prior delirium occurrence (OR (per every 1 point average LSEQ change) 0.97, 95% CI 0.72 to 1.31). For the predictive analysis, among the 387/985 (39.1%) 24-hour periods where an LSEQ result was followed by an ICDSC result, delirium occurred during 56/387 (14.5%) periods. On regression analysis, the LSEQ score did not predict subsequent delirium occurrence (OR (per 1 point LSEQ change) 1.02, 95% CI 0.99 to 1.05). CONCLUSIONS The sleep quality ICU patients perceive neither affects nor predicts delirium occurrence. TRIAL REGISTRATION NUMBER NCT01791296.
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Affiliation(s)
- Matthew S Duprey
- Pharmacy and Health Systems Sciences, Northeastern University, Boston, Massachusetts, USA
| | - John W Devlin
- Pharmacy and Health Systems Sciences, Northeastern University, Boston, Massachusetts, USA
| | - Yoanna Skrobik
- Medicine, McGill University Health Centre, Montreal, Quebec, Canada
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Rose L, Burry L, Blackwood B. Core outcome sets in intensive care–what are they and why do we need them? An example for delirium. Nurs Crit Care 2021; 26:144-146. [DOI: 10.1111/nicc.12627] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 03/26/2021] [Indexed: 12/14/2022]
Affiliation(s)
- Louise Rose
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care King's College London London UK
| | - Lisa Burry
- Department of Pharmacy & Medicine, Sinai Health System, Leslie Dan Faculty of Pharmacy University of Toronto Toronto Canada
| | - Bronagh Blackwood
- Wellcome‐Wolfson Institute for Experimental Research Faculty of Medicine Health and Life Sciences, Queen's University Belfast Belfast UK
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A Core Outcome Set for Research Evaluating Interventions to Prevent and/or Treat Delirium in Critically Ill Adults: An International Consensus Study (Del-COrS). Crit Care Med 2021; 49:1535-1546. [PMID: 33870914 DOI: 10.1097/ccm.0000000000005028] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Delirium in critically ill adults is highly prevalent and has multiple negative consequences. To-date, trials of interventions to prevent or treat delirium report heterogenous outcomes. To develop international consensus among key stakeholders for a core outcome set for future trials of interventions to prevent and/or treat delirium in critically ill adults. DESIGN Core outcome set development, as recommended by the Core Outcome Measures in Effectiveness Trials Handbook. Methods of generating items for the core outcome set included a systematic review and qualitative interviews with ICU survivors and family members. Consensus methods include a two-round web-based Delphi process and a face-to-face meeting using nominal group technique methods. SUBJECTS International representatives from three stakeholder groups: 1) clinical researchers, 2) ICU interprofessional clinicians, and 3) ICU survivors and family members. SETTING Telephone interviews, web-based surveys, and a face-to-face consensus meeting held at the 2019 European Delirium Association's annual meeting in Edinburgh, Scotland. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS Qualitative interviews with 24 ICU survivors and family members identified 36 potential outcomes; six were additional to the 97 identified from the systematic review. After item reduction, 32 outcomes were presented in Delphi Round 1; 179 experts participated, 38 ICU survivors/family members (21%), 100 clinicians (56%), 41 researchers (23%). Three additional outcomes were added to Round 2; 134 Round 1 participants (75%) completed it. Upon conclusion of the consensus building processes, the final core outcome set comprised seven outcomes: delirium occurrence (including prevalence or incidence); delirium severity; time to delirium resolution; health-related quality of life; emotional distress (i.e., anxiety, depression, acute and posttraumatic stress); cognition (including memory); and mortality. CONCLUSIONS This core outcome set, endorsed by the American and Australian Delirium Societies and European Delirium Association, is recommended for future clinical trials evaluating delirium prevention or treatment interventions in critically ill adults.
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Association Between Incident Delirium Treatment With Haloperidol and Mortality in Critically Ill Adults. Crit Care Med 2021; 49:1303-1311. [PMID: 33861548 PMCID: PMC8282692 DOI: 10.1097/ccm.0000000000004976] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Haloperidol is commonly administered in the ICU to reduce the burden of delirium and its related symptoms despite no clear evidence showing haloperidol helps to resolve delirium or improve survival. We evaluated the association between haloperidol, when used to treat incident ICU delirium and its symptoms, and mortality. DESIGN Post hoc cohort analysis of a randomized, double-blind, placebo-controlled, delirium prevention trial. SETTING Fourteen Dutch ICUs between July 2013 and December 2016. PATIENTS One-thousand four-hundred ninety-five critically ill adults free from delirium at ICU admission having an expected ICU stay greater than or equal to 2 days. INTERVENTIONS Patients received preventive haloperidol or placebo for up to 28 days until delirium occurrence, death, or ICU discharge. If delirium occurred, treatment with open-label IV haloperidol 2 mg tid (up to 5 mg tid per delirium symptoms) was administered at clinician discretion. MEASUREMENTS AND MAIN RESULTS Patients were evaluated tid for delirium and coma for 28 days. Time-varying Cox hazards models were constructed for 28-day and 90-day mortality, controlling for study-arm, delirium and coma days, age, Acute Physiology and Chronic Health Evaluation-II score, sepsis, mechanical ventilation, and ICU length of stay. Among the 1,495 patients, 542 (36%) developed delirium within 28 days (median [interquartile range] with delirium 4 d [2-7 d]). A total of 477 of 542 (88%) received treatment haloperidol (2.1 mg [1.0-3.8 mg] daily) for 6 days (3-11 d). Each milligram of treatment haloperidol administered daily was associated with decreased mortality at 28 days (hazard ratio, 0.93; 95% CI, 0.91-0.95) and 90 days (hazard ratio, 0.97; 95% CI, 0.96-0.98). Treatment haloperidol administered later in the ICU course was less protective of death. Results were stable by prevention study-arm, predelirium haloperidol exposure, and haloperidol treatment protocol adherence. CONCLUSIONS Treatment of incident delirium and its symptoms with haloperidol may be associated with a dose-dependent improvement in survival. Future randomized trials need to confirm these results.
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Jin H, Zhang J, Hu Q, Ping J, Jiang T, Du B, Duan X. Naloxone Alleviate the Severity of Delirium in Hospitalized Patients With Parkinsonism: Three Case Reports. Front Psychiatry 2021; 12:748958. [PMID: 34777052 PMCID: PMC8578847 DOI: 10.3389/fpsyt.2021.748958] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 09/29/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose: Delirium is common in geriatric with Parkinson's disease (PD). Treatments for delirium have generally been neuroleptics; however, antipsychotics have potential effect to block striatal dopamine D2 receptors and worsen symptom of parkinsonism. We explored whether naloxone can alleviate delirium in PD and other forms of parkinsonism. Patients and Methods: Patients with parkinsonism who met the delirium criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) received naloxone infusions once or twice daily. Treatment effects were evaluated by the delirium rating scale-revised 98 (DRS-R98), including non-cognitive and cognitive subscales; the Richmond agitation-sedation scale (RASS); and the mini mental status examination (MMSE). Results: Two patients with primary parkinsonism, one with vascular PD were observed. The daily dose of naloxone was 2.08 ± 0.64 mg (range: 1-4 mg). Medication time last from 1 h to 7 days without side effects observed. Following with naloxone infusions, DRS-R98 scores decreased within 12 h and MMSE scores increased. The psychotic symptoms, disorientation, and attention deficits were alleviated significantly, while RASS scores decreased with naloxone treatment. Conclusion: Naloxone alleviated psychotic symptoms, improved cognitive dysfunction, and irritability in patients with delirium in the context of PD. The preliminary findings point out that the opioid system may be involved in the pathophysiology of delirium, which may be one of potential treat targets for delirium of PD.
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Affiliation(s)
- Haiyan Jin
- Department of Psychiatry, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jie Zhang
- Department of Psychiatry, The Third People's Hospital of Zhongshan, Zhongshan, China
| | - Qiongyue Hu
- Department of Psychiatry, Qingdao Mental Health Center, Qingdao University, Qingdao, China
| | - Junjiao Ping
- Department of Psychiatry, The Third People's Hospital of Zhongshan, Zhongshan, China
| | - Tingyun Jiang
- Department of Psychiatry, The Third People's Hospital of Zhongshan, Zhongshan, China
| | - Baoguo Du
- Department of Psychiatry, The Third People's Hospital of Zhongshan, Zhongshan, China
| | - Xin Duan
- Department of Geriatric Psychiatry, Wuzhongpei Memorial Hospital, Foshan, China
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Prevalence and management of delirium in intensive care units in the Netherlands: An observational multicentre study. Intensive Crit Care Nurs 2020; 61:102925. [DOI: 10.1016/j.iccn.2020.102925] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 07/21/2020] [Accepted: 07/26/2020] [Indexed: 01/06/2023]
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Delirium Superimposed on Dementia in Perioperative Period and Intensive Care. J Clin Med 2020; 9:jcm9103279. [PMID: 33066174 PMCID: PMC7601948 DOI: 10.3390/jcm9103279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 09/28/2020] [Accepted: 10/06/2020] [Indexed: 11/30/2022] Open
Abstract
Delirium is a life-threatening condition, the causes of which are still not fully understood. It may develop in patients with pre-existing dementia. Delirium superimposed on dementia (DSD) can go completely unnoticed with routine examination. It may happen in the perioperative period and in the critical care setting, especially in the ageing population. Difficulties in diagnosing and lack of specific pharmacological and non-pharmacological treatment make DSD a seriously growing problem. Patient-oriented, multidirectional preventive measures should be applied to reduce the risk of DSD. For this reason, anesthesiologists and intensive care specialists should be aware of this interesting condition in their everyday clinical practice.
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He R, Wang F, Shen H, Zeng Y, LijuanZhang. Association between increased neutrophil-to-lymphocyte ratio and postoperative delirium in elderly patients with total hip arthroplasty for hip fracture. BMC Psychiatry 2020; 20:496. [PMID: 33028273 PMCID: PMC7539448 DOI: 10.1186/s12888-020-02908-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 09/30/2020] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Delirium is a common complication in elderly patients with total hip arthroplasty (THA) for hip fracture. The mechanism of postoperative delirium (POD) is associated with the neuroinflammatory process. The aim of this study was to the incidence and perioperative risk factors of POD and investigate whether NLR could serve as a potential marker for POD in elderly patients with THA for hip fracture. METHODS This was a multicenter prospective study, we included elderly patients with THA for hip fracture under general anesthesia. Receiver operating characteristic (ROC) curve was performed to identify the optimal cut point of NLR for POD. The relationship between NLR and POD was analyzed by multivariable analysis. RESULTS Seven hundred eighty patients (mean age 73.33 ± 7.66) were eligible for inclusion in the study. 23.33% (182/780) of patients had POD. ROC curve analysis showed that the optimal cut point of NLR for POD was NLR ≥ 3.5. Compared with no POD, higher NLR, older age, diabetes, and higher neutrophil count were more likely in patients with POD(P < 0.05). Multivariate logistic regression analysis showed that NLR ≥ 3.50 [adjusted odds ratio(aOR), 3.93; confidence interval (CI), 2.47-6.25; P < 0.001)], older age (aOR, 1.04; 95%CI, 1.02-1.07; P = 0.001), diabetes (aOR, 1.58; 95% CI, 1.06-2.36; P = 0.025),higher neutrophil count (aOR, 1.25; 95%CI, 1.15-1.35; P < 0.001) were associated with increased risk of POD. CONCLUSIONS Older age, diabetes, higher neutrophil count, and NLR ≥ 3.5 were independent risk factors for POD, and NLR can be used as a potential marker for prediction of delirium in elderly patients with THA for hip fracture.
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Affiliation(s)
- Rui He
- Department of Joint Surgery, The Second People’s Hospital of Chengdu, Chengdu, 610021 People’s Republic of China
| | - Fei Wang
- Department of Joint Surgery, The Third People’s Hospital of Chengdu, Chengdu, 610000 People’s Republic of China
| | - Huarui Shen
- Department of Joint Surgery, Affiliated Traditional Chinese Medical Hospital of Southwest Medical University of Sichuan Province, Luzhou, 646000 People’s Republic of China
| | - Yong Zeng
- Department of Joint Surgery, The Second People’s Hospital of Chengdu, Chengdu, 610021 People’s Republic of China
| | - LijuanZhang
- Department of Neurology, The Second Affiliated Hospital of Chengdu College, Nuclear Industry 416 Hospital, Chengdu, 610051 People’s Republic of China
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Vondeling AM, Knol W, Egberts TCG, Slooter AJC. Anticholinergic drug exposure at intensive care unit admission affects the occurrence of delirium. A prospective cohort study. Eur J Intern Med 2020; 78:121-126. [PMID: 32487370 DOI: 10.1016/j.ejim.2020.04.062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 04/09/2020] [Accepted: 04/29/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Anticholinergic drugs may increase the risk of delirium in non-critically ill patients, but it is unclear whether exposure to these drugs is also a risk factor for Intensive Care Unit (ICU) delirium. In this study the hypothesis was tested that anticholinergic drug exposure at ICU admission increases the risk to develop delirium during ICU stay, particularly in patients with advanced age and severe sepsis. METHODS A prospective cohort study was performed in the mixed 32-bed medical-surgical ICU of the University Medical Center Utrecht, the Netherlands in the period from January 2011 till June 2013. Included were nonneurological patients that were consecutively admitted for more than 24 hours. The presence of delirium was evaluated each day using a validated algorithm based on the Confusion Assessment Method for the ICU (CAM-ICU), the initiation of delirium treatment as well as chart review by researchers. Anticholinergic drug exposure at ICU admission was assessed using the Anticholinergic Drug Scale (ADS). To evaluate the association between anticholinergic drug exposure at ICU admission and the risk of developing delirium, we performed multivariable competing risk Cox proportional hazard analysis corrected for confounding factors. RESULTS Approximately half (47%, n=513) of the 1090 included patients developed delirium during ICU admission. The absolute risk for delirium development increased with more anticholinergic drug exposure: 42% in patients with ADS score=0, 49% in patients with ADS score=1, and 53% in patients with ADS higher than 1. Taking competing events (death and discharge) and potential confounding factors into account, the subdistribution hazard ratio (SHR) was 1.13 (95% CI: 0.91-1.40) for ADS score=1 point and 1.35 (95% CI: 1.09-1.68) for ADS ≥2 compared with an ADS score=0 (no anticholinergic drug exposure). The effect was strongest during the first days of ICU admittance and was strongest in patients above 65 year without severe sepsis and/or septic shock (SHR 2.15, 95% CI 1.43-3.25). CONCLUSIONS Anticholinergic drug exposure at ICU admission increases the risk of delirium in critically ill patients. This effect was most pronounced in patients older than 65 years without severe sepsis and/or septic shock, and declining over time.
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Affiliation(s)
- Ariël M Vondeling
- Department of Geriatric Medicine, Diakonessenhuis Utrecht, the Netherlands; Department of Geriatric Medicine and Expertise Centre Pharmacotherapy in Old Persons (EPHOR), University Medical Centre Utrecht, Utrecht University, the Netherlands.
| | - Wilma Knol
- Department of Geriatric Medicine and Expertise Centre Pharmacotherapy in Old Persons (EPHOR), University Medical Centre Utrecht, Utrecht University, the Netherlands.
| | - Toine C G Egberts
- Department of Clinical Pharmacy, University Medical Center Utrecht & Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands.
| | - Arjen J C Slooter
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
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Voils SA, Shoulders BR, Singh S, Solberg LM, Garrett TJ, Frye RF. Intensive Care Unit Delirium in Surgical Patients Is Associated with Upregulation in Tryptophan Metabolism. Pharmacotherapy 2020; 40:500-506. [PMID: 32246498 DOI: 10.1002/phar.2392] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 03/16/2020] [Accepted: 03/17/2020] [Indexed: 11/06/2022]
Abstract
INTRODUCTION In intensive care unit (ICU) patients, delirium is frequent, occurs early in ICU admission, and is associated with poor outcomes. Risk models based on clinical factors have shown variable performance in terms of predictive ability. Identification of a candidate biomarker that associates with delirium may lead to a better understanding of disease mechanism, validation biomarker studies, and the ability to develop targeted interventions for prevention and treatment of delirium. This study analyzed metabolite concentrations early in the course of ICU admission to assess the association with delirium onset. METHODS Within 24 hours of ICU admission, blood samples for global and targeted metabolomics analyses in adult surgical ICU patients were collected prospectively. Metabolites were determined using mass spectrometry/ultra-high-pressure liquid chromatography and analyzed in patients with delirium and a group of controls matched on age, sex, and admission Sequential Organ Function Assessment (SOFA) score. RESULTS Patients in the study (65 per group) were a mean age of 59 years, had a median SOFA score of 6, and were most commonly admitted to the ICU following major trauma. In the delirium group, median onset of delirium was 3 (interquartile range 1-6) days, and the most common delirium subtype was mixed (56%). Kynurenic acid was significantly increased, and tryptophan concentration was significantly decreased in the delirium group (p=0.04). The ratio of kynurenine-to-tryptophan concentration was significantly higher in the delirium group (p=0.005). CONCLUSIONS Evidence of upregulation was found in the tryptophan metabolic pathway in delirious patients because tryptophan concentrations were lower, tryptophan metabolites were higher, and the kynurenine-to-tryptophan ratio was increased. These findings suggest a role of increased inflammation and accumulation of neurotoxic metabolites in the pathogenesis of ICU delirium. Future studies should target this pathway to validate metabolites in the tryptophan pathway as risk biomarkers in patients with ICU delirium.
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Affiliation(s)
- Stacy A Voils
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, Florida
| | - Bethany R Shoulders
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, Florida
| | - Sonal Singh
- Molecular Genetics - Early Target Discovery, Takeda Pharmaceuticals, San Diego, California
| | - Laurence M Solberg
- Geriatric Research, Education, and Clinical Center (GRECC), North Florida South Georgia Veterans Health System, Gainesville, Florida
| | - Timothy J Garrett
- Department of Pathology, Immunology, and Laboratory Medicine, Southeast Center for Integrated Metabolomics, Core 1 PI: Mass Spectrometry Services, University of Florida, Gainesville, Florida
| | - Reginald F Frye
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, Florida
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Duprey MS, van den Boogaard M, van der Hoeven JG, Pickkers P, Briesacher BA, Saczynski JS, Griffith JL, Devlin JW. Association between incident delirium and 28- and 90-day mortality in critically ill adults: a secondary analysis. Crit Care 2020; 24:161. [PMID: 32312288 PMCID: PMC7171767 DOI: 10.1186/s13054-020-02879-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 04/06/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND While delirium prevalence and duration are each associated with increased 30-day, 6-month, and 1-year mortality, the association between incident ICU delirium and mortality remains unclear. We evaluated the association between both incident ICU delirium and days spent with delirium in the 28 days after ICU admission and mortality within 28 and 90 days. METHODS Secondary cohort analysis of a randomized, double-blind, placebo-controlled trial conducted among 1495 delirium-free, critically ill adults in 14 Dutch ICUs with an expected ICU stay ≥2 days where all delirium assessments were completed. In the 28 days after ICU admission, patients were evaluated for delirium and coma 3x daily; each day was coded as a delirium day [≥1 positive Confusion Assessment Method for the ICU (CAM-ICU)], a coma day [no delirium and ≥ 1 Richmond Agitation Sedation Scale (RASS) score ≤ - 4], or neither. Four Cox-regression models were constructed for 28-day mortality and 90-day mortality; each accounted for potential confounders (i.e., age, APACHE-II score, sepsis, use of mechanical ventilation, ICU length of stay, and haloperidol dose) and: 1) delirium occurrence, 2) days spent with delirium, 3) days spent in coma, and 4) days spent with delirium and/or coma. RESULTS Among the 1495 patients, 28 day mortality was 17% and 90 day mortality was 21%. Neither incident delirium (28 day mortality hazard ratio [HR] = 1.02, 95%CI = 0.75-1.39; 90 day mortality HR = 1.05, 95%CI = 0.79-1.38) nor days spent with delirium (28 day mortality HR = 1.00, 95%CI = 0.95-1.05; 90 day mortality HR = 1.02, 95%CI = 0.98-1.07) were significantly associated with mortality. However, both days spent with coma (28 day mortality HR = 1.05, 95%CI = 1.02-1.08; 90 day mortality HR = 1.05, 95%CI = 1.02-1.08) and days spent with delirium or coma (28 day mortality HR = 1.03, 95%CI = 1.00-1.05; 90 day mortality HR = 1.03, 95%CI = 1.01-1.06) were significantly associated with mortality. CONCLUSIONS This analysis suggests neither incident delirium nor days spent with delirium are associated with short-term mortality after ICU admission. TRIAL REGISTRATION ClinicalTrials.gov, Identifier NCT01785290 Registered 7 February 2013.
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Affiliation(s)
- Matthew S Duprey
- Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, 360 Huntington Ave, Boston, MA, 02115, USA
| | - Mark van den Boogaard
- Department of Intensive Care, Radboud Institute for Health Sciences, Radboud University Medical Center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands
| | - Johannes G van der Hoeven
- Department of Intensive Care, Radboud Institute for Health Sciences, Radboud University Medical Center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands
| | - Peter Pickkers
- Department of Intensive Care, Radboud Institute for Health Sciences, Radboud University Medical Center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands
| | - Becky A Briesacher
- Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, 360 Huntington Ave, Boston, MA, 02115, USA
| | - Jane S Saczynski
- Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, 360 Huntington Ave, Boston, MA, 02115, USA
| | - John L Griffith
- Department of Health Sciences, Bouve College of Health Sciences, Northeastern University, 360 Huntington Ave, Boston, MA, 02115, USA
| | - John W Devlin
- Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, 360 Huntington Ave, Boston, MA, 02115, USA.
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Rose L, Agar M, Burry L, Campbell N, Clarke M, Lee J, Marshall J, Siddiqi N, Page V. Reporting of Outcomes and Outcome Measures in Studies of Interventions to Prevent and/or Treat Delirium in the Critically Ill: A Systematic Review. Crit Care Med 2020; 48:e316-e324. [PMID: 32205622 DOI: 10.1097/ccm.0000000000004238] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES To inform development of a core outcome set, we evaluated the scope and variability of outcomes, definitions, measures, and measurement time-points in published clinical trials of pharmacologic or nonpharmacologic interventions, including quality improvement projects, to prevent and/or treat delirium in the critically ill. DATA SOURCES We searched electronic databases, systematic review repositories, and trial registries (1980 to March 2019). STUDY SELECTION AND DATA EXTRACTION We included randomized, quasi-randomized, and nonrandomized intervention studies of pharmacologic and nonpharmacologic interventions. We extracted data on study characteristics, verbatim descriptions of study outcomes, and measurement characteristics. We assessed quality of outcome reporting using the Management of Otitis Media with Effusion in Children with Cleft Palate study scoring system; risk of bias and study quality using the Cochrane tool and Scottish Intercollegiate Guidelines Network checklists. We categorized reported outcomes using Core Outcome Measures in Effectiveness Trials taxonomy. DATA SYNTHESIS From 195 studies (1/195 pediatric) recruiting 74,632 participants and reporting a mean (SD) of 10 (6.2) outcome domains, we identified 12 delirium-specific outcome domains. Delirium incidence (147, 75% of studies), duration (67, 34%), and antipsychotic use (42, 22%) were most commonly reported. We identified a further 94 non-delirium-specific outcome domains within 19 Core Outcome Measures in Effectiveness Trials taxonomy categories. For both delirium-specific and nonspecific outcome domains, we found multiple outcomes in domains due to differing descriptions and time-points. The Confusion Assessment Method-ICU with Richmond Agitation-Sedation Scale to assess sedation was the most common measure used to ascertain delirium (51, 35%). Measurement generally began at randomization or ICU admission, and lasted from 1 to 30 days, ICU/hospital discharge. Frequency of measurement was highly variable with daily measurement and greater than daily measurement reported for 36% and 37% of studies, respectively. CONCLUSIONS We identified substantial heterogeneity and multiplicity of outcome selection and measurement in published studies. These data will inform the consensus building stage of a core outcome set to inform delirium research in the critically ill.
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Affiliation(s)
- Louise Rose
- Department of Critical Care Medicine, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, United Kingdom
| | - Meera Agar
- Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Lisa Burry
- Department of Pharmacy, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Mount Sinai Hospital, Sinai Health System, Toronto, ON, Canada
| | - Noll Campbell
- College of Pharmacy, Indiana University-Purdue University, Indianapolis, IN
| | - Mike Clarke
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, Northern Ireland
| | - Jacques Lee
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - John Marshall
- St Michael's Hospital and Li Ka Shing Research Institute, Toronto, ON, Canada
| | - Najma Siddiqi
- School of Medicine, York University, York, United Kingdom
| | - Valerie Page
- Intensive Care Unit, Watford General Hospital, Watford, United Kingdom
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Pozzi C, Tatzer VC, Álvarez EA, Lanzoni A, Graff MJL. The applicability and feasibility of occupational therapy in delirium care. Eur Geriatr Med 2020; 11:209-216. [DOI: 10.1007/s41999-020-00308-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 03/07/2020] [Indexed: 01/20/2023]
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Dopaminergic Hyperactivity in Neurological Patients with Delirium. Arch Med Res 2020; 50:477-483. [PMID: 32018069 DOI: 10.1016/j.arcmed.2019.11.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 10/23/2019] [Accepted: 11/12/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Delirium has important etiological, prognostic, and therapeutic implications. The study of neurochemical markers in this condition is relevant to the understanding of its pathophysiology. The assessment of the dopamine system is particularly relevant, as dopamine antagonists are the most used drugs in delirium. AIM To analyze neurotransmission markers in patients with delirium, focusing in the dopamine metabolite, homovanillic acid. METHODS A case-control study was performed at the National Institute of Neurology and Neurosurgery, Mexico, including hospitalized patients in which lumbar puncture was obtained for diagnostic purposes. Cases were selected if they fulfilled DSM-5 criteria for delirium. Age-paired controls were patients in which delirium was ruled out, selected at the same clinical scenario, during the same period. Neurological and systemic diagnoses were registered. Delirium was assessed using the DRS-98-R instrument. The dopamine metabolite, homovanillic acid (HVA), was measured by means of high-performance liquid chromatography. Other neurotransmission markers were also measured (5-hydroxyindoleacetic acid, glutamate, aspartate, GABA, glycine, arginine, citrulline, nitrites, and nitrates). A logistic regression model was used to determine pathogenic factors associated with the presence of delirium. RESULTS 68 neurological patients with delirium and 68 patients without delirium were included. Higher homovanillic acid levels in cerebrospinal fluid were significantly associated with delirium. This result was significant after a subanalysis in patients without exposure to antipsychotics. Male gender and autoimmune limbic encephalitis were also associated with the presence of delirium. CONCLUSIONS In hospitalized neurological patients, dopaminergic hyperactivity and autoimmune limbic encephalitis are pathogenic factors associated with the presence of delirium.
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The Design and validation of a Nursing Plan for Elderly Patients with Postoperative Delirium. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16224504. [PMID: 31731593 PMCID: PMC6888289 DOI: 10.3390/ijerph16224504] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 11/07/2019] [Accepted: 11/12/2019] [Indexed: 11/17/2022]
Abstract
Delirium is the sudden alteration of the state of consciousness and perception, fluctuating over hours or days. It predominates in older adults and is associated with the aging process. The incidence of delirium increases between 10% and 15% in surgical interventions. The objective of this study was the design and validation of a nursing care plan for elderly patients with postoperative delirium. This study was based on the Delphi method and applied to nursing professionals at the Hospital Universitario del Caribe, Cartagena. The sample consisted of 36 nurses with knowledge of the taxonomy of nursing diagnoses. The care plan was applied in two rounds. For the analysis, measures of central tendency and dispersion were used, as well as frequency and percentages. The participants were women (90.9%) from the hospitalization service (51.5%), with training in Nursing Diagnosis (NANDA), Nursing interventions classification (NIC) and Nursing Outcome Classifications (NOC) (78.8%). The validated care plan has eight diagnostic features. Highlights include “Risk for Ineffective Cerebral Tissue Perfusion” and “Disturbed Sleep Pattern” (in 98.1%; 11 results), with the highest score in the first round being “Vital Signs” (with 100%) and “Sleep” (100%) and “Mobility” (100%) in the second round. Forty-four interventions and 18 suggested activities were identified. This care plan offers the nursing professionals reliable and pertinent tools in clinical practice for the management of patients with postoperative delirium.
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Kotfis K, Bott-Olejnik M, Szylińska A, Listewnik M, Rotter I. Characteristics, Risk Factors And Outcome Of Early-Onset Delirium In Elderly Patients With First Ever Acute Ischemic Stroke - A Prospective Observational Cohort Study. Clin Interv Aging 2019; 14:1771-1782. [PMID: 31695347 PMCID: PMC6814355 DOI: 10.2147/cia.s227755] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 09/20/2019] [Indexed: 12/21/2022] Open
Abstract
Introduction Post-stroke delirium is a common clinical problem, occurring in 10% to 48% of patients. It has been associated with longer hospitalization times, increased mortality and worse functional outcome. In early phase of stroke, it may be regarded as particularly difficult to differentiate from other neurological symptoms. For practical purposes, there is a need to identify simple pre-operative laboratory parameters that may aid delirium diagnosis early after stroke. Our aim was to identify the incidence of early-onset (first 24 hrs) post-stroke delirium, its risk factors and outcomes (complications and mortality) in patients with first-ever acute ischemic stroke (AIS). Material and methods A retrospective analysis of a prospective observational study (NCT03944694) was performed. Patients were screened for delirium using CAM-ICU method. Clinical and laboratory data were collected, including baseline inflammatory parameters. Results Final analysis included 760 patients, 121 (15.9%) developed delirium. Patients with delirium were older (75.9±13.5 years, p<0.001). Most common complications in the delirium group were pulmonary (57.8% vs 21.4%, p<0.001), cardiac (38.8% vs 13.6%, p<0.001) and renal (13.2% vs 7.5%, p=0.038). Neutrophil-to-lymphocyte ratio (NLR) (6.71±9.65 vs 4.55±5.51, p<0.001), C-reactive protein level (32.59±65.94 vs 15.70±38.56, p<0.001) and troponin T level (72.59±180.15 vs 26.85±77.62, p<0.001) were higher in delirious patients and platelet-to white blood cell count ratio (PWR) (23.42±9.51 vs 27.13±10.58, p<0.001) was lower. Multivariable logistic regression showed that atrial fibrillation (OR 1.651, p=0.049), higher Rankin score on admission (OR 1.689, p<0.001), hemianopia (OR 2.422, p=0.003) and PWR <20.22 (OR 2.197, p=0.002) were independently associated with delirium. Kaplan–Meier curves indicated that mortality increased for patients with delirium at 3 months (p<0.001) and 1 year (p<0.001) after AIS. Conclusion Atrial fibrillation, higher Rankin score, hemianopia and lower PWR were independently associated with early onset delirium in patients with first ever AIS. This confirms that deprivation of senses and early generalized inflammatory response are critical for delirium development.
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Affiliation(s)
- Katarzyna Kotfis
- Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, Szczecin 70-204, Poland
| | - Marta Bott-Olejnik
- Neurology Department of a Regional Specialist Hospital in Gryfice, Gryfice 72-300, Poland
| | - Aleksandra Szylińska
- Department of Medical Rehabilitation and Clinical Physiotherapy, Pomeranian Medical University, Szczecin 70-204, Poland
| | - Mariusz Listewnik
- Department of Cardiac Surgery, Pomeranian Medical University, Szczecin 70-204, Poland
| | - Iwona Rotter
- Department of Medical Rehabilitation and Clinical Physiotherapy, Pomeranian Medical University, Szczecin 70-204, Poland
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Could Neutrophil-to-Lymphocyte Ratio (NLR) Serve as a Potential Marker for Delirium Prediction in Patients with Acute Ischemic Stroke? A Prospective Observational Study. J Clin Med 2019; 8:jcm8071075. [PMID: 31336587 PMCID: PMC6679160 DOI: 10.3390/jcm8071075] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Revised: 07/18/2019] [Accepted: 07/19/2019] [Indexed: 01/26/2023] Open
Abstract
Delirium is an acute brain disorder that commonly occurs in patients with acute ischemic stroke (AIS). Pathomechanism of delirium is related to the neuroinflammatory process and oxidative stress. Search for readily available diagnostic marker that will aid clinicians in early identification of delirium is ongoing. The aim of this study was to investigate whether neutrophil-to-lymphocyte ratio (NLR) could serve as a potential marker for delirium prediction in patients with AIS and to find an easy diagnostic tool using laboratory and clinical parameters to predict delirium. Prospective observational study (NCT03944694) included patients with AIS admitted to the neurology department of a district general hospital. All patients were screened for delirium using CAM-ICU (Confusion Assessment Method for Intensive Care Unit). Demographic and medical history data and admission lab results, including differential white blood cell analysis, were collected from all patients. We included 1001 patients in the final analysis. The mean age of the sample was 71 years, and 52% of patients were males. The incidence of early-onset delirium was 17.2%. The NLR was elevated in delirious patients (6.39 ± 8.60 vs. 4.61 ± 5.61, p < 0.001). The best cut-off value of NLR to predict delirium using the receiver operating characteristics (ROC) was determined at 4.86. Multivariable logistic regression analysis showed that the odds ratio (OR) for developing delirium with NLR > 4.86 (adjusted for age, sex, body mass index (BMI), comorbidities, and baseline neurology) was 1.875 (95% CI 1.314-2.675, p = 0.001). As a result of different combinations of markers and clinical parameters based on logistic regression, a formula-DELirium in Acute Ischemic Stroke (DELIAS score)-was obtained with the area under the ROC curve of 0.801 (p < 0.001). After regression of the cut-off points of the obtained curve, a significant correlation of the DELIAS score was observed with the occurrence of early-onset delirium (OR = 8.976, p < 0.001) and with delirium until the fifth day after AIS (OR = 7.744, p < 0.001). In conclusion, NLR can be regarded as a potential marker for prediction of early-onset delirium after AIS. On the basis of combined laboratory and clinical parameters, the DELIAS score was calculated, which gave the highest predictive value for delirium in the analyzed group of patients after ischemic stroke. However, further studies are needed to validate these findings.
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The Evidence Clash Between Statins and Delirium: Should They Stay, Should They Go, or Should They Be Started? Crit Care Med 2019; 45:1574-1576. [PMID: 28816845 DOI: 10.1097/ccm.0000000000002559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kishk OA, Simone S, Lardieri AB, Graciano AL, Tumulty J, Edwards S. Antipsychotic Treatment of Delirium in Critically Ill Children: A Retrospective Matched Cohort Study. J Pediatr Pharmacol Ther 2019; 24:204-213. [PMID: 31093019 PMCID: PMC6510524 DOI: 10.5863/1551-6776-24.3.204] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To describe the use of pharmacologic treatment in critically ill children treated according to a delirium protocol and compare those treated with antipsychotics to those treated non-pharmacologically. METHODS> The study included a retrospective matched cohort describing patients who were pharmacologically treated for delirium compared to those with delirium but not treated in a PICU from December 2013 to September 2015, using a delirium management protocol. Patients were matched by age, sex, diagnosis, mechanical ventilation (MV), and presence of delirium. RESULTS Of 1875 patients screened, 188 (10.03%) were positive for delirium. Of those, 15 patients (8%) were treated with an antipsychotic for delirium. Patients with delirium treated with antipsychotics were younger, had more delirium days (6 vs. 3, p=0.022), longer MV days (14 vs. 7, p=0.017), and longer PICU length of stay (34 vs. 16 days, p=0.029) than in the untreated group. Haloperidol, risperidone, and quetiapine were used in 9, 6, and 2 patients, respectively. Two patients were treated with multiple antipsychotics. Antipsychotic treatment was initiated on day 2 of delirium for 8 of 15 patients (53.3%). Ten patients in the treatment group had improved delirium scores by day 2 of treatment. No significant differences in sedation exposure between groups. No significant adverse effects were reported. CONCLUSIONS No significant adverse events seen in this small cohort of critically ill pediatric patients with delirium treated with antipsychotic therapy. Patients with early-onset delirium refractory to non-pharmacologic treatment may have a more effective response to antipsychotic therapy than patients with late-onset refractory delirium.
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Maagaard M, Barbateskovic M, Perner A, Jakobsen JC, Wetterslev J. Dexmedetomidine for the prevention of delirium in critically ill patients - A protocol for a systematic review. Acta Anaesthesiol Scand 2019; 63:540-548. [PMID: 30671925 DOI: 10.1111/aas.13313] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 11/20/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND Delirium is a common complication in critically ill patients and carries an increased risk of mortality and morbidity. Dexmedetomidine can potentially prevent delirium by diminishing predisposing factors. The evidence regarding the use of dexmedetomidine in preventing delirium is conflicting. This protocol aims to identify the beneficial and harmful effects of dexmedetomidine in the prevention of delirium. METHODS This protocol uses the recommendations of the Cochrane Collaboration, the Preferred Report Items of Systematic Reviews with Meta-Analysis Protocols, and the eight-step assessment procedure suggested by Jakobsen and colleagues. We wish to assess in critically ill patients, if dexmedetomidine versus placebo can reduce the incidence of delirium and improve clinical outcomes. We will include all randomised trials assessing the use of dexmedetomidine in the prevention of delirium. To identify trials, we will search the Cochrane Central Register of Controlled Trials, Medical Literature Analysis and Retrieval System Online, Excerpta Medica database, Latin American and Caribbean Health Sciences Literature, Science Citation Index Expanded on Web of Science, Chinese Biomedical Literature Database, China National Knowledge Infrastructure, Chinese Science Journal Database, and BIOSIS. Two authors will screen the literature and extract data. We will use the Cochrane risk of bias tool to evaluate trials. Extracted data will be analysed using Review Manager 5 and Trial Sequential Analysis. We will create a "Summary of Findings"-table in which we will present our primary and secondary outcomes. We will assess the quality of evidence using GRADE. DISCUSSION This systematic review can potentially aid clinicians in decision-making and benefit the many critically ill patients at risk of delirium.
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Affiliation(s)
- Mathias Maagaard
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Marija Barbateskovic
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Anders Perner
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Intensive Care, Department 4131, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Janus Christian Jakobsen
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Cardiology, Holbaek Hospital, Holbaek, Denmark
| | - Jørn Wetterslev
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Maagaard M, Barbateskovic M, Perner A, Jakobsen JC, Wetterslev J. Dexmedetomidine for the management of delirium in critically ill patients-A protocol for a systematic review. Acta Anaesthesiol Scand 2019; 63:549-557. [PMID: 30701537 DOI: 10.1111/aas.13329] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 12/12/2018] [Accepted: 12/29/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Delirium is a common complication in critically ill patients and carries an increased risk of mortality and morbidity. Dexmedetomidine can potentially treat delirium by diminishing predisposing factors. The evidence regarding the use of dexmedetomidine in the management of delirium is conflicting. This protocol aims to identify the beneficial and harmful effects of dexmedetomidine in the management of delirium. METHODS This protocol uses the recommendations of the Cochrane Collaboration, the Preferred Report Items of Systematic reviews with Meta-Analysis Protocols, and the eight-step assessment procedure suggested by Jakobsen and colleagues. We wish to assess in critically ill patients with delirium, if dexmedetomidine vs placebo is effective in managing delirium and improving clinical outcomes. We will include all relevant randomised clinical trials assessing the use of dexmedetomidine in treating delirium. To identify trials, we will search the Cochrane Central Register of Controlled Trials, Medical Literature Analysis and Retrieval System Online, Excerpta Medica database, Latin American and Caribbean Health Sciences Literature, Science Citation Index Expanded on Web of Science, Chinese Biomedical Literature Database, China National Knowledge Infrastructure, Chinese Science Journal Database, and BIOSIS. Two authors will screen the literature and extract data. The Cochrane risk of bias tool will be used to evaluate included trials. Extracted data will be analysed using Review Manager 5 and Trial Sequential Analysis. We will create a 'Summary of Findings'-table in which we will present our primary and secondary outcomes. We will assess the quality of evidence using GRADE assessment. DISCUSSION This systematic review can potentially aid clinicians in decision making and benefit the many critically ill patients developing delirium.
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Affiliation(s)
- Mathias Maagaard
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Marija Barbateskovic
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Anders Perner
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Intensive Care, Department 4131, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Janus C Jakobsen
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Cardiology, Holbaek Hospital, Holbaek, Denmark
| | - Jørn Wetterslev
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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The Benefits of Implementing an Early Mobility Protocol in Postoperative Neurosurgical Spine Patients. Am J Nurs 2019; 118:46-53. [PMID: 29794923 DOI: 10.1097/01.naj.0000534851.58255.41] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
: Background: Despite the known benefits of early postsurgical mobility, there are no clear recommendations on early mobility among uncomplicated postoperative neurosurgical spine patients. PURPOSE The purpose of this quality improvement initiative was to establish an NP-led early mobility protocol to reduce uncomplicated postsurgical spine patients' length of stay (LOS) in the hospital and eliminate the variability of postsurgical care. A secondary objective was to educate and empower nursing staff to initiate the early mobility protocol independently and incorporate it in their practice to improve patient care. METHODS Two neurosurgery NPs led an interprofessional team to develop the early mobility protocol. Team members provided preadmission preoperative education to communicate the necessity for early mobility and provide information about the protocol. New nursing guidelines called for patient mobility on the day of surgery, within six hours of arrival on the medical-surgical unit. Nurses were empowered to get patients out of bed independently, without a physical therapy consultation; they also removed urinary catheters and discontinued IV opioids when patients' status permitted. RESULTS Over a one-year period, implementation of the protocol resulted in a nine-hour reduction in LOS per hospitalization in neurosurgical spine patients who underwent lumbar laminectomies. The protocol also allowed nurses more autonomy in patient care and was a catalyst for patient involvement in their postoperative mobility. Given the success of the protocol, it is being replicated by other surgical services throughout the organization. CONCLUSIONS This low-cost, high-reward initiative aligns with the strategic plan of the organization and ensures that high-quality, patient-centered care remains the priority. NPs in other institutions can modify this protocol to promote postoperative mobility in their organizations.
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Cunningham ME, Vogel AM. Analgesia, sedation, and delirium in pediatric surgical critical care. Semin Pediatr Surg 2019; 28:33-42. [PMID: 30824132 DOI: 10.1053/j.sempedsurg.2019.01.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The alleviation of discomfort and distress is an essential component of the management of critically ill surgical patients. Pain and anxiety have multifocal etiologies that may be related to an underlying disease or surgical procedure, ongoing medical therapy, invasive monitors, an unfamiliar, complex and chaotic environment, as well as fear. Pharmacologic and non-pharmacologic therapies have complex risk benefit profiles. A fundamental understanding of analgesia, sedation, and delirium is essential for optimizing important outcomes in critically ill pediatric surgical patients. There has been a recent emphasis on goal directed, evidence based, and patient-centered management of the physical and psychological needs of these children. The purpose of this article is to review and summarize recent advances and describe current practice of these important subjects in the pediatric surgical intensive care environment.
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Affiliation(s)
- Megan E Cunningham
- Texas Children's Hospital, Division of Pediatric Surgery, Department of Surgery, 6701 Fannin Street, Houston, TX 77030, USA.
| | - Adam M Vogel
- Texas Children's Hospital, Division of Pediatric Surgery, Department of Surgery, 6701 Fannin Street, Houston, TX 77030, USA; Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA.
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Papathanassoglou EDE, Skrobik Y, Hegadoren K, Thompson P, Stelfox HT, Norris C, Rose L, Bagshaw SM, Meier M, LoCicero C, Ashmore R, Sparrow Brulotte T, Hassan I, Park T, Kutsogiannis DJ. Relaxation for Critically ill Patient Outcomes and Stress-coping Enhancement (REPOSE): a protocol for a pilot randomised trial of an integrative intervention to improve critically ill patients' delirium and related outcomes. BMJ Open 2019; 9:e023961. [PMID: 30782719 PMCID: PMC6340454 DOI: 10.1136/bmjopen-2018-023961] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Delirium is a common complication of critical illness, associated with negative patient outcomes. Preventive or therapeutic interventions are mostly ineffective. Although relaxation-inducing approaches may benefit critically ill patients, no well-designed studies target delirium prevention as a primary outcome. The objective of this study is to assess feasibility and treatment effect estimates of a multimodal integrative intervention incorporating relaxation, guided imagery and moderate pressure touch massage for prevention of critical illness delirium and for related outcomes. METHODS AND ANALYSIS Randomised, controlled, single-blinded trial with two parallel groups (1:1 allocation: intervention and standard care) and stratified randomisation (age (18-64 years and ≥65 years) and presence of trauma) with blocking, involving 104 patients with Intensive Care Delirium Screening Checklist (ICDSC): 0-3 recruited from two academic intensive care units (ICUs). Intervention group participants receive the intervention in addition to standard care for up to five consecutive days (or until transfer/discharge); control group participants receive standard care and a sham intervention. We will assess predefined feasibility outcomes, that is, recruitment rates and protocol adherence. The primary clinical outcome is incidence of delirium (ICDSC ≥4). Secondary outcomes include pain scores, inflammatory biomarkers, heart rate variability, stress and quality of life (6 weeks and 4 months) post-ICU discharge. Feasibility measures will be analysed descriptively, and outcomes will be analysed longitudinally. Estimates of effects will be calculated. ETHICS AND DISSEMINATION The study has received approval from the Human Research Ethics Board, University of Alberta. Results will inform the design of a future multicentre trial. TRIAL REGISTRATION NUMBER NCT02905812; Pre-results.
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Affiliation(s)
| | - Yoanna Skrobik
- Department of Medicine, Regroupement de Soins Critiques Respiratoires, FRQS, McGill University, Montreal, Quebec, Canada
| | | | - Patrica Thompson
- Critical Care Research Group, Royal Alexandra Hospital, Edmonton, AB, Canada
| | | | - Colleen Norris
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Louise Rose
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- King's College London, London, UK
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- General Systems ICU, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Michael Meier
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- General Systems ICU, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Cheryl LoCicero
- Registered Massage Therapist (RMT), Certified Advanced Rolfer, Vancouver, Canada
| | - Rhonda Ashmore
- Registered Massage Therapist (RMT), PT, Hamilton, Ontario, Canada
| | | | - Imran Hassan
- EPICORE Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Tanya Park
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Demetrios J Kutsogiannis
- Critical Care Research Group, Royal Alexandra Hospital, Edmonton, AB, Canada
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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Kotfis K, Szylińska A, Listewnik M, Brykczyński M, Ely EW, Rotter I. Diabetes and elevated preoperative HbA1c level as risk factors for postoperative delirium after cardiac surgery: an observational cohort study. Neuropsychiatr Dis Treat 2019; 15:511-521. [PMID: 30863073 PMCID: PMC6388975 DOI: 10.2147/ndt.s196973] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Postoperative delirium (POD) is a common complication of cardiac surgery associated with increased mortality, morbidity, and long-term cognitive dysfunction. Diabetic patients, especially those with poor diabetes control and long-standing hyperglycemia, may be at risk of developing delirium. The aim of this study was to analyze whether the occurrence of POD in cardiac surgery is associated with diabetes or elevated preoperative glycated hemoglobin (HbA1c) level. MATERIALS AND METHODS We performed a cohort analysis of prospectively collected data from a register of cardiac surgery department of a university hospital. Delirium assessment was performed twice a day during the first 5 days after the operation based on Diagnostic Statistical Manual of Mental Disorders, fifth edition criteria. RESULTS We analyzed a cohort of 3,178 consecutive patients, out of which 1,010 (31.8%) were diabetic and 502 (15.8%) were diagnosed with POD. Patients with delirium were more often diabetic (42.03% vs 29.86%, P<0.001) and on oral diabetic medications (34.66% vs 24.07%, P<0.001), no difference was found in patients with insulin treatment. Preoperative HbA1c was elevated above normal (≥6%) in more delirious than nondelirious patients (44.54% vs 33.04%, P<0.001), but significance was reached only in nondiabetic patients (20.44% vs 14.86%, P=0.018). In univariate analysis, the diagnosis of diabetes was associated with an increased risk of developing POD (OR: 1.703, 95% CI: 1.401-2.071, P<0.001), but only for patients on oral diabetic medications (OR: 1.617, 95% CI: 1.319-1.983, P<0.001) and an association was noted between HbA1c and POD (OR: 1.269, 95% CI: 1.161-1.387, P<0.001). Multivariate analysis controlled for diabetes showed that POD was associated with age, heart failure, preoperative creatinine, extracardiac arteriopathy, and preoperative HbA1c level. CONCLUSION More diabetic patients develop POD after cardiac surgery than nondiabetic patients. Elevated preoperative HbA1c level is a risk factor for postcardiac surgery delirium regardless of the diagnosis of diabetes.
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Affiliation(s)
- Katarzyna Kotfis
- Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, Szczecin, Poland
| | - Aleksandra Szylińska
- Department of Medical Rehabilitation and Clinical Physiotherapy, Pomeranian Medical University, Szczecin, Poland,
| | - Mariusz Listewnik
- Department of Cardiac Surgery, Pomeranian Medical University, Szczecin, Poland
| | | | - E Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Iwona Rotter
- Department of Medical Rehabilitation and Clinical Physiotherapy, Pomeranian Medical University, Szczecin, Poland,
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Glucose variability during delirium in diabetic and non-diabetic intensive care unit patients: A prospective cohort study. PLoS One 2018; 13:e0205637. [PMID: 30439957 PMCID: PMC6237332 DOI: 10.1371/journal.pone.0205637] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 09/30/2018] [Indexed: 12/20/2022] Open
Abstract
PURPOSE To determine whether glucose variability is altered during delirium days compared to non-delirious days in critically ill patients with and without diabetes in the intensive care unit (ICU). MATERIALS AND METHODS Critically ill patients with delirious and non-delirious days during ICU stay were included from a prospective cohort study which was conducted from January 2011- June 2013. Glucose variability was measured each observation day using various definitions (change in mean glucose, standard deviation, mean absolute glucose, daily delta and occurrence of hypo- and hyperglycemia). Mixed-effects models and generalized mixed-effects models with logit link function were performed to study the association between delirium and glucose variability, adjusting for potential confounders. RESULTS With the exception of the risk of hypoglycemia, delirium was not linked to higher glucose variability using the various definitions of this estimate. For hypoglycemia, we did find an association with delirium in diabetic patients (OR adj.: 2.78; 95% CI: 1.71-6.32, p = 0.005), but not in non-diabetic patients (OR adj.: 1.16; 95% CI: 0.58-2.28, p = 0.689). CONCLUSIONS Despite the positive association between delirium and hypoglycemia in critically ill patients with diabetes, delirium was not associated with more pronounced glucose variability. Our findings suggest that glucose levels should be monitored more closely in diabetic patients during delirium at the ICU to prevent hypoglycemia.
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Flükiger J, Hollinger A, Speich B, Meier V, Tontsch J, Zehnder T, Siegemund M. Dexmedetomidine in prevention and treatment of postoperative and intensive care unit delirium: a systematic review and meta-analysis. Ann Intensive Care 2018; 8:92. [PMID: 30238227 PMCID: PMC6148680 DOI: 10.1186/s13613-018-0437-z] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Accepted: 09/06/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND To determine the preventive and therapeutic effect of dexmedetomidine on intensive care unit (ICU) delirium. METHODS The literature search using PubMed and the Cochrane Central Register of Controlled Trials was performed (August 1, 2018) to detect all randomized controlled trials (RCTs) of adult ICU patients receiving dexmedetomidine. Articles were included if they assessed the influence of dexmedetomidine compared to a sedative agent on incidence of ICU delirium or treatment of this syndrome. Accordingly, relevant articles were allocated to the following two groups: (1) articles that assessed the delirium incidence (incidence comparison) or articles that assessed the treatment of delirium (treatment comparison). Incidence of delirium and delirium resolution were the primary outcomes. We combined treatment effects comparing dexmedetomidine versus (1) placebo, (2) standard sedatives, and (3) opioids in random-effects meta-analyses. Risk of bias for each included RCT was assessed following Cochrane standards. RESULTS The literature search resulted in 28 articles (25 articles/4975 patients for the incidence comparison and three articles/166 patients for the treatment comparison). In the incidence comparison, heterogeneity was present in different subgroups. Administration of dexmedetomidine was associated with significantly lower overall incidence of delirium when compared to placebo (RR 0.52; 95% CI 0.39-0.70; I2 = 37%), standard sedatives (RR 0.63; 95% CI 0.46-0.86; I2 = 69%), as well as to opioids (RR 0.61; 95% CI 0.44-0.83; I2 = 0%). Use of dexmedetomidine significantly increased the risks of bradycardia and hypotension. Limited data were available on circulatory insufficiency and mortality. In the treatment comparison, the comparison drugs in the three RCTs were placebo, midazolam, and haloperidol. The resolution of delirium was measured differently in each study. Two out of the three studies indicated clear favorable effects for dexmedetomidine (i.e., compared to placebo and midazolam). The study comparing dexmedetomidine with haloperidol was a pilot study (n = 20) with high variability in the results. CONCLUSION Findings suggest that dexmedetomidine reduces incidence and duration of ICU delirium. Furthermore, our systematic searches show that there is limited evidence if a delirium shall be treated with dexmedetomidine.
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Affiliation(s)
- Julian Flükiger
- Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Alexa Hollinger
- Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland. .,Department of Anaesthesiology, Burn and Critical Care Medicine, AP-HP, Saint Louis and Lariboisière University Hospitals, 2 rue Ambroise Paré, 75010, Paris, France. .,Inserm 942 Paris, Biomarqueurs et maladies cardiaques, Hôpital Lariboisière - Bâtiment Viggo Petersen, 41, boulevard de la Chapelle, 75475, Paris Cedex 10, France.
| | - Benjamin Speich
- Department of Clinical Research, Basel Institute for Clinical Epidemiology and Biostatistics, University of Basel and University Hospital Basel, Basel, Switzerland.,Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Vera Meier
- Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Janna Tontsch
- Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Tatjana Zehnder
- Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Martin Siegemund
- Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
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Hong K, Kim N, Song S, Hong G. Cycling of Dexmedetomidine May Prevent Delirium After Liver Transplantation. Transplant Proc 2018; 50:1080-1082. [DOI: 10.1016/j.transproceed.2017.11.076] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Accepted: 11/21/2017] [Indexed: 12/11/2022]
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Smith JM, Van Aman MN, Schneiderhahn ME, Edelman R, Ercole PM. Assessment of Delirium in Intensive Care Unit Patients: Educational Strategies. J Contin Educ Nurs 2018; 48:239-244. [PMID: 28459497 DOI: 10.3928/00220124-20170418-09] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2015] [Accepted: 12/06/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND Delirium is an acute brain dysfunction associated with poor outcomes in intensive care unit (ICU) patients. Critical care nurses play an important role in the prevention, detection, and management of delirium, but they must be able to accurately assess for it. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) instrument is a reliable and valid method to assess for delirium, but research reveals most nurses need practice to use it proficiently. METHOD A pretest-posttest design was used to evaluate the success of a multimodal educational strategy (i.e., online learning module coupled with standardized patient simulation experience) on critical care nurses' knowledge and confidence to assess and manage delirium using the CAM-ICU. RESULTS Participants (N = 34) showed a significant increase (p < .001) in confidence in their ability to assess and manage delirium following the multimodal education. No statistical change in knowledge of delirium existed following the education. CONCLUSION A multimodal educational strategy, which included simulation, significantly added confidence in critical care nurses' performance using the CAM-ICU. J Contin Nurs Educ. 2017;48(5):239-244.
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Rains J, Chee N. The role of occupational and physiotherapy in multi-modal approach to tackling delirium in the intensive care. J Intensive Care Soc 2017; 18:318-322. [PMID: 29123562 PMCID: PMC5661800 DOI: 10.1177/1751143717720589] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
The presence of delirium within critical care remains a long-standing challenge for patients and clinicians alike. A myriad of pre-disposing and precipitating factors lead to this patient cohort being high risk for developing delirium during their critical care stay. Until now, non-pharmacological management of these patients usually encompasses a 'bundle' of principles to reduce delirium days. These bundles have limited focus on the entire multi-disciplinary team (including occupational therapists and physiotherapists) who could assist with the reduction of delirium. The purpose of this analysis is to review the current literature and develop a mnemonic, which may help facilitate collaborative working for patients with delirium. Electronic databases were searched for non-pharmacological managements of delirium within intensive care settings, after 2006. Critical appraisal using Critical Appraisal Skills Programme methodology was completed by the author. Multi-intervention approaches and bundles are successful at reducing delirium days, and in some cases, reducing hospital length of stay. The key components of these bundles include spontaneous breathing trials, daily sedation holds, addressing pain relief, early mobilisation and to a small extent normalisation of a daily routine. There is limited research into the role of therapy within this patient group, but there is a role for cognitive therapy, functional tasks, and a greater rehab emphasis within other patient populations such as stroke and elderly care. The critical care population have similar rehabilitation needs to these groups, and therefore would benefit from similar treatment plans. Critical care patients with delirium may benefit from a range of additional therapeutic activities to reduce the duration of delirium. The D.E.L.I.R.I.U.M mnemonic has been developed to encompass all the key elements of current delirium research in a simplistic memorable fashion. Further work is needed to trial the usefulness of the mnemonic in clinical practice to enable the entire multi-disciplinary team work collaboratively to reduce delirium with the intensive care.
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Affiliation(s)
- Jenny Rains
- Royal Bournemouth and Christchurch Hospitals, NHS Foundation Trust, Bournemouth, UK
| | - Nigel Chee
- Royal Bournemouth and Christchurch Hospitals, NHS Foundation Trust, Bournemouth, UK
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Rose L, Agar M, Burry LD, Campbell N, Clarke M, Lee J, Siddiqi N, Page VJ. Development of core outcome sets for effectiveness trials of interventions to prevent and/or treat delirium (Del-COrS): study protocol. BMJ Open 2017; 7:e016371. [PMID: 28928181 PMCID: PMC5623471 DOI: 10.1136/bmjopen-2017-016371] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Delirium is a common, serious and potentially preventable condition with devastating impact on the quality of life prompting a proliferation of interventional trials. Core outcome sets aim to standardise outcome reporting by identifying outcomes perceived fundamental for measurement in trials of a specific interest area. Our aim is to develop international consensus on two core outcome sets for trials of interventions to prevent and/or treat delirium, irrespective of study population. We aim to identify additional core outcomes specific to the critically ill, acutely hospitalised patients, palliative care and older adults. METHODS AND ANALYSIS We will conduct a systematic review of published and ongoing delirium trials (1980 onwards) and one-on-one interviews of patients who have experienced delirium and family members. These data will inform Delphi round 1 of a two-stage consensus process. In round 2, we will provide participants their own response, summarised group responses and those of patient/family participants for rescoring. We will randomise participants to receive feedback as proportion scoring the outcome as critical or as group mean responses. We will hold a consensus meeting using nominal group technique to finalise outcomes for inclusion. We will repeat the Delphi process and consensus meeting to select measures for each core outcome. We will recruit 240 Delphi participants giving us 80% power to detect a 1.0-1.5 point (9-point scale) difference by feedback method between rounds. We will analyse differences for subsequent scores, magnitude of opinion change, items retained and level of agreement. ETHICS AND DISSEMINATION We are obtaining research ethics approvals according to local governance. Participation will be voluntary and data deidentified. Support from three international delirium organisations will be instrumental in dissemination and core outcome set uptake. We will disseminate through peer-reviewed open access publications and present at conferences selected to reach a wide range of knowledge users.
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Affiliation(s)
- Louise Rose
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Meera Agar
- Faculty of Health Sciences, University of Technology, Sydney, New South Wales, Australia
| | - Lisa D Burry
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Noll Campbell
- College of Pharmacy, Indiana University-Purdue University, Indianapolis, Indiana, USA
| | - Mike Clarke
- School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
| | - Jacques Lee
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Valerie J Page
- Department of Anaesthetics, Watford General Hospital, Watford, UK
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Abstract
PURPOSE/OBJECTIVE The purposes of this article are to describe the scientific literature on assessment, prevention, and management of delirium in critically ill children and to articulate the implications for clinical nurse specialists, in translating the evidence into practice. DESCRIPTION A literature search was conducted in 4 databases-OvidMEDLINE, Cumulative Index to Nursing and Allied Health Literature, PsychINFO, and Web of Science-using the terms "delirium," "child," and "critically ill" for the period of 2006 to 2016. OUTCOME The scientific literature included articles on diagnosis, prevalence, risk factors, adverse outcomes, screening tools, prevention, and management. The prevalence of delirium in critically ill children is up to 30%. Risk factors include age, developmental delay, severity of illness, and mechanical ventilation. Adverse outcomes include increased mortality, hospital length of stay, and cost for the critically ill child with delirium. Valid and reliable delirium screening tools are available for critically ill children. Prevention and management strategies include interventions to address environmental triggers, sleep disruption, integrated family care, and mobilization. CONCLUSION Delirium is a common occurrence for the critically ill child. The clinical nurse specialist is accountable for leading the implementation of practice changes that are based on evidence to improve patient outcomes. Screening and early intervention for delirium are key to mitigating adverse outcomes for critically ill children.
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van de Pol I, van Iterson M, Maaskant J. Effect of nocturnal sound reduction on the incidence of delirium in intensive care unit patients: An interrupted time series analysis. Intensive Crit Care Nurs 2017; 41:18-25. [DOI: 10.1016/j.iccn.2017.01.008] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 01/09/2017] [Accepted: 01/22/2017] [Indexed: 01/02/2023]
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Abstract
This study aimed to evaluate the effectiveness of the delirium prevention interventions recommended by the Delirium Prevention Guidelines for Elderly Stroke Patients (DPGESP). The DPGESP comprises nine dimensions with 28 interventions, including risk factor assessment, orientation disorder prevention, sleeping pattern maintenance, sensory interventions, constipation, dehydration, hypoxia and infection prevention, pain management, and appropriate nutrition maintenance. This quasi-experimental study used a nonequivalent control group and a pretest–posttest design. The experimental and control groups each included 54 patients, and the participants were elderly patients who were admitted to the stroke unit. The study outcomes were the delirium incidence and severity, stroke impact, and length of hospitalization. Posttest values for delirium incidence, severity, stroke impact, and length of hospitalization were significantly improved in the experimental group. Implementation of the DPGESP had beneficial effects on the delirium incidence and severity, stroke impact, and length of hospitalization among elderly patients admitted to a stroke unit.
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Bennett C. Identifying delirium in older adults with pre-existing mental illness. Nurse Pract 2017; 42:39-44. [PMID: 28514272 DOI: 10.1097/01.npr.0000516123.22868.c6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Acute delirium complicates care and can be easily overlooked in older adults with preexisting mental illness. Evidence-based measures have demonstrated that early diagnosis, identification, and correction of modifiable factors can lead to improved care and less morbidity in these patients.
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Affiliation(s)
- Courtney Bennett
- Courtney Bennett is an adult psychiatric mental health NP at East Mississippi State Hospital, Meridian, Miss
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Abstract
OBJECTIVES To determine whether delirium during ICU stay is associated with long-term mental health problems defined as symptoms of anxiety, depression, and posttraumatic stress disorder. DESIGN Prospective cohort study. SETTING Survey study, 1 year after discharge from a medical-surgical ICU in the Netherlands. PATIENTS One-year ICU survivors of an ICU admission lasting more than 48 hours, without a neurologic disorder or other condition that would impede delirium assessment during ICU stay. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS One year after discharge, ICU survivors received a survey containing the Hospital Anxiety and Depression Scale with a subscale for symptoms of depression and a subscale for symptoms of anxiety, and the Impact of Event Scale 15 item measuring symptoms of posttraumatic stress disorder. Participants were classified as having experienced no delirium (n = 270; 48%), a single day of delirium (n = 86; 15%), or multiple days of delirium (n = 211; 37%) during ICU stay. Log-binomial regression was used to assess the association between delirium and symptoms of anxiety, depression, and posttraumatic stress disorder. The study population consisted of 567 subjects; of whom 246 subjects (43%) reported symptoms of anxiety (Hospital Anxiety and Depression Scale with a subscale for anxiety, ≥ 8), and 254 (45%) symptoms of depression (Hospital Anxiety and Depression Scale with a subscale for depression, ≥ 8). In 220 patients (39%), the Impact of Event Scale 15 item was greater than or equal to 35, indicating a high probability of posttraumatic stress disorder. There was substantial overlap between these mental health problems-63% of the subjects who scored positive for the presence of any three of the mental health problems, scored positive for all three. No association was observed between either a single day or multiple days of delirium and symptoms of anxiety, depression, or posttraumatic stress disorder. CONCLUSIONS Although symptoms of anxiety, depression, and posttraumatic stress disorder were found to be common 1 year after critical illness, the occurrence of delirium during ICU stay did not increase the risk of these long-term mental health problems.
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Pallaria TJ, Panebianco C, Kamienski MC. Perioperative Delirium Protocol for the Older Patient. J Perianesth Nurs 2017; 33:275-280. [PMID: 29784256 DOI: 10.1016/j.jopan.2016.08.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 08/06/2016] [Accepted: 08/13/2016] [Indexed: 11/25/2022]
Abstract
PURPOSE Delirium is an acute change in cognition and attention. It may affect any age group. It is most common in older patients and is associated with a significant increase in mortality. The purpose of this project was to implement an assessment protocol to identify patients at risk for postoperative delirium. DESIGN A case study approach was used. METHODS The Confusion Assessment Method (CAM) tool for screening and diagnostic purposes was used to train surgeons, anesthesia providers, and nurses. A standardized delirium assessment and management protocol was developed and implemented. FINDINGS The CAM and geriatric preoperative assessment was used with the patient discussed in the case study. The patient did not experience postoperative delirium and was discharged from perioperative services on the same day. CONCLUSION Evidence informs us that early recognition and multifaceted interventions can prevent postoperative delirium in the elderly.
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Abstract
Critical illness increases the probability of a neurologic complication. There are many reasons to consult a neurologist in a critically ill patient and most often it is altered alertness with no intuitive plausible explanation. Other common clinical neurologic problems facing the intensive care specialist and consulting neurologist in everyday decisions are coma following prolonged cardiovascular surgery, newly perceived motor asymmetry, seizures or other abnormal movements, and generalized muscle weakness. Assessment of long-term neurologic prognosis is another frequent reason for consultation and often to seek additional information about the patient's critical condition by the attending intensivist. Generally speaking, consultations in medical or surgical ICU's may have a varying catalog of complexity and may involve close management of major acute brain injury. This chapter introduces the main principles and scope of this field. Being able to do these consults effectively-often urgent and at any hour of the day-requires a good knowledge of general intensive care and surgical procedures. An argument can be made to involve neurointensivists or neurohospitalists in these complicated consults.
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Melatonin and melatonin agonists to prevent and treat delirium in critical illness: a systematic review protocol. Syst Rev 2016; 5:199. [PMID: 27881185 PMCID: PMC5122010 DOI: 10.1186/s13643-016-0378-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 11/09/2016] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Delirium is a syndrome characterized by acute fluctuations and alterations in attention and arousal. Critically ill patients are at particularly high risk, and those that develop delirium are more likely to experience poor clinical outcomes such as prolonged duration of ICU and hospital length of stay, and increased mortality. Melatonin and melatonin agonists (MMA) have the potential to decrease the incidence and severity of delirium through their hypnotic and sedative-sparing effects, thus improving health-related outcomes. The objective of this review is to synthesize the available evidence pertaining to the efficacy and safety of MMA for the prevention and treatment of ICU delirium. METHODS We will search Ovid MEDLINE, Web of Science, EMBASE, PsycINFO, the Cochrane Central Register of Controlled Trials (CENTRAL), and CINAHL to identify studies evaluating MMA in critically ill populations. We will also search http://apps.who.int/trialsearch for ongoing and unpublished studies and PROSPERO for registered reviews. We will not impose restrictions on language, date, or journal of publication. Authors will independently screen for eligible studies using pre-defined criteria; data extraction from eligible studies will be performed in duplicate. The Cochrane Risk of Bias Scale and the Newcastle-Ottawa Scale will be used to assess the risk of bias and quality of randomized and non-randomized studies, respectively. Our primary outcome of interest is delirium incidence, and secondary outcomes include duration of delirium, number of delirium- and coma-free days, use of physical and chemical (e.g., antipsychotics or benzodiazepines) restraints, duration of mechanical ventilation, ICU and hospital length of stay, mortality, long-term neurocognitive outcomes, hospital discharge disposition, and adverse events. We will use Review Manager (RevMan) to pool effect estimates from included studies. We will present results as relative risks with 95% confidence intervals for dichotomous outcomes and as mean differences, or standardized mean differences, for continuous outcomes. DISCUSSION Current guidelines make no pharmacological recommendations for either the prevention or treatment of ICU delirium. This systematic review will synthesize the available evidence on the efficacy and safety of MMA for this purpose, thus potentially informing clinical decision-making and improving patient outcomes. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42015024713.
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