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Deschamps A, Ben Abdallah A, Jacobsohn E, Saha T, Djaiani G, El-Gabalawy R, Overbeek C, Palermo J, Courbe A, Cloutier I, Tanzola R, Kronzer A, Fritz BA, Schmitt EM, Inouye SK, Avidan MS. Electroencephalography-Guided Anesthesia and Delirium in Older Adults After Cardiac Surgery: The ENGAGES-Canada Randomized Clinical Trial. JAMA 2024; 332:112-123. [PMID: 38857019 PMCID: PMC11165413 DOI: 10.1001/jama.2024.8144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 04/18/2024] [Indexed: 06/11/2024]
Abstract
Importance Intraoperative electroencephalogram (EEG) waveform suppression, suggesting excessive general anesthesia, has been associated with postoperative delirium. Objective To assess whether EEG-guided anesthesia decreases the incidence of delirium after cardiac surgery. Design, Setting, and Participants Randomized, parallel-group clinical trial of 1140 adults 60 years or older undergoing cardiac surgery at 4 Canadian hospitals. Recruitment was from December 2016 to February 2022, with follow-up until February 2023. Interventions Patients were randomized in a 1:1 ratio (stratified by hospital) to receive EEG-guided anesthesia (n = 567) or usual care (n = 573). Patients and those assessing outcomes were blinded to group assignment. Main Outcomes and Measures The primary outcome was delirium during postoperative days 1 through 5. Intraoperative measures included anesthetic concentration and EEG suppression time. Secondary outcomes included intensive care and hospital length of stay. Serious adverse events included intraoperative awareness, medical complications, and 30-day mortality. Results Of 1140 randomized patients (median [IQR] age, 70 [65-75] years; 282 [24.7%] women), 1131 (99.2%) were assessed for the primary outcome. Delirium during postoperative days 1 to 5 occurred in 102 of 562 patients (18.15%) in the EEG-guided group and 103 of 569 patients (18.10%) in the usual care group (difference, 0.05% [95% CI, -4.57% to 4.67%]). In the EEG-guided group compared with the usual care group, the median volatile anesthetic minimum alveolar concentration was 0.14 (95% CI, 0.15 to 0.13) lower (0.66 vs 0.80) and there was a 7.7-minute (95% CI, 10.6 to 4.7) decrease in the median total time spent with EEG suppression (4.0 vs 11.7 min). There were no significant differences between groups in median length of intensive care unit (difference, 0 days [95% CI, -0.31 to 0.31]) or hospital stay (difference, 0 days [95% CI, -0.94 to 0.94]). No patients reported intraoperative awareness. Medical complications occurred in 64 of 567 patients (11.3%) in the EEG-guided group and 73 of 573 (12.7%) in the usual care group. Thirty-day mortality occurred in 8 of 567 patients (1.4%) in the EEG-guided group and 13 of 573 (2.3%) in the usual care group. Conclusions and Relevance Among older adults undergoing cardiac surgery, EEG-guided anesthetic administration to minimize EEG suppression, compared with usual care, did not decrease the incidence of postoperative delirium. This finding does not support EEG-guided anesthesia for this indication. Trial Registration ClinicalTrials.gov Identifier: NCT02692300.
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Affiliation(s)
- Alain Deschamps
- Montreal Heart Institute, Department of Anesthesiology and Pain Medicine, Université de Montreal, Montreal, Quebec, Canada
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Eric Jacobsohn
- Department of Anesthesiology Perioperative and Pain Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Tarit Saha
- Department of Anesthesiology and Perioperative Medicine, Queen’s University, Kingston, Ontario, Canada
| | - George Djaiani
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Renée El-Gabalawy
- Departments of Clinical Health Psychology and Anesthesiology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Charles Overbeek
- Montreal Heart Institute, Department of Anesthesiology and Pain Medicine, Université de Montreal, Montreal, Quebec, Canada
| | - Jennifer Palermo
- Montreal Heart Institute, Department of Anesthesiology and Pain Medicine, Université de Montreal, Montreal, Quebec, Canada
| | - Athanase Courbe
- Montreal Heart Institute, Department of Anesthesiology and Pain Medicine, Université de Montreal, Montreal, Quebec, Canada
| | - Isabelle Cloutier
- Montreal Health Innovations Coordinating Center, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Rob Tanzola
- Department of Anesthesiology and Perioperative Medicine, Queen’s University, Kingston, Ontario, Canada
| | - Alex Kronzer
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Bradley A. Fritz
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Eva M. Schmitt
- Department of Medicine, Beth Israel-Deaconess Medical Center and the Marcus Institute for Aging Research, Hebrew Senior Life, Harvard Medical School, Boston, Massachusetts
| | - Sharon K. Inouye
- Department of Medicine, Beth Israel-Deaconess Medical Center and the Marcus Institute for Aging Research, Hebrew Senior Life, Harvard Medical School, Boston, Massachusetts
| | - Michael S. Avidan
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
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Gao Y, Gan X. A novel nomogram for the prediction of subsyndromal delirium in patients in intensive care units: A prospective, nested case-controlled study. Int J Nurs Stud 2024; 155:104767. [PMID: 38653158 DOI: 10.1016/j.ijnurstu.2024.104767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 03/26/2024] [Accepted: 03/27/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Subsyndromal delirium is a dynamic, recognizable condition commonly observed in intensive care unit (ICU) patients that can lead to poor patient prognosis, and its prompt recognition and management can prevent disease progression. However, no evidence-based predictive tool has been developed specifically to assess the occurrence of subsyndromal delirium in the ICU. OBJECTIVE To develop and validate a novel, simple and effective tool for estimating the risk of subsyndromal delirium among ICU patients. DESIGN A prospective, nested case-controlled study. DATA SOURCES A total of 731 patients were recruited from the central ICU of a tertiary hospital in southwestern China from August 2021 to November 2022. METHODS The least absolute shrinkage and selection operator was applied to screen potential features for univariate and multivariate logistic regression. A nomogram was constructed using the selected variables. The performance of the nomogram was evaluated by combining the area under the receiver operating characteristic curve (AUC), calibration curves and decision curve analysis (DCA). RESULTS The prevalence of subsyndromal delirium among ICU patients was 23.06 %. Multiple logistic regression analysis revealed that the independent predictive factors for subsyndromal delirium among ICU patients were vision impairment, a history of falls, the use of restraint, blood transfusion, the use of antibiotics, surgery, the Caprini score, and the Braden score, all of which were used to construct the nomogram. The AUCs for the model were 0.710 (95 % CI, 0.654-0.766, P < 0.001) and 0.825 (95 % CI, 0.732-0.917, P < 0.001) in the training and validation cohorts, respectively, indicating that the model had high accuracy in distinguishing patients with and without subsyndromal delirium. The calibration curve of the nomogram showed good consistency between the predicted and actual probabilities. The DCA indicated that the nomogram has clinical application for patients in the ICU. CONCLUSIONS We developed an easy-to-use nomogram for identifying subsyndromal delirium in ICU patients with satisfactory predictive ability based on simple and easily accessible clinical features. The nomogram can identify ICU patients at high-risk for subsyndromal delirium and may be a useful subsyndromal delirium tool for current ICU physicians.
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Affiliation(s)
- Yan Gao
- Nursing Department, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China; School of Nursing, Chongqing Medical University, Chongqing, China
| | - Xiuni Gan
- Nursing Department, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China; School of Nursing, Chongqing Medical University, Chongqing, China.
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Cheng J, Lao Y, Chen X, Qiao X, Sui W, Gong X, Zhuang Y. Dynamic Nomogram for Subsyndromal Delirium in Adult Intensive Care Unit: A Prospective Cohort Study. Neuropsychiatr Dis Treat 2023; 19:2535-2548. [PMID: 38029051 PMCID: PMC10676691 DOI: 10.2147/ndt.s432776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 11/13/2023] [Indexed: 12/01/2023] Open
Abstract
Purpose To develop a dynamic nomogram of subsyndromal delirium (SSD) in intensive care unit (ICU) patients and internally validate its efficacy in predicting SSD. Patients and Methods Patients who met the inclusion and exclusion criteria in the ICU of a tertiary hospital in Zhejiang from September 2021 to June 2022 were selected as the research objects. The patient data were randomly divided into the training set and validation set according to the ratio of 7:3. The least absolute shrinkage and selection operator (LASSO) and multivariate logistic regression were used to screen the predictors of SSD, and R software was used to construct a dynamic nomogram. Receiver operating characteristic (ROC) curve, calibration band and decision curve were used to evaluate the discrimination, calibration and clinical effectiveness of the model. Results A total of 1000 eligible patients were included, including 700 in the training set and 300 in the validation set. Age, drinking history, C reactive protein level, APACHE II, indwelling urinary catheter, mechanical ventilation, cerebrovascular disease, respiratory failure, constraint, dexmedetomidine, and propofol were predictors of SSD in ICU patients. The ROC curve values of the training set was 0.902 (95% confidence interval: 0.879-0.925), the best cutoff value was 0.264, the specificity was 78.4%, and the sensitivity was 88.0%. The ROC curve values of the validation set was 0.888 (95% confidence interval: 0.850-0.930), the best cutoff value was 0.543, the specificity was 94.9%, and the sensitivity was 70.9%. The calibration band showed good calibration in the training and validation set. Decision curve analysis showed that the net benefit in the model was significantly high. Conclusion The dynamic nomogram has good predictive performance, so it is a precise and effective tool for medical staff to predict and manage SSD in the early stage.
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Affiliation(s)
- Junning Cheng
- Nursing Department, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, People’s Republic of China
| | - Yuewen Lao
- Nursing Department, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, People’s Republic of China
| | - Xiangping Chen
- Nursing Department, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, People’s Republic of China
| | - Xiaoting Qiao
- Nursing Department, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, People’s Republic of China
| | - Weijing Sui
- Nursing Department, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, People’s Republic of China
| | - Xiaoyan Gong
- Nursing Department, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, People’s Republic of China
| | - Yiyu Zhuang
- Nursing Department, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, People’s Republic of China
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Sachdev A, Moges Y, Rubin M, Sremac AC, Arvanitakis Z, McCarthy RJ. Early incident and subsyndromal delirium in older patients undergoing elective surgical procedures: a randomized clinical trial of an avoid delirium protocol. FRONTIERS IN ANESTHESIOLOGY 2023; 2:1268263. [PMID: 38650976 PMCID: PMC11034801 DOI: 10.3389/fanes.2023.1268263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
Background Pharmacological avoidance guidelines for preventing delirium have been suggested; however, there are limited pragmatic studies of these strategies. Early (<24 h) delirium can be observed in the postoperative care unit and is associated with an increased risk of subsequent delirium. We examined the effectiveness of an avoid delirium protocol (ADP) in older (>65 years) patients undergoing elective surgeries. Methods The randomized controlled trial assessed an ADP developed using the American Geriatric Society's Clinical Practice Guidelines for Postoperative Delirium in Older Adults, on early (<24 h) incident or subsyndromal delirium. Delirium was assessed using the confusion assessment method before surgery, in the post-anesthesia care unit, and on postoperative day 1. The primary outcome of early delirium was the combined incidence of incident or subsyndromal delirium. Results Early delirium was identified in 24/235 patients (10.2%) with a risk ratio of 1.27 (95% CI 0.59-2.73, P = 0.667) for patients randomized to the ADP. In cases with protocol adherence and no benzodiazepine use, early delirium was present in 10/ 73 (13.7%) compared to 14/148 (9.5%) in non-adherent cases [risk ratio 1.45 (95% CI 0.57-3.10, P = 0.362)]. Lower American Society of Anesthesiologists physical class [odds ratio 3.31 (95% CI 1.35-8.92, P = 0.008)] and an inpatient admission [odds ratio 2.67 (95% CI 1.55-4.87, P = 0.0002)] were associated with early delirium. Conclusions Our findings suggest that pharmacological avoidance protocols limiting or avoiding the use of specific classes of medications are not effective in reducing early incident or subsyndromal delirium in older patients undergoing elective surgery.
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Affiliation(s)
- Alisha Sachdev
- Department of Anesthesiology, Rush University Medical Center, Chicago, IL, United States
| | - Yabtsega Moges
- Department of Anesthesiology, Rush University Medical Center, Chicago, IL, United States
| | - Micah Rubin
- Department of Anesthesiology, Rush University Medical Center, Chicago, IL, United States
| | - Amanda C. Sremac
- Department of Anesthesiology, Rush University Medical Center, Chicago, IL, United States
| | - Zoe Arvanitakis
- Rush Alzheimer’s Disease Center, Rush University Medical Center, Chicago, IL, United States
| | - Robert J. McCarthy
- Department of Anesthesiology, Rush University Medical Center, Chicago, IL, United States
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Paulino MC, Conceição C, Silvestre J, Lopes MI, Gonçalves H, Dias CC, Serafim R, Salluh JIF, Póvoa P. Subsyndromal Delirium in Critically Ill Patients-Cognitive and Functional Long-Term Outcomes. J Clin Med 2023; 12:6363. [PMID: 37835007 PMCID: PMC10573694 DOI: 10.3390/jcm12196363] [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: 08/28/2023] [Revised: 10/01/2023] [Accepted: 10/02/2023] [Indexed: 10/15/2023] Open
Abstract
Subsyndromal delirium (SSD) in the Intensive Care Unit (ICU) is associated with an increased morbidity with unknown post-discharge functional and cognitive outcomes. We performed a prospective multicenter study to analyze the mental status of patients during their first 72 h after ICU admission and its trajectory, with follow-ups at 3 and 6 months after hospital discharge. Amongst the 106 included patients, SSD occurred in 24.5% (n = 26) and was associated with the duration of mechanical ventilation (p = 0.003) and the length of the ICU stay (p = 0.002). After the initial 72 h, most of the SSD patients (30.8%) improved and no longer had SSD; 19.2% continued to experience SSD and one patient (3.8%) progressed to delirium. The post-hospital discharge survival rate for the SSD patients was 100% at 3 months and 87.5% at 6 months. At admission, 96.2% of the SSD patients were fully independent in daily living activities, 66.7% at 3-month follow-up, and 100% at 6-month follow-up. Most SSD patients demonstrated a cognitive decline from admission to 3-month follow-up and improved at 6 months (IQCODE-SF: admission 3.13, p < 0.001; 3 months 3.41, p = 0.019; 6 months 3.19, p = 0.194). We concluded that early SSD is associated with worse outcomes, mainly a transitory cognitive decline after hospital discharge at 3 months, with an improvement at 6 months. This highlights the need to prevent and identify this condition during ICU stays.
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Affiliation(s)
- Maria Carolina Paulino
- NOVA Medical School, New University of Lisbon, 1150-082 Lisbon, Portugal; (J.S.); (P.P.)
- Department of Intensive Care, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, 1150-199 Lisbon, Portugal;
- Department of Intensive Care, Hospital da Luz Lisboa, 1500-650 Lisbon, Portugal;
| | - Catarina Conceição
- Department of Intensive Care, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, 1150-199 Lisbon, Portugal;
- Lisbon School of Medicine, University of Lisbon (FMUL), 1649-028 Lisbon, Portugal
| | - Joana Silvestre
- NOVA Medical School, New University of Lisbon, 1150-082 Lisbon, Portugal; (J.S.); (P.P.)
- Department of Intensive Care, Hospital dos Lusíadas, 1500-458 Lisbon, Portugal
| | - Maria Inês Lopes
- Department of Intensive Care, Hospital da Luz Lisboa, 1500-650 Lisbon, Portugal;
| | - Hernâni Gonçalves
- Center for Health Technology and Services Research (CINTESIS@RISE), Faculty of Medicine, University of Porto, 4200-450 Porto, Portugal; (H.G.); (C.C.D.)
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, 4200-450 Porto, Portugal
| | - Cláudia Camila Dias
- Center for Health Technology and Services Research (CINTESIS@RISE), Faculty of Medicine, University of Porto, 4200-450 Porto, Portugal; (H.G.); (C.C.D.)
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, 4200-450 Porto, Portugal
| | - Rodrigo Serafim
- D’OR Institute for Research and Education, Rio de Janeiro 22281-100, Brazil; (R.S.); (J.I.F.S.)
- Post-Graduate Program, Federal University of Rio de Janeiro, Rio de Janeiro 21941-913, Brazil
| | - Jorge I. F. Salluh
- D’OR Institute for Research and Education, Rio de Janeiro 22281-100, Brazil; (R.S.); (J.I.F.S.)
- Post-Graduate Program, Federal University of Rio de Janeiro, Rio de Janeiro 21941-913, Brazil
| | - Pedro Póvoa
- NOVA Medical School, New University of Lisbon, 1150-082 Lisbon, Portugal; (J.S.); (P.P.)
- Department of Intensive Care, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, 1150-199 Lisbon, Portugal;
- Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, C 5000 Odense, Denmark
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Perpetuo LH, Ferreira W, da Silva DJ, Jurno ME, Vale TC. Incidence Rate and Factors Associated with Delirium and Subsyndromal Delirium in Patients with COVID-19 in an Intensive Care Unit. J Clin Med 2023; 12:jcm12113789. [PMID: 37297983 DOI: 10.3390/jcm12113789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 05/17/2023] [Accepted: 05/26/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Delirium subsyndrome (SSD) and delirium (DL) are known complications in the intensive care unit (ICU) and are associated with worse clinical outcomes. The aim of this study was to screen for SSD and DL in individuals with COVID-19 admitted to the ICU and to study the associated factors and clinical outcomes. METHOD An observational, longitudinal study was conducted in the reference ICU for COVID-19. All admitted individuals with COVID-19 were screened for SSD and DL during their ICU stay using the Intensive Care Delirium Screening Checklist (ICDSC). Individuals with SSD and/or DL were compared to those without SSD and/or DL. RESULTS Ninety-three patients were evaluated, of which 46.7% had SSD and/or DL. The incidence rate was 4.17 cases/100 person-days. Individuals with SSD and/or DL had higher severity of illness on admission to the ICU, as measured by the APACHE II score (median 16 versus 8 points, p < 0.001). SSD and/or DL were associated with longer ICU and hospital stays (median 19 versus 6 days, p < 0.001 and median 22 versus 7 days, p < 0.001, respectively). CONCLUSION Individuals with SSD and/or DL had greater disease severity and longer ICU and hospital stays when compared to those without SSD and/or DL. This reinforces the importance of screening for consciousness disorders in the ICU.
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Affiliation(s)
- Lara Helena Perpetuo
- Programa de Pós-Graduação em Saúde, Faculdade de Medicina, Associação Hospitalar Bom Jesus de Congonhas, Universidade Federal de Juiz de Fora, Congonhas 36415-000, MG, Brazil
| | - Wellington Ferreira
- Faculdade de Medicina, Universidade Federal de São João Del Rei, Divinópolis 35501-296, MG, Brazil
| | - Danilo Jorge da Silva
- Programa de Pós-Graduação em Saúde, Faculdade de Medicina, Universidade Federal de Juiz de Fora, Juiz de Fora 36036-900, MG, Brazil
| | | | - Thiago Cardoso Vale
- Programa de Pós-Graduação em Saúde, Faculdade de Medicina, Universidade Federal de Juiz de Fora, Juiz de Fora 36036-900, MG, Brazil
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Tokuda R, Nakamura K, Takatani Y, Tanaka C, Kondo Y, Ohbe H, Kamijo H, Otake K, Nakamura A, Ishikura H, Kawazoe Y. Sepsis-Associated Delirium: A Narrative Review. J Clin Med 2023; 12:1273. [PMID: 36835809 PMCID: PMC9962483 DOI: 10.3390/jcm12041273] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 01/21/2023] [Accepted: 01/30/2023] [Indexed: 02/09/2023] Open
Abstract
Delirium is characterized by an acutely altered mental status accompanied by reductions in cognitive function and attention. Delirium in septic patients, termed sepsis-associated delirium (SAD), differs in several specific aspects from the other types of delirium that are typically encountered in intensive care units. Since sepsis and delirium are both closely associated with increased morbidity and mortality, it is important to not only prevent but also promptly diagnose and treat SAD. We herein reviewed the etiology, pathogenesis, risk factors, prevention, diagnosis, treatment, and prognosis of SAD, including coronavirus disease 2019 (COVID-19)-related delirium. Delirium by itself not only worsens long-term prognosis, but it is also regarded as an important factor affecting the outcome of post-intensive care syndrome. In COVID-19 patients, the difficulties associated with adequately implementing the ABCDEF bundle (Assess, prevent, and manage pain; Both spontaneous awakening and breathing trials: Choice of analgesia and sedation; Delirium assess, prevent, and manage; Early mobility and exercise; Family engagement/empowerment) and the need for social isolation are issues that require the development of conventional care for SAD.
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Affiliation(s)
- Rina Tokuda
- Tajima Emergency and Critical Care Medical Center, Toyooka Public Hospital, Hyogo 668-8501, Japan
| | - Kensuke Nakamura
- Department of Emergency and Critical Care Medicine, Teikyo University Hospital, Tokyo 173-8606, Japan
| | - Yudai Takatani
- Department of Primary Care and Emergency Medicine, Kyoto University Hospital, Kyoto 606-8507, Japan
| | - Chie Tanaka
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, Tokyo 206-8512, Japan
| | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Chiba 279-0021, Japan
| | - Hiroyuki Ohbe
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo 113-8654, Japan
| | - Hiroshi Kamijo
- Department of Emergency and Critical Care Medicine, Shinshu University Hospital, Nagano 390-0802, Japan
| | - Kosuke Otake
- Department of Emergency and Critical Care Center, Nippon Medical School Musashikosugi Hospital, Kanagawa 211-8533, Japan
| | - Atsuo Nakamura
- Department of Emergency and Critical Care Medicine, Iizuka City Hospital, Fukuoka 820-8505, Japan
| | - Hiroyasu Ishikura
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, Fukuoka University, Fukuoka 814-0180, Japan
| | - Yu Kawazoe
- Department of Emergency Critical Care Center, Sendai Medical Center, Miyagi 983-0045, Japan
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Tachibana M, Inada T. Poor prognostic impact of delirium: especially on mortality and institutionalisation. Psychogeriatrics 2023; 23:187-195. [PMID: 36416212 DOI: 10.1111/psyg.12914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 10/19/2022] [Accepted: 11/04/2022] [Indexed: 11/24/2022]
Abstract
The course of delirium is associated with increased hospital costs, healthcare complications, increased mortality, and long-term poor outcomes. Despite delirium being long recognised as one of the most important prognostic components of patients with illnesses, delirium remains poorly understood, effective management options are limited, and no effective treatment has yet been established. This review evaluated the effects of delirium on mortality, institutionalisation, and dementia in various situations to clarify its prognostic seriousness to elucidate important areas for clinical practice and future research. The effect of delirium on mortality in COVID-19 patients was similar to that in other diseases. The effect of delirium on mortality in patients with delirium between the ages of 18 and 65 may be higher than in those with delirium aged over 65, but studies are scarce. Promoting recognition of delirium at all ages is needed. With careful attention to the specific factors in younger patients that contribute to delirium, healthcare providers may be able to decrease the poor impact of delirium on clinical outcomes. Evaluation of the association between interventions for delirium such as sedation in present clinical practice and the prognosis of delirium is lacking, and further clinical studies are essential.
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Affiliation(s)
- Masako Tachibana
- Department of Psychiatry, Nagoya University Hospital, Nagoya-shi, Japan.,Department of Psychiatry, Nagoya Ekisaikai Hospital, Nagoya-shi, Japan
| | - Toshiya Inada
- Department of Psychiatry, Nagoya University Graduate School of Medicine, Nagoya-shi, Japan
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Serafim RB, Dal-Pizzol F, Souza-Dantas V, Soares M, Bozza FA, Póvoa P, Luiz RR, Lapa e Silva JR, Salluh JIF. Impact of Subsyndromal Delirium Occurrence and Its Trajectory during ICU Stay. J Clin Med 2022; 11:jcm11226797. [PMID: 36431274 PMCID: PMC9692318 DOI: 10.3390/jcm11226797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 11/05/2022] [Accepted: 11/10/2022] [Indexed: 11/19/2022] Open
Abstract
Despite recent advances in the field, the association between subsyndromal delirium (SSD) in the ICU and poor outcomes is not entirely clear. We performed a retrospective multicentric observational study analyzing mental status during the first 72 h of ICU stay. Of the 681 patients included, SSD occurred in 22.7%. Considering the worst cognitive assessment during the first 72 h, 233 (34%) patients had normal mental status, 124 (18%) patients had SSD and 324 (48%) patients had delirium or coma. SSD was not independently associated with an increased risk of death when compared with normal mental status (OR 95%IC 1.0 vs. 1.35 [0.73−1.49], p = 0.340), but was associated with a longer ICU LOS (7.0 (4−12) vs. 4 (3−8) days, p < 0.001). SSD patients who deteriorated to delirium or coma (21%) had a longer ICU LOS in comparison with those who improved or maintained mental status (8 (5−11) vs. 6 (4−8) days, p = 0.025), but did not have an increase in mortality. The main factors associated with the progression from SSD to delirium or coma were the use of mechanical ventilation, the use of intravenous benzodiazepines and a baseline APACHE II score > 23 points. Our findings support the association of SSD with increased ICU LOS, but not with ICU mortality. Monitoring the trajectory of SSD early at ICU admission can help to identify patients with increased risk of conversion from SSD to delirium or coma.
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Affiliation(s)
- Rodrigo B. Serafim
- Instituto D’Or de Pesquisa e Ensino, Rio de Janeiro 22281-100, Brazil
- Hospital Copa D’Or, Rio de Janeiro 22031-011, Brazil
- Hospital Universitário Clementino Fraga Filho/Instituto de Doenças do Tórax, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-913, Brazil
- Correspondence:
| | - Felipe Dal-Pizzol
- Laboratório de Fisiopatologia experimental, Programa de Pós-Graduação em Ciências da Saúde, Universidade do Extremo Sul Catarinense, Criciúma 88806-000, Brazil
| | | | - Marcio Soares
- Instituto D’Or de Pesquisa e Ensino, Rio de Janeiro 22281-100, Brazil
- Programa de Pós-Graduação em Clínica Médica, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-913, Brazil
| | - Fernando A. Bozza
- Instituto de Pesquisa Clínica Evandro Chagas, FIOCRUZ, Rio de Janeiro 22281-100, Brazil
| | - Pedro Póvoa
- Unidade de Cuidados Intensivos Polivalente, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, 1150-199 Lisboa, Portugal
- NOVA Medical School, CEDOC, Universidade Nova de Lisboa, 1150-082 Lisboa, Portugal
- Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, C 5000 Odense, Denmark
| | - Ronir Raggio Luiz
- Programa de Pós-Graduação em Clínica Médica, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-913, Brazil
- Instituto de Saúde Coletiva, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-592, Brazil
| | - José R. Lapa e Silva
- Hospital Universitário Clementino Fraga Filho/Instituto de Doenças do Tórax, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-913, Brazil
- Programa de Pós-Graduação em Clínica Médica, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-913, Brazil
| | - Jorge I. F. Salluh
- Instituto D’Or de Pesquisa e Ensino, Rio de Janeiro 22281-100, Brazil
- Programa de Pós-Graduação em Clínica Médica, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-913, Brazil
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10
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Xing H, Zhu S, Liu S, Xia M, Jing M, Dong G, Ni W, Li L. Knowledge, attitudes and practices of ICU nurses regarding subsyndromal delirium among 20 hospitals in China: a descriptive cross-sectional survey. BMJ Open 2022; 12:e063821. [PMID: 36127111 PMCID: PMC9490617 DOI: 10.1136/bmjopen-2022-063821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES This study sought to investigate nurses' knowledge, attitudes and practices, and analyse the influencing factors for subsyndromal delirium (SSD). DESIGN A descriptive cross-sectional survey. SETTING E-questionnaires were distributed to intensive care unit (ICU) nurses from 20 tertiary-grade, A-class hospitals in Henan Province, China. PARTICIPANTS A total of 740 ICU nurses participated in the questionnaire survey. MAIN OUTCOME MEASURES Each dimension score is converted to a percentage scale. A score of ≤60% on each dimension of the questionnaire was considered a negative score, <80% was considered a intermediate score and ≥80% was considered an excellent score. RESULTS A total of 733 questionnaires were included in the study. More than half of the nurses were at the intermediate level, and a few nurses were at the excellent level. Nurses self-assessed their level of knowledge was intermediate. In the attitudes dimension, nurses' attitudes were negative. The results of the practical dimension showed that most nurses could carry out the clinical practice. Multiple linear regression analysis showed that educational level and received SSD training were influencing factors. CONCLUSIONS ICU nursing staff overestimated their knowledge of SSD and showed a negative attitude towards it. Various forms of education and training are necessary.
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Affiliation(s)
- Huanmin Xing
- Department of Intensive Care Unit, Henan Provincial People's Hospital, Zhengzhou, China
- Department of Intensive Care Unit, People's Hospital of Zhengzhou University, Zhengzhou, China
- Department of Intensive Care Unit, People's Hospital of Henan University, Zhengzhou, China
- Henan Provincial Key Medicine Laboratory of Nursing, Zhengzhou, China
| | - Shichao Zhu
- Department of Intensive Care Unit, Henan Provincial People's Hospital, Zhengzhou, China
- Department of Intensive Care Unit, People's Hospital of Zhengzhou University, Zhengzhou, China
- Department of Intensive Care Unit, People's Hospital of Henan University, Zhengzhou, China
- Henan Provincial Key Medicine Laboratory of Nursing, Zhengzhou, China
| | - Shiqing Liu
- Department of Oral and Maxillofacial Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ming Xia
- Department of Intensive Care Unit, Henan Provincial People's Hospital, Zhengzhou, China
- Department of Intensive Care Unit, People's Hospital of Zhengzhou University, Zhengzhou, China
- Department of Intensive Care Unit, People's Hospital of Henan University, Zhengzhou, China
- Henan Provincial Key Medicine Laboratory of Nursing, Zhengzhou, China
| | - Mengjuan Jing
- Department of Intensive Care Unit, Henan Provincial People's Hospital, Zhengzhou, China
- Department of Intensive Care Unit, People's Hospital of Zhengzhou University, Zhengzhou, China
- Department of Intensive Care Unit, People's Hospital of Henan University, Zhengzhou, China
- Henan Provincial Key Medicine Laboratory of Nursing, Zhengzhou, China
| | - Guangyan Dong
- Department of Intensive Care Unit, Henan Provincial People's Hospital, Zhengzhou, China
- Department of Intensive Care Unit, People's Hospital of Zhengzhou University, Zhengzhou, China
- Department of Intensive Care Unit, People's Hospital of Henan University, Zhengzhou, China
- Henan Provincial Key Medicine Laboratory of Nursing, Zhengzhou, China
| | - Weiwei Ni
- Department of Intensive Care Unit, Henan Provincial People's Hospital, Zhengzhou, China
- Department of Intensive Care Unit, People's Hospital of Zhengzhou University, Zhengzhou, China
- Department of Intensive Care Unit, People's Hospital of Henan University, Zhengzhou, China
- Henan Provincial Key Medicine Laboratory of Nursing, Zhengzhou, China
| | - Liming Li
- Henan Provincial Key Medicine Laboratory of Nursing, Zhengzhou, China
- Nursing Department, Henan Provincial People's Hospital, Zhengzhou, China
- Nursing Department, People's Hospital of Zhengzhou University, Zhengzhou, China
- Nursing Department, People's Hospital of Henan University, Zhengzhou, China
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11
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Taylor J, Parker M, Casey CP, Tanabe S, Kunkel D, Rivera C, Zetterberg H, Blennow K, Pearce RA, Lennertz RC, Sanders RD. Postoperative delirium and changes in the blood-brain barrier, neuroinflammation, and cerebrospinal fluid lactate: a prospective cohort study. Br J Anaesth 2022; 129:219-230. [PMID: 35144802 PMCID: PMC9465948 DOI: 10.1016/j.bja.2022.01.005] [Citation(s) in RCA: 56] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 12/28/2021] [Accepted: 01/03/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Case-control studies have associated delirium with blood-brain barrier (BBB) permeability. However, this approach cannot determine whether delirium is attributable to high pre-existing permeability or to perioperative changes. We tested whether perioperative changes in cerebrospinal fluid/plasma albumin ratio (CPAR) and plasma S100B were associated with delirium severity. METHODS Participants were recruited to two prospective cohort studies of non-intracranial surgery (NCT01980511, NCT03124303, and NCT02926417). Delirium severity was assessed using the Delirium Rating Scale-98. Delirium incidence was diagnosed with the 3D-Confusion Assessment Method (3D-CAM) or CAM-ICU (CAM for the ICU). CSF samples from 25 patients and plasma from 78 patients were analysed for albumin and S100B. We tested associations between change in CPAR (n=11) and S100B (n=61) and delirium, blood loss, CSF interleukin-6 (IL-6), and CSF lactate. RESULTS The perioperative increase in CPAR and S100B correlated with delirium severity (CPAR ρ=0.78, P=0.01; S100B ρ=0.41, P<0.001), delirium incidence (CPAR P=0.012; S100B P<0.001) and CSF IL-6 (CPAR ρ=0.66 P=0.04; S100B ρ=0.75, P=0.025). Linear mixed-effect analysis also showed that decreased levels of S100B predicted recovery from delirium symptoms (P=0.001). Linear regression demonstrated that change in plasma S100B was independently associated with surgical risk, cardiovascular surgery, blood loss, and hypotension. Blood loss also correlated with CPAR (ρ=0.64, P=0.04), S100B (ρ=0.70, P<0.001), CSF lactate (R=0.81, P=0.01), and peak delirium severity (ρ=0.36, P=0.01). CONCLUSION Postoperative delirium is associated with a breakdown in the BBB. This increased permeability is dynamic and associated with a neuroinflammatory and lactate response. Strategies to mitigate blood loss may protect the BBB.
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Affiliation(s)
- Jennifer Taylor
- Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, NSW, Australia
| | - Margaret Parker
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Cameron P Casey
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Sean Tanabe
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - David Kunkel
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Cameron Rivera
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden; Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden; Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK; UK Dementia Research Institute at UCL, London, UK; Hong Kong Center for Neurodegenerative Diseases, Hong Kong, China
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
| | - Robert A Pearce
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Richard C Lennertz
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Robert D Sanders
- Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, NSW, Australia.
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12
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Stollings JL, Kotfis K, Chanques G, Pun BT, Pandharipande PP, Ely EW. Delirium in critical illness: clinical manifestations, outcomes, and management. Intensive Care Med 2021; 47:1089-1103. [PMID: 34401939 PMCID: PMC8366492 DOI: 10.1007/s00134-021-06503-1] [Citation(s) in RCA: 116] [Impact Index Per Article: 38.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 07/29/2021] [Indexed: 12/22/2022]
Abstract
Delirium is the most common manifestation of brain dysfunction in critically ill patients. In the intensive care unit (ICU), duration of delirium is independently predictive of excess death, length of stay, cost of care, and acquired dementia. There are numerous neurotransmitter/functional and/or injury-causing hypotheses rather than a unifying mechanism for delirium. Without using a validated delirium instrument, delirium can be misdiagnosed (under, but also overdiagnosed and trivialized), supporting the recommendation to use a monitoring instrument routinely. The best-validated ICU bedside instruments are CAM-ICU and ICDSC, both of which also detect subsyndromal delirium. Both tools have some inherent limitations in the neurologically injured patients, yet still provide valuable information about delirium once the sequelae of the primary injury settle into a new post-injury baseline. Now it is known that antipsychotics and other psychoactive medications do not reliably improve brain function in critically ill delirious patients. ICU teams should systematically screen for predisposing and precipitating factors. These include exacerbations of cardiac/respiratory failure or sepsis, metabolic disturbances (hypoglycemia, dysnatremia, uremia and ammonemia) receipt of psychoactive medications, and sensory deprivation through prolonged immobilization, uncorrected vision and hearing deficits, poor sleep hygiene, and isolation from loved ones so common during COVID-19 pandemic. The ABCDEF (A2F) bundle is a means to facilitate implementation of the 2018 Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (PADIS) Guidelines. In over 25,000 patients across nearly 100 institutions, the A2F bundle has been shown in a dose-response fashion (i.e., greater bundle compliance) to yield improved survival, length of stay, coma and delirium duration, cost, and less ICU bounce-backs and discharge to nursing homes.
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Affiliation(s)
- Joanna L Stollings
- Critical Illness Brain Dysfunction Survivorship Center, Nashville, Vanderbilt University Medical Center, 1211 Medical Center Drive, B-131 VUH, Nashville, TN, 37232-7610, USA.
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Katarzyna Kotfis
- Department Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, Szczecin, Poland
| | - Gerald Chanques
- Department of Anaesthesia and Critical Care Medicine, Saint Eloi Hospital, Montpellier University Hospital Center, and PhyMedExp, University of Montpellier, INSERM, CNRS, Montpellier, France
| | - Brenda T Pun
- Critical Illness Brain Dysfunction Survivorship Center, Nashville, Vanderbilt University Medical Center, 1211 Medical Center Drive, B-131 VUH, Nashville, TN, 37232-7610, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Pratik P Pandharipande
- Critical Illness Brain Dysfunction Survivorship Center, Nashville, Vanderbilt University Medical Center, 1211 Medical Center Drive, B-131 VUH, Nashville, TN, 37232-7610, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - E Wesley Ely
- Critical Illness Brain Dysfunction Survivorship Center, Nashville, Vanderbilt University Medical Center, 1211 Medical Center Drive, B-131 VUH, Nashville, TN, 37232-7610, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA
- Geriatric Research, Education and Clinical Center Service, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care System, Nashville, TN, USA
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13
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Risk factors for postoperative delirium and subsyndromal delirium in older patients in the surgical ward: A prospective observational study. PLoS One 2021; 16:e0255607. [PMID: 34339463 PMCID: PMC8328296 DOI: 10.1371/journal.pone.0255607] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 07/20/2021] [Indexed: 11/19/2022] Open
Abstract
Postoperative delirium (POD) and subsyndromal delirium (SSD) among older patients is a common, serious condition associated with a high incidence of negative outcomes. However, there are few accurate methods for the early detection of POD and SSD in surgical wards. This study aimed to identify risk factors of POD and SSD in older patients who were scheduled for surgery in a surgical ward. This was a prospective observational study. Study participants were older than 65 years, underwent urology surgery, and were hospitalized in the surgical ward between April and September 2019. Delirium symptoms were assessed using the Confusion Assessment Method (CAM) on the preoperative day, the day of surgery, and postoperative days 1–3 by the surgical ward nurses. SSD was defined as the presence of one or more CAM criteria and the absence of a diagnosis of delirium based on the CAM algorithm. Personal characteristics, clinical data, cognitive function, physical functions, laboratory test results, medication use, type of surgery and anesthesia, and use of physical restraint and bed sensor were collected from medical records. Multiple logistic regression analyses were conducted to identify the risk factors for both POD and SSD. A total of 101 participants (mean age 74.9 years) were enrolled; 19 (18.8%) developed POD (n = 4) and SSD (n = 15). The use of bed sensors (odds ratio 10.2, p = .001) was identified as a risk factor for both POD and SSD. Our findings suggest that the use of bed sensors might be related to the development of both POD and SSD among older patients in surgical wards.
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14
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Cilloniz C, Peroni HJ, Gabarrús A, García-Vidal C, Pericàs JM, Bermejo-Martin J, Torres A. Lymphopenia Is Associated With Poor Outcomes of Patients With Community-Acquired Pneumonia and Sepsis. Open Forum Infect Dis 2021; 8:ofab169. [PMID: 34189165 PMCID: PMC8231373 DOI: 10.1093/ofid/ofab169] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 03/30/2021] [Indexed: 12/29/2022] Open
Abstract
Background Lymphopenia is a marker of poor prognosis in patients with community-acquired pneumonia (CAP), yet its impact on outcomes in patients with CAP and sepsis remains unknown. We aim to investigate the impact of lymphopenia on outcomes, risk of intensive care unit (ICU) admission, and mortality in CAP patients with sepsis. Methods This was a retrospective, observational study of prospectively collected data from an 800-bed tertiary teaching hospital (2005–2019). Results Of the 2203 patients with CAP and sepsis, 1347 (61%) did not have lymphopenia, while 856 (39%) did. When compared with the nonlymphopenic group, patients with sepsis and lymphopenia more frequently required ICU admission (P = .001), had a longer hospital length of stay (P ˂ .001), and presented with a higher rate of in-hospital (P ˂ .001) and 30-day mortality (P = .001). Multivariable analysis showed that C-reactive protein ≥15 mg/dL, lymphopenia, pleural effusion, and acute respiratory distress syndrome within 24 hours of admission were risk factors for ICU admission; age ≥80 years was independently associated with decreased ICU admission. In addition, age ≥80 years, chronic renal disease, chronic neurologic disease, being a nursing home resident, lymphopenia, and pleural effusion were independently associated with increased 30-day mortality, whereas pneumococcal vaccination, diabetes mellitus, and fever were independently associated with reduced 30-day mortality. Conclusions Lymphopenia was independently associated with risk of ICU admission and higher in-hospital and 30-day mortality in patients with CAP and sepsis. Early identification of lymphopenia could help identify septic patients with CAP who require or will shortly require critical care.
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Affiliation(s)
- Catia Cilloniz
- Department of Pneumology, Hospital Clinic of Barcelona, Barcelona, Spain.,August Pi i Sunyer Biomedical Research Institute-IDIBAPS, University of Barcelona, Barcelona, Spain.,Biomedical Research Networking Centres in Respiratory Diseases (Ciberes) Barcelona, Spain
| | - Héctor José Peroni
- Respiratory Medicine Unit, Internal Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.,Emergency Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Albert Gabarrús
- Department of Pneumology, Hospital Clinic of Barcelona, Barcelona, Spain.,August Pi i Sunyer Biomedical Research Institute-IDIBAPS, University of Barcelona, Barcelona, Spain.,Biomedical Research Networking Centres in Respiratory Diseases (Ciberes) Barcelona, Spain
| | | | - Juan M Pericàs
- Infectious Disease Department, Hospital Clinic of Barcelona, Barcelona, Spain.,Vall d'Hebron Institute for Research, Barcelona, Spain
| | - Jesús Bermejo-Martin
- Group for Biomedical Research in Sepsis (BioSepsis), Instituto de Investigación Biomédica de Salamanca (IBSAL), Paseo de San Vicente, Salamanca, Spain.,Hospital Universitario Río Hortega de Valladolid, Valladolid, Spain
| | - Antoni Torres
- Department of Pneumology, Hospital Clinic of Barcelona, Barcelona, Spain
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15
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Subsyndromal Delirium in Cardiac Surgery Patients: Risk Factors and Outcomes of the Different Trajectories. J Cardiovasc Nurs 2021; 37:41-49. [PMID: 33657067 DOI: 10.1097/jcn.0000000000000793] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Subsyndromal delirium (SSD), a subthreshold form of delirium, is related to longer length of stay and increased mortality rates among older adults. Risk factors and outcomes of SSD in cardiac surgery patients are not fully understood. OBJECTIVE The aim of this study was to assess and describe the characteristics and outcomes related to trajectories of SSD and delirium in cardiac surgery patients. METHODS In this secondary analysis of a retrospective case-control (1:1) cohort study, SSD was defined as a score between 1 and 3 on the Intensive Care Delirium Screening Checklist paired with an absence of diagnosis of delirium on the day of assessment. Potential risk factors (eg, age) and outcomes (eg, mortality) were identified from existing literature. Patients were grouped into 4 trajectories: (1) without SSD or delirium, (2) SSD only, (3) both, and (4) delirium only. These trajectories were contrasted using analysis of variance or χ2 test. RESULTS Among the cohort of 346 patients, 110 patients did not present with SSD or delirium, 62 presented with only SSD, 69 presented with both, and 105 presented with only delirium. In comparison with patients without SSD or delirium, patients with SSD presented preoperative risk factors known for delirium (ie, older age, higher European System for Cardiac Operative Risk Evaluation II) but underwent less complicated surgical procedures, received fewer transfusions postoperatively, and had a lower positive fluid balance postoperatively than patients who presented with delirium. Patients with both SSD and delirium had worse outcomes in comparison with those with delirium only. CONCLUSION This study stresses the importance for healthcare professionals to identify SSD and prevent its progression to delirium.
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Abstract
This integrative review presents the most recent and relevant critical care nursing research publications in the United States. A comprehensive search identified publications on the topics of delirium; early mobility; communication; palliative care; tele-intensive care unit; care bundle implementation; and prevention, detection, and early management of infection. The evidence is summarized for each of these topics, as well as other research, with suggestions and guidance for end users.
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Affiliation(s)
- Sheila A Alexander
- Acute and Tertiary Care, School of Nursing, Critical Care Medicine, School of Medicine, University of Pittsburgh, 336 Victoria Building, 3500 Victoria Street, Pittsburgh, PA 15261, USA.
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The CAM-ICU-7 and ICDSC as measures of delirium severity in critically ill adult patients. PLoS One 2020; 15:e0242378. [PMID: 33196655 PMCID: PMC7668609 DOI: 10.1371/journal.pone.0242378] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 11/01/2020] [Indexed: 11/19/2022] Open
Abstract
Background In clinical practice, a dichotomous approach to delirium identification may no longer be relevant when existing delirium screening tools measure a range of scores. The objective of this study was to compare the Confusion Assessment Method for the Intensive Care Unit 7-item (CAM-ICU-7) and the Intensive Care Delirium Screening Checklist (ICDSC) as measures of the spectrum of delirium severity in critically ill adult patients. Methods In this cross-sectional study, 218 patients underwent 641 paired assessments by bedside nurses (ICDSC, as per usual care) and trained research assistants (CAM-ICU-7). Correlation between the CAM-ICU-7 and ICDSC scores was evaluated. Logistic regression was used to explore associations between CAM-ICU-7 or ICDSC score and length of ICU stay and mechanical ventilation (receipt, ≥96 hours). Results Delirium prevalence evaluated by the CAM-ICU-7 and ICDSC were 46.3% (95% CI:39.7–53.0) and 34.4% (95% CI:28.3–41.0). Prevalence of less than clinical threshold symptoms of delirium evaluated by the CAM-ICU-7 (score: 1–2) and ICDSC (score: 1–3) were 30.3% (95%CI:24.5–36.7) and 50.9% (95%CI:44.3–57.6). The CAM-ICU-7 and ICDSC had significant positive correlation (0.58, p<0.001). Agreement between the tools as measures of delirium was moderate (kappa = 0.51) and as measures of less than clinical threshold symptoms of delirium was fair (kappa = 0.21). Less than clinical threshold symptoms of delirium identified by the ICDSC, not CAM-ICU-7, were associated with prolonged length of ICU stay (≥7 days) in patients <65 years of age [Odds Ratio (OR) 9.2, 95% CI:2.5–34.0] and mechanical ventilation (receipt: OR 2.8, 95% CI:1.3–6.4; ≥96 hours: OR 6.6, 95% CI:1.9–22.9), when compared to patients with no delirium. Conclusions The CAM-ICU-7 and ICDSC are measures of the spectrum of delirium severity that are closely correlated. Less than clinical threshold symptoms of delirium measure by the ICDSC is a better predictor of outcomes, when compared with the CAM-ICU-7.
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Browning SG, Watters R, Thomson-Smith C. Impact of Therapeutic Music Listening on Intensive Care Unit Patients: A Pilot Study. Nurs Clin North Am 2020; 55:557-569. [PMID: 33131632 DOI: 10.1016/j.cnur.2020.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
This pilot study investigated the association between patient-specific, therapeutic music listening as a nursing intervention for mechanically ventilated patients, and the proportion of time those patients were considered to have intensive care unit delirium. The pilot study used the person-centered nursing framework as its theoretic foundation. Findings from an intimate prospective cohort design encourage an expanded look at potential benefits of therapeutic music listening in large, multisite, randomized clinical trials. Research and practice implications are discussed.
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Affiliation(s)
- Stacey G Browning
- Whitson-Hester School of Nursing, Tennessee Technological University, P.O. Box 5001, Cookeville, TN 38505, USA.
| | - Richard Watters
- Vanderbilt University School of Nursing, 218 Godchaux Hall, Nashville, TN 37240, USA
| | - Clare Thomson-Smith
- Vanderbilt University School of Nursing, 217 Godchaux Hall, Nashville, TN 37240, USA
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Quantification of Neurological Blood-Based Biomarkers in Critically Ill Patients With Coronavirus Disease 2019. Crit Care Explor 2020; 2:e0238. [PMID: 33063038 PMCID: PMC7535554 DOI: 10.1097/cce.0000000000000238] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Supplemental Digital Content is available in the text. Objectives: To provide an objective characterization of acute neurologic injury in critically ill patients with coronavirus disease 2019. Design: Prospective observational study. Demographics, comorbidities, and daily clinical physiologic and laboratory data were collected. Plasma levels of neurofilament-light chain, total tau, ubiquitin carboxy-terminal hydrolase L1, and glial fibrillary acidic protein were measured. The primary neurologic outcome was delirium defined by the Intensive Care Delirium Screening Checklist (scale 1–8). Associations among plasma biomarkers, respiratory failure, and inflammation were analyzed. Setting: Multicenter study in ICUs. Patients: Critically ill patients with respiratory failure, with coronavirus disease 2019, or without (ICU control). Measurements and Main Results: A total of 27 patients with coronavirus disease 2019 and 19 ICU controls were enrolled. Compared with ICU controls with pneumonia of other etiology, patients with coronavirus disease 2019 had significantly higher glial fibrillary acidic protein (272 pg/mL [150–555 pg/mL] vs 118 pg/mL [78.5–168 pg/mL]; p = 0.0009). In coronavirus disease 2019 patients, glial fibrillary acidic protein (rho = 0.5115, p = 0.0064), ubiquitin carboxy-terminal hydrolase L1 (rho = 0.4056, p = 0.0358), and neurofilament-light chain (rho = 0.6223, p = 0.0005) positively correlated with Intensive Care Delirium Screening Checklist score and were increased in patients with delirium (Intensive Care Delirium Screening Checklist ≥ 4) in the coronavirus disease 2019 group but not in ICU controls. There were no associations between the measures of respiratory function or cytokines with glial fibrillary acidic protein, total tau, ubiquitin carboxy-terminal hydrolase L1, or neurofilament-light chain levels in patients with coronavirus disease 2019. Conclusions: Plasma glial fibrillary acidic protein is two-fold higher in critically ill patients with coronavirus disease 2019 compared with ICU controls. Higher levels of glial fibrillary acidic protein, ubiquitin carboxy-terminal hydrolase L1, and neurofilament-light chain associate with delirium in patients with coronavirus disease 2019. Elevated plasma glial fibrillary acidic protein, ubiquitin carboxy-terminal hydrolase L1, and neurofilament-light chain are independent of respiratory function and peripheral cytokines.
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21
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Atterton B, Paulino MC, Povoa P, Martin-Loeches I. Sepsis Associated Delirium. ACTA ACUST UNITED AC 2020; 56:medicina56050240. [PMID: 32443606 PMCID: PMC7279289 DOI: 10.3390/medicina56050240] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 05/13/2020] [Accepted: 05/14/2020] [Indexed: 01/04/2023]
Abstract
Sepsis is a potentially life-threatening condition caused by a systemic dysregulated host response to infection. The brain is particularly susceptible to the effects of sepsis with clinical manifestations ranging from mild confusion to a deep comatose state. Sepsis-associated delirium (SAD) is a cerebral manifestation commonly occurring in patients with sepsis and is thought to occur due to a combination of neuroinflammation and disturbances in cerebral perfusion, the blood brain barrier (BBB) and neurotransmission. The neurological impairment associated with SAD can persist for months or even longer, after the initial septic episode has subsided which may impair the rehabilitation potential of sepsis survivors. Early identification and treatment of the underlying sepsis is key in the management of SAD as once present it can be difficult to control. Through the regular use of validated screening tools for delirium, cases of SAD can be identified early; this allows potentially aggravating factors to be addressed promptly. The usefulness of biomarkers, neuroimaging and electroencephalopathy (EEG) in the diagnosis of SAD remains controversial. The Society of Critical Care Medicine (SCCM) guidelines advise against the use of medications to treat delirium unless distressing symptoms are present or it is hindering the patient’s ability to wean from organ support.
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Affiliation(s)
- Ben Atterton
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James’s Hospital, St. James Street, Dublin 8, Dublin, D08 NHY1, Ireland;
| | - Maria Carolina Paulino
- Polyvalent Intensive Care Unit, São Francisco Xavier Hospital, Centro Hospitalar de Lisboa Ocidental, 1449-005 Lisbon, Portugal; (M.C.P.); (P.P.)
| | - Pedro Povoa
- Polyvalent Intensive Care Unit, São Francisco Xavier Hospital, Centro Hospitalar de Lisboa Ocidental, 1449-005 Lisbon, Portugal; (M.C.P.); (P.P.)
- NOVA Medical School, CHRC, New University of Lisbon, 1099-085 Lisbon, Portugal
- Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, 5000 Odense, Denmark
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James’s Hospital, St. James Street, Dublin 8, Dublin, D08 NHY1, Ireland;
- Hospital Clinic, IDIBAPS, Universidad de Barcelona, Ciberes, 08036 Barcelona, Spain
- Correspondence:
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Serafim RB, Paulino MC, Povoa P. What every intensivist needs to know about subsyndromal delirium in the intensive care unit. Rev Bras Ter Intensiva 2020; 32:14-16. [PMID: 32401995 PMCID: PMC7206940 DOI: 10.5935/0103-507x.20200004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 10/15/2019] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Maria Carolina Paulino
- Unidade Polivalente de Terapia Intensiva, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal
| | - Pedro Povoa
- Unidade Polivalente de Terapia Intensiva, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal
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Vahidy FS, Bambhroliya AB, Meeks JR, Rahman O, Ely EW, Slooter AJC, Tyson JE, Miller CC, McCullough LD, Savitz SI, Khan B. In-hospital outcomes and 30-day readmission rates among ischemic and hemorrhagic stroke patients with delirium. PLoS One 2019; 14:e0225204. [PMID: 31725810 PMCID: PMC6855446 DOI: 10.1371/journal.pone.0225204] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 10/29/2019] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Delirium is associated with poor outcomes among critically ill patients. However, it is not well characterized among patients with ischemic or hemorrhagic stroke (IS and HS). We provide the population-level frequency of in-hospital delirium and assess its association with in-hospital outcomes and with 30-day readmission among IS and HS patients. METHODS We analyzed Nationwide in-hospital and readmission data for years 2010-2015 and identified stroke patients using ICD-9 codes. Delirium was identified using validated algorithms. Outcomes were in-hospital mortality, length of stay, unfavorable discharge disposition, and 30-day readmission. We used survey design logistic regression methods to provide national estimates of proportions and 95% confidence intervals (CI) for delirium, and odds ratios (OR) for association between delirium and poor outcomes. RESULTS We identified 3,107,437 stroke discharges of whom 7.45% were coded to have delirium. This proportion significantly increased between 2010 (6.3%) and 2015 (8.7%) (aOR, 95% CI: 1.04, 1.03-1.05). Delirium proportion was higher among HS patients (ICH: 10.0%, SAH: 9.8%) as compared to IS patients (7.0%). Delirious stroke patients had higher in-hospital mortality (12.3% vs. 7.8%), longer in-hospital stay (11.6 days vs. 7.3 days) and a significantly greater adjusted risk of 30-day-readmission (16.7%) as compared to those without delirium (12.2%) (aRR, 95% CI: 1.13, 1.11-1.15). Upon readmission, patients with delirium at initial admission continued to have a longer length of stay (7.7 days vs. 6.6 days) and a higher in-hospital mortality (9.3% vs. 6.4%). CONCLUSION Delirium identified through claims data in stroke patients is independently associated with poor in-hospital outcomes both at index admission and readmission. Identification and management of delirium among stroke patients provides an opportunity to improve outcomes.
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Affiliation(s)
- Farhaan S. Vahidy
- The Institute of Stroke and Cerebrovascular Diseases and The Department of Neurology, McGovern Medical School at University of Texas Health Science Center, Houston, Texas, United States of America
| | - Arvind B. Bambhroliya
- The Institute of Stroke and Cerebrovascular Diseases and The Department of Neurology, McGovern Medical School at University of Texas Health Science Center, Houston, Texas, United States of America
| | - Jennifer R. Meeks
- The Institute of Stroke and Cerebrovascular Diseases and The Department of Neurology, McGovern Medical School at University of Texas Health Science Center, Houston, Texas, United States of America
| | - Omar Rahman
- Division of Pulmonary/Critical Care, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - E. Wesley Ely
- Critical Illness, Brain Dysfunction, Survivorship (CIBS) Center, Vanderbilt University Medical Center, Department of Medicine, Nashville, Tennessee, United States of America
- Tennessee Valley Veteran’s Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, TN, United States of America
| | - Arjen J. C. Slooter
- Department of Intensive Care Medicine and Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jon E. Tyson
- Center for Clinical Research and Evidence Based Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, United States of America
| | - Charles C. Miller
- Center for Clinical Research and Evidence Based Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, United States of America
| | - Louise D. McCullough
- The Institute of Stroke and Cerebrovascular Diseases and The Department of Neurology, McGovern Medical School at University of Texas Health Science Center, Houston, Texas, United States of America
| | - Sean I. Savitz
- The Institute of Stroke and Cerebrovascular Diseases and The Department of Neurology, McGovern Medical School at University of Texas Health Science Center, Houston, Texas, United States of America
| | - Babar Khan
- Division of Pulmonary/Critical Care, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
- Indiana University Center for Aging Research, Regenstrief Institute, Inc, Indiana University Center for Health Innovation and Implementation Science; Indiana Clinical and Translational Sciences Institute, Indianapolis, Indiana, United States of America
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Gutierrez R, Egaña JI, Saez I, Reyes F, Briceño C, Venegas M, Lavado I, Penna A. Intraoperative Low Alpha Power in the Electroencephalogram Is Associated With Postoperative Subsyndromal Delirium. Front Syst Neurosci 2019; 13:56. [PMID: 31680886 PMCID: PMC6813625 DOI: 10.3389/fnsys.2019.00056] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 10/03/2019] [Indexed: 12/15/2022] Open
Abstract
Background Postoperative delirium (PD) and subsyndromal delirium (PSSD) are frequent complications in older patients associated with poor long-term outcome. It has been suggested that certain electroencephalogram features may be capable of identifying patients at risk during surgery. Thus, the goal of this study was to characterize intraoperative electroencephalographic markers to identify patients prone to develop PD or PSSD. Methods We conducted an exploratory observational study in older patients scheduled for elective major abdominal surgery. Intraoperative 16 channels electroencephalogram was recorded, and PD/PSSD were diagnosed after surgery with the confusion assessment method (CAM). The total power spectra and relative power of alpha band were calculated. Results PD was diagnosed in 2 patients (6.7%), and 11 patients (36.7%) developed PSSD. All of them (13 patients, PD/PSSD group) were compared with patients without any alterations in CAM (17 patients, control group). There were no detectable power spectrum differences before anesthesia between both groups of patients. However, PD/PSSD group in comparison with control group had a lower intraoperative absolute alpha power during anesthesia (4.4 ± 3.8 dB vs. 9.6 ± 3.2 dB, p = 0.0004) and a lower relative alpha power (0.09 ± 0.06 vs. 0.21 ± 0.08, p < 0.0001). These differences were independent of the anesthetic dose. Finally, relative alpha power had a good ability to identify patients with CAM alterations in the ROC analysis (area under the curve 0.90 (CI 0.78-1), p < 0.001). Discussion In conclusion, a low intraoperative alpha power is a novel electroencephalogram marker to identify patients who will develop alterations in CAM - i.e., with PD or PSSD - after surgery.
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Affiliation(s)
- Rodrigo Gutierrez
- Departamento de Anestesiología y Medicina Perioperatoria, Hospital Clínico, Universidad de Chile, Santiago, Chile.,Centro de Investigación Clínica Avanzada (CICA), Facultad de Medicina, Hospital Clínico, Universidad de Chile, Santiago, Chile
| | - Jose I Egaña
- Departamento de Anestesiología y Medicina Perioperatoria, Hospital Clínico, Universidad de Chile, Santiago, Chile
| | - Iván Saez
- Centro de Investigación Clínica Avanzada (CICA), Facultad de Medicina, Hospital Clínico, Universidad de Chile, Santiago, Chile
| | - Fernando Reyes
- Departamento de Anestesiología y Medicina Perioperatoria, Hospital Clínico, Universidad de Chile, Santiago, Chile
| | - Constanza Briceño
- Departamento de Terapia Ocupacional y Ciencia de la Ocupación, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Mariana Venegas
- Escuela de Medicina, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Isidora Lavado
- Escuela de Medicina, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Antonello Penna
- Departamento de Anestesiología y Medicina Perioperatoria, Hospital Clínico, Universidad de Chile, Santiago, Chile.,Centro de Investigación Clínica Avanzada (CICA), Facultad de Medicina, Hospital Clínico, Universidad de Chile, Santiago, Chile
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Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Crit Care Med 2019; 46:e825-e873. [PMID: 30113379 DOI: 10.1097/ccm.0000000000003299] [Citation(s) in RCA: 1822] [Impact Index Per Article: 364.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To update and expand the 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU. DESIGN Thirty-two international experts, four methodologists, and four critical illness survivors met virtually at least monthly. All section groups gathered face-to-face at annual Society of Critical Care Medicine congresses; virtual connections included those unable to attend. A formal conflict of interest policy was developed a priori and enforced throughout the process. Teleconferences and electronic discussions among subgroups and whole panel were part of the guidelines' development. A general content review was completed face-to-face by all panel members in January 2017. METHODS Content experts, methodologists, and ICU survivors were represented in each of the five sections of the guidelines: Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption). Each section created Population, Intervention, Comparison, and Outcome, and nonactionable, descriptive questions based on perceived clinical relevance. The guideline group then voted their ranking, and patients prioritized their importance. For each Population, Intervention, Comparison, and Outcome question, sections searched the best available evidence, determined its quality, and formulated recommendations as "strong," "conditional," or "good" practice statements based on Grading of Recommendations Assessment, Development and Evaluation principles. In addition, evidence gaps and clinical caveats were explicitly identified. RESULTS The Pain, Agitation/Sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) panel issued 37 recommendations (three strong and 34 conditional), two good practice statements, and 32 ungraded, nonactionable statements. Three questions from the patient-centered prioritized question list remained without recommendation. CONCLUSIONS We found substantial agreement among a large, interdisciplinary cohort of international experts regarding evidence supporting recommendations, and the remaining literature gaps in the assessment, prevention, and treatment of Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) in critically ill adults. Highlighting this evidence and the research needs will improve Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) management and provide the foundation for improved outcomes and science in this vulnerable population.
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Assessment of Delirium Using the Confusion Assessment Method in Older Adult Inpatients in Malaysia. Geriatrics (Basel) 2019; 4:geriatrics4030052. [PMID: 31514465 PMCID: PMC6787739 DOI: 10.3390/geriatrics4030052] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 09/02/2019] [Accepted: 09/10/2019] [Indexed: 11/28/2022] Open
Abstract
The detection of delirium in acutely ill older patients is challenging with the lack of informants and the necessity to identify subtle and fluctuating signs. We conducted a cross-sectional study among older patients admitted to a university hospital in Malaysia to determine the presence, characteristics, and mortality outcomes of delirium. Consecutive patients aged ≥65years admitted to acute medical wards were recruited from August to September 2016. Cognitive screening was performed using the mini-mental test examination (MMSE) and the Confusion Assessment Method (CAM). The CAM-Severity (CAM-S) score was also performed in all patients. Of 161 patients recruited, 43 (26.7%) had delirium. At least one feature of delirium from the CAM-S short and long severity scores were present in 48.4% and 67.1%, respectively. Older age (OR: 1.07, 95% CI: 1.01–1.14), immobility (OR: 3.16, 95% CI: 1.18–8.50), cognitive impairment (OR: 5.04, 95% CI: 2.07–12.24), and malnutrition (OR: 3.37; 95% CI: 1.15–9.85) were significantly associated with delirium. Older patients with delirium had a higher risk of mortality (OR: 7.87, 95% CI: 2.42–25.57). Delirium is common among older patients in our setting. A large proportion of patients had altered mental status on admission to hospital although they did not fulfill the CAM criteria of delirium. This should prompt further studies on strategies to identify delirium and the use of newer, more appropriate assessment tools in this group of vulnerable individuals.
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Delirium: Evaluation and Management. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2019. [DOI: 10.1007/s40141-019-00223-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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