Delirium Monitoring: Yes or No? That Is The Question

Diagnosing delirium in perioperative and intensive care medicine

PURPOSE OF REVIEW

This article reviews the current literature on instruments used for screening and diagnosing delirium in perioperative and intensive care medicine. It summarizes recent findings to guide clinicians and researchers in choosing the most appropriate tools.

RECENT FINDINGS

The incidence of delirium in hospitalized patients ranges from 5% to over 50%, depending on the population of patients studied. Failure to diagnose delirium in a timely manner is associated with serious adverse outcomes, including death and institutionalization. Valid assessment tests are needed for delirium detection, as early identification and treatment of delirium may help to prevent complications. Currently, there are more than 30 available instruments, which have been developed to assist with the screening and diagnosis of delirium. However, these tools vary greatly in sensitivity, specificity, and administration time, and their overabundance challenges the selection of specific tool as well as direct comparisons and interpretation of results across studies.

SUMMARY

Overlooking or misdiagnosing delirium may result in poor patient outcomes. Familiarizing healthcare workers with the variety of delirium assessments and selecting the most appropriate tool to their needs is an important step toward improving awareness and recognition of delirium.

The Delirium Interview as a new reference standard in studies on delirium assessment tools

BACKGROUND

The reference standard in studies on delirium assessment tools is usually based on the clinical judgment of only one delirium expert and may be concise, unstandardized, or not specified at all. This multicenter study investigated the performance of the Delirium Interview, a new reference standard for studies on delirium assessment tools allowing classification of delirium based on written reports.

METHODS

We tested the diagnostic accuracy of our standardized Delirium Interview by comparing delirium assessments of the reported results with live assessments. Our reference, the live assessment, was performed by two delirium experts and one well-trained researcher who registered the results. Their delirium assessment was compared to the majority vote of three other independent delirium experts who judged the rapportage of the Delirium Interview. Our total pool consisted of 13 delirium experts with an average of 13 ± 8 years of experience.

RESULTS

We included 98 patients (62% male, mean age 69 ± 12 years), of whom 56 (57%) intensive care units (ICUs) patients, 22 (39%) patients with a Richmond Agitation Sedation Scale (RASS) < 0 and 26 (27%) non-verbal assessments. The overall prevalence of delirium was 28%. The Delirium Interview had a sensitivity of 89% (95% confidence interval [CI]: 71%-98%) and specificity of 82% (95% CI: 71%-90%), compared to the diagnosis of an independent panel of two delirium experts and one researcher who examined the patients themselves. Negative and positive predictive values were 95% (95% CI: 86%-0.99%), respectively, 66% (95% CI: 49%-80%). Stratification into ICU and non-ICU patients yielded similar results.

CONCLUSION

The Delirium Interview is a feasible reference method for large study cohorts evaluating delirium assessment tools since experts could assess delirium with high accuracy without seeing the patient at the bedside.

Delirium prevention and management in hospitalized older adults

ABSTRACT

Delirium is a common neurocognitive disorder among hospitalized older adults, and it can have devastating effects. The purpose of this article is to inform NPs in the hospital setting to recognize, prevent, and manage delirium in older adults. The roles of nonpharmacologic and pharmacologic interventions are described.

Factors Associated With Spontaneous Awakening Trial and Spontaneous Breathing Trial Performance in Adults With Critical Illness: Analysis of a Multicenter, Nationwide, Cohort Study

BACKGROUND

Broad-scale adoption of spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs) into everyday practice has been slow, and uncertainty exists regarding what factors facilitate or impede their routine delivery.

RESEARCH QUESTION

What patient, practice, and pharmacologic factors are associated with SAT and SBT performance and to what extent do they predict overall SAT/SBT performance?

STUDY DESIGN AND METHODS

This secondary analysis used data collected from a national quality improvement collaborative composed of 68 diverse ICUs. Adults with critical illness adults who received mechanical ventilation and/or continuously infused sedative medications were included. We performed mixed-effects logistic regression modeling, created receiver operating characteristic curves, and calculated the area under the curve (AUC).

RESULTS

Included in the SAT and SBT analysis were 4,847 and 4,938 patients, respectively. In multivariable models controlling for admitting patient characteristics, factors independently associated with higher odds of a next-day SAT and SBT included physical restraint use (adjusted odds ratio [AOR], 1.63; 95% CI, 1.42-1.87; AOR, 1.83; 95% CI, 1.60-2.09), documented target sedation level (AOR, 1.68; 95% CI, 1.41-2.01; AOR, 1.46; 95% CI, 1.24-1.72), more frequent level of arousal assessments (AOR, 1.22; 95% CI, 1.03-1.43; AOR, 1.32; 95% CI, 1.13-1.54), and dexmedetomidine administration (AOR, 1.23; 95% CI, 1.05-1.45; AOR, 1.52; 95% CI, 1.27-1.80). Factors independently associated with lower odds of a next-day SAT and SBT included deep sedation/coma (AOR, 0.69; 95% CI, 0.60-0.80; AOR, 0.33; 95% CI, 0.28-0.37) and benzodiazepine (AOR, 0.83; 95% CI, 0.72-0.95; AOR, 0.67; 95% CI, 0.59-0.77) or ketamine (AOR, 0.34; 95% CI, 0.16-0.71; AOR, 0.40; 95% CI, 0.18-0.88) administration. Models incorporating admitting, daily, and unit variations displayed moderate discriminant accuracy in predicting next-day SAT (AUC, 0.73) and SBT (AUC, 0.72) performance.

INTERPRETATION

There are a number of modifiable factors associated with SAT/SBT performance that are amenable to the development and testing of implementation interventions.

The DEMS-DOSS study: validating a delirium monitoring tool in hospitalised older adults

Objective

to evaluate the sensitivity, specificity and test–retest reliability of the Delirium Early Monitoring System-Delirium Observation Screening Scale (DEMS-DOSS).

Design

prospective diagnostic accuracy study of a convenience sample of admitted older adults with DEMS-DOSS and reference standard assessments.

Setting

60-bed aged care precinct at a metropolitan hospital in Sydney, Australia.

Participants

156 patients (aged ≥65 years old) were recruited to participate between April 2018 and March 2020. One hundred participants were included in the analysis.

Measurements

Participants were scored on the DEMS-DOSS. Trained senior aged care nurses conducted a standardised clinical interview based on the Diagnostic and Statistical Manual of Mental Disorder (DSM)-IV delirium criteria, within two hours of DEMS-DOSS completion. The senior aged care nurse undertaking the DSM-IV interview was blinded to the results of the DEMS-DOSS.

Results

Participants’ mean age was 84 (SD ±7.3) years and 39% (n = 39) had a documented diagnosis of dementia. Delirium was detected in 38% (n = 38) according to the reference standard. The DEMS-DOSS had a sensitivity of 76.3% and a specificity of 75.8% for delirium. The area under the receiver operating characteristics curve for delirium was 0.76. The test–retest reliability of the DEMS-DOSS was found to be high (r = 0.915).

Conclusion

DEMS-DOSS is a sensitive and specific tool to assist with monitoring new onset and established delirium in hospitalised older adults. Further studies are required to evaluate the impact of the monitoring tool on health outcomes.

Inclusion of interleukin-6 improved performance of postoperative delirium prediction for patients undergoing coronary artery bypass graft (POD-CABG): A derivation and validation study

BACKGROUND

Patients undergoing coronary artery bypass graft (CABG) are at high risk for developing postoperative delirium (POD). A simple prediction rule may benefit patients from early identification of POD followed by adequate preventive strategies. The purpose of the current study was to develop and validate a POD prediction rule for patients undergoing CABG (POD-CABG), by considering all possible perioperative factors.

METHODS

In this prospective cohort study, patients who underwent first elective isolated CABG were continuously enrolled from May 2014 to November 2015 in a tertiary hospital. Delirium was assessed using the Confusion Assessment Method for Intensive Care Unit. Patients' perioperative risk factors were collected through interviews and review of medical records. The area under receiver-operating characteristic curve (AUC) was used to assess the overall performance of the predictive rule.

RESULTS

A total of 242 and 148 patients were enrolled in the derivation and validation cohorts, respectively. Multiple logistic regression analysis identified seven variables that were independently associated with POD: age (≥65 years), gender (female), history of myocardial infarction and diabetes mellitus, postoperative atrial fibrillation, the use of intra-aortic balloon pump, and serum interleukin-6 ≥478 pg/ml at 18 hours after surgery. The AUC of the POD-CABG was 0.84 (95% CI, 0.79-0.90) in the derivation cohort, and was 0.86 (95% CI, 0.80-0.91) after bootstrap resampling. The AUC was 0.81 (95% CI, 0.73-0.88) after the POD-CABG was applied to the validation cohort.

CONCLUSIONS

The POD-CABG with inclusion of interleukin-6 demonstrated good performance in predicting POD.

Diagnosis and Risk Factors for Delirium in Elderly Patients in the Emergency Rooms and Intensive Care Unit of the National Geriatric Hospital Emergency Department: A Cross-Sectional Observational Study

Purpose

To diagnose delirium and identify risk factors for its development in elderly patients in the emergency department (ED) and intensive care units (ICU) at the National Geriatric Hospital (Vietnam).

Patients and Methods

A cross-sectional observational study was conducted with a convenience sample of non-surgical patients admitted to ED and ICU at Hanoi National Geriatric Hospital in Vietnam. In total, 163 patients met the selection criteria and were included in the study. Screening involved using the Confusion Assessment Method (CAM) and the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). The diagnosis was established according to the DSM-5 and ICD-10 codes.

Results

Delirium was found in a total of 106 (63.1%) patients. The factors significantly affecting its development were vision impairment (OR, 3.3; 95% CI, 1.5 to 7.4, P=0.003), hearing impairment (OR, 3.6; 95% CI, 1.77 to 7.36, P=0.0001), acute or chronic kidney failure (OR, 7.1; 95% CI, 2.05 to 6.39, P<0.001), respiratory disorders (OR, 2.7; 95% CI, 1.4 to 5.2, P=0.004), and malnutrition (OR, 9.17; 95% CI, 3.43–24.5, P=0.0001). The list also include the fall risk factors (OR, 12.2; 95% CI, 4.1–36.3, P=0.0001), frailty (OR, 8.35; 95% CI, 3.4–20.6, P=0.0001), activities of daily living (OR, 8.35; 95% CI, 3.4–20.6, P=0.0001), hyponatremia (OR, 2.48; 95% CI, 1.07 to 5.75, P=0.001), hypernatremia (OR, 13.1; 95% CI, 1.67 to 2.5, P=0.001), and treatment interventions. In addition, delirium was linked to the duration of ICU admission (OR, 6.53; 95% CI, 4.5–25.5, P < 0.0001).

Conclusion

The CAM/CAM-ICU diagnostic algorithm makes it possible to diagnose delirium successfully. The present study confirmed the role of several premorbid and triggering factors in the occurrence of delirium in elderly patients in ED and ICU. There is a need for further research into risk factors for delirium in elderly patients.

Delirium Severely Worsens Outcome in Patients with COVID-19-A Retrospective Cohort Study from Temporary Critical Care Hospitals

Delirium is a sign of deterioration of homeostasis and worse prognosis. The aim of this study was to investigate the frequency, risk factors and prognosis of delirium in patients with COVID-19 in a temporary acute setting hospital. A retrospective cohort analysis of data collected between October 2020 and February 2021 from two temporary acute care hospitals was performed. All consecutive hospitalized patients ≥18 years old with COVID-19 were included. An assessment of consciousness was carried out at least two times a day, including neurological examination. Delirium was identified through retrospective chart review according to DSM-5 criteria if present at least once during hospitalization. Analysis included 201 patients, 39 diagnosed with delirium (19.4%). Delirious patients were older (p < 0.001), frailer (p < 0.001) and the majority were male (p = 0.002). Respiratory parameters were worse in this group with higher oxygen flow (p = 0.013), lower PaO2 (p = 0.043) and higher FiO2 (p = 0.006). The mortality rate was significantly higher in patients with delirium (46.15% vs 3.70%, p < 0.001) with OR 17.212 (p < 0.001) corrected for age and gender. Delirious patients experienced significantly more complications: cardiovascular (OR 7.72, p < 0.001), pulmonary (OR 8.79, p < 0.001) or septic (OR 3.99, p = 0.029). The odds of mortality in patients with COVID-19 presenting with delirium at any point of hospitalization were seventeen times higher.

Postoperative Delirium is Not Associated with Long-Term Decline in Activities of Daily Living or Mortality After Laryngectomy

Purpose

To determine the relationships between postoperative delirium (POD) and postoperative activities of daily living (ADL) and mortality in patients undergoing laryngectomy. We hypothesized that POD would reduce postoperative ADL and increase postoperative mortality.

Patients and Methods

The prospective study included older participants (age ≥65 y) undergoing total laryngectomy, partial laryngectomy, total laryngectomy plus neck dissection, or partial laryngectomy plus neck dissection under general anesthesia. The diagnosis of delirium was based on the Confusion Assessment Method algorithm, which was administered on postoperative days 1 through 6. ADL were evaluated using the Chinese version of the Index of ADL scale. Follow-up assessments of ADL and mortality were conducted 24 months after surgery.

Results

Of 127 participants (aged 70.3 ± 4.1 y), 19 (15.0%) developed POD. POD was not associated with a decrease in ADL after laryngectomy (p=0.599) nor with an increase in postoperative mortality [3/19 (15.8%) vs 12/108 (11.1%), p=0.560, Log rank test]. However, longer surgery duration was significantly associated with worse overall survival (OR, 3.262; 95% CI, 1.261–9.169, p=0.025).

Conclusion

POD was not associated with long-term ADL or mortality after laryngectomy. Prolonged surgery was the only factor associated with a higher postoperative mortality rate.

Occurrence of Delirium during ECMO Therapy in a Critical Care Unit in Poland-A Cross-Sectional Pilot Study

BACKGROUND

The problem of delirium during extracorporeal membrane oxygenation (ECMO) therapy, which has rarely been studied, is an important issue since it is necessary to ensure patient safety during therapy. This study aimed to show the incidence of delirium in patients after extracorporeal membrane oxygenation therapy and factors affecting the occurrence of delirium in this group of patients.

DESIGN

A cross-sectional study was conducted.

METHOD

The study involved a group of patients from an intensive cardiac care unit who received extracorporeal membrane oxygenation therapy. The study lasted for more than two years, in the period from 2018 until 2020. The Nursing Delirium Screening Scale (NuDESC) and the Delirium Observation Screening Scale (DOSS) were applied. Additionally, the patients were examined using Numeric Rating Scale (NRS), the Insomnia Severity Index (ISI), the Richmond Agitation Sedation Scale (RASS), the Ramsay Sedation Scale (RSS), and a thirst intensity scale; ultimately, relationships between these factors and delirium were examined.

RESULTS

In patients who underwent ExtraCorporeal Membrane Oxygenation (ECMO) therapy, delirium was confirmed by the NuDESC in 68.75% of patients in the evening hours, while it was measured by the DOSS scale in 84.38% of patients in the morning. The study found that ECMO delirium was not associated with hyperactivity, sleep disturbance, sedation, pain, or thirst.

CONCLUSION

Delirium in patients undergoing ECMO therapy was confirmed by both the NuDESC and DOSS. Factors such as thirst and sleep disturbance after ECMO therapy were shown to influence the occurrence of delirium. The diagnosis of delirium using standardized scales is possible provided that more tests are carried out. Research should be conducted to determine whether the NuDESC is equivalent to the DOSS.

Cardiac Delirium Index for Predicting the Occurrence of Postoperative Delirium in Adult Patients After Coronary Artery Bypass Grafting

Background

Postoperative delirium (POD) is a serious complication of cardiac surgery. It is an acute neuropsychiatric syndrome. The aim of this study was to analyze the CARDEL Index, composed of advancing age, preoperative glycated hemoglobin and the platelet-to-WBC ratio (PWR) previously described and calculated, using a different patient database, to assess its usefulness as a marker for predicting postoperative delirium after coronary artery by-pass grafting (CABG).

Methods

A retrospective analysis of 1098 patients who underwent, isolated CABG procedures between 2017 and 2019 was performed.

Results

Within the study group, 164/1098 (14.93%) patients were diagnosed with delirium. Preoperative inflammatory parameters were elevated in patients with delirium: White Blood Cell count (p=0.003), Neutrophil count (p=0.016) and C-reactive protein (p<0.001). A decrease in preoperative PWR was shown in patients with delirium (p=0.008). Delirious patients spent more time mechanically ventilated (p<0.001) and had longer hospitalization times (p=0.002). Mortality at 1 year was significantly higher in patients with POD (p<0.001). The CARDEL Index in this study group for POD detection has the largest area under the curve (AUC) of 0.664 (p<0.001) and a cut-off value of 8.08.

Conclusion

CARDEL Index may be treated as a potentially valuable tool for delirium prediction in patients after CABG.

Effects of Intravenous Anesthetics vs Inhaled Anesthetics on Early Postoperative Sleep Quality and Complications of Patients After Laparoscopic Surgery Under General Anesthesia

OBJECTIVE

Decreased postoperative sleep quality remains a serious problem in surgical settings at present. The purpose of our study was to compare the effect of propofol vs sevoflurane on early postoperative sleep quality and complications of patients receiving laparoscopic surgery after general anesthesia.

METHODS

Seventy-four patients undergoing selective laparoscopic surgery under general anesthesia were randomly assigned to the propofol group or sevoflurane group. The wireless portable sleep monitor (WPSM) is used to collect sleep quality on the night before surgery (sleep preop 1), the first night after surgery (sleep POD 1), and the third night after surgery (sleep POD 3). Record the subjective sleep quality and dreaming state during the operation. The perioperative hemodynamics, postoperative sleep and complications were also evaluated.

RESULTS

Compared with Sleep preop 1, patients showed lower sleep efficiency, Stable sleep and Unstable sleep during Sleep POD 1 and Sleep POD 3. In addition, compared with the propofol group, the proportion of REM sleep in the sevoflurane group was much higher during Sleep POD 1 and Sleep POD 3, and the incidence of dreaming was also higher in the sevoflurane group. Patients in the propofol group had better pain relief at 2, 4, and 6 hours after surgery. And the incidence of postoperative nausea and vomiting and dizziness in the sevoflurane group was significantly higher than that in the propofol group.

CONCLUSION

The degree of postoperative sleep efficiency was better on Sleep POD1 and Sleep POD3; the incidence of postoperative nausea and vomiting, and dizziness was lower; and postoperative pain was slighter when the operation was performed under propofol anesthesia compared with patients in the sevoflurane group. Propofol should be considered a better choice during the operation to promote the patient's postoperative sleep quality, relieve postoperative pain and improve the incidence of postoperative dizziness and nausea and vomiting.

Challenges of Delirium Management in Patients with Traumatic Brain Injury: From Pathophysiology to Clinical Practice

Traumatic brain injury (TBI) can initiate a very complex disease of the central nervous system (CNS), starting with the primary pathology of the inciting trauma and subsequent inflammatory and CNS tissue response. Delirium has long been regarded as an almost inevitable consequence of moderate to severe TBI, but more recently has been recognized as an organ dysfunction syndrome with potentially mitigating interventions. The diagnosis of delirium is independently associated with prolonged hospitalization, increased mortality and worse cognitive outcome across critically ill populations. Investigation of the unique problems and management challenges of TBI patients is needed to reduce the burden of delirium in this population. In this narrative review, possible etiologic mechanisms behind post-traumatic delirium are discussed, including primary injury to structures mediating arousal and attention and secondary injury due to progressive inflammatory destruction of the brain parenchyma. Other potential etiologic contributors include dysregulation of neurotransmission due to intravenous sedatives, seizures, organ failure, sleep cycle disruption or other delirium risk factors. Delirium screening can be accomplished in TBI patients and the presence of delirium portends worse outcomes. There is evidence that multi-component care bundles including an analgesia-prioritized sedation algorithm, regular spontaneous awakening and breathing trials, protocolized delirium assessment, early mobility and family engagement can reduce the burden of ICU delirium. The aim of this review is to summarize the approach to delirium in TBI patients with an emphasis on pathogenesis and management. Emerging CNS-active drug therapies that show promise in preclinical studies are highlighted.

Postoperative Delirium is a Risk Factor of Poor Evolution Three Years After Cardiac Surgery: An Observational Cohort Study

Background

After cardiac surgery, postoperative delirium (POD) is common and is associated with long-term changes in cognitive function. Impact on health-related quality of life (QOL) and long-term dependence are not well known. This aim of this study is to evaluate the role of POD in poor evolution at three years after surgery including poor QOL and dependence and mortality.

Patients and Methods

We enrolled and followed 173 patients 60 years of age or older who were planning to undergo cardiac surgery with cardiopulmonary bypass. The primary composite outcome was death of any causes, or patients with either a loss of QOL (evaluated with of EuroQuol verbal 5D EQ5D less than 50), or a loss of two points on the instrumental activities of daily living occurring three years after surgery. POD was diagnosed with the use of Confusion Assessment Method. Multivariate logistic regression was performed.

Results

At three years, 74 patients (42.8%) had a poor evolution. Independent risk factors in poor patient evolution were sex (female gender; OR: 3.6; 95%CI: 1.45-8.7; p=0.006), metabolic status (diabetic patients; OR: 4; 95%CI: 1.6-10.2; p=0.002), Euroscore 2 (Euroscore 2 >1.5; OR: 5.2; 95%CI: 1.7-15.4; p=0.003) and POD (OR: 3.3; 95%CI 1.4-7.8; p=0.006). Coronary disease was protective (OR: 0.3; 95%CI: 0.14-0.71; p=0.006).

Conclusion

After cardiac surgery, POD significantly altered patient evolution and increased risk of dependence and loss of QOL.

Predictors of Delirium in Octogenarian Patients Hospitalized for a Hip Fracture

INTRODUCTION

Since delirium is a major complication that can arise after a patient with a hip fracture has been hospitalized, it is considered to be one of the most common geriatric conditions. Therefore, its prevention and early detection are essential for reducing both the length of the patient's stay in the hospital and complications during the hospitalization process.

OBJECTIVE

To identify and analyze the predictors for developing delirium in octogenarians who were admitted to hospital for a hip fracture.

METHODOLOGY

A prospective study conducted with a sample of 287 patients aged 80 years and older (mean age 87.2 ± 3.2 years; 215 women, 72 men), recruited from the Trauma Unit of the University Hospital of León (Spain). Further, 71.1% of the patients lived in a family member's home, while the other 28.9% lived in a nursing home. After observing each patient's interactions with their doctor in a clinical setting, the data for this study were obtained by reviewing the selected patients' charts. The variables analyzed were sociodemographic information (age, sex, and place of residence), medical information (type of hip break and surgical intervention), cognitive impairment (MMSE score), functional level (Barthel Index score), and clinical information (pharmacological, comorbidities, complications, and the diagnosis and assessment of the severity of delirium in a patient). The univariate and multivariate logistic regression analysis showed a significant relationship between acute confusional state and the following variables: anemia, American Society of Anesthesiologists (ASA) III and IV patients, state of cognitive frailty and functional level, a urinary tract infection, changes in the visual field, renal arterial occlusion, and the type and dosage of drugs administered (this variable was identified in the multivariate model). The inverse relationship between anemia and acute confusional state is surprising.

CONCLUSION

This research shows that clinical observation of acute confusional state is necessary but not sufficient for addressing this condition early and adequately in older adults who have been hospitalized for a hip fracture.

The Effect of Preoperative Carbohydrate Loading on Clinical and Biochemical Outcomes after Cardiac Surgery: A Systematic Review and Meta-Analysis of Randomized Trials

Background and aim: Preoperative fasting leads to metabolic stress and causes insulin resistance in patients undergoing cardiac surgery. The aim of this study was to assess the effect of preoperative oral carbohydrate loading (OCH) on outcome in patients undergoing planned cardiac surgery by systematically reviewing the literature and synthesizing evidence from randomized controlled trials (RCTs). Methods: Systematic search of PubMed/MEDLINE/Embase/Cinahl/Web of Science/ClinicalTrials databases was performed to identify relevant RCTs from databased inception until 05/03/2020. We included studies that compared outcome measures between OCH with control (placebo or standard starvation). We conducted a random-effect meta-analysis of clinical and biochemical parameters. Results: Nine studies (N = 9) were included with a total of 507 patients. OCH significantly decreased aortic clamping duration (n = 151, standardized mean difference (SMD) = −0.28, 95% confidence interval (CI) = −0.521 to −0.038, p = 0.023 and differences in means (DM) = −6.388, 95%CI = −11.246 to −1.529, p = 0.010). Patients from treatment groups had shorter intensive care unit (ICU) stay (n = 202, SMD = −0.542, 95%CI = −0.789 to −0.295, p < 0.001 and DM = −25.925, 95%CI = −44.568 to −7.283, p = 0.006) and required fewer units of insulin postoperatively (n = 85, SMD = −0.349, 95%CI = −0.653 to −0.044, p = 0.025 and DM = −4.523, 95%CI = −8.417 to −0.630, p = 0.023). The necessity to use inotropic drugs was significantly lower in the OCH group (risk ratio (RR) = 0.795, 95%CI = 0.689 to 0.919, p = 0.002). All other primary outcomes did not reveal a significant effect. Conclusions: Preoperative OCH in patients undergoing cardiac surgery demonstrated a 20% reduction in the use of inotropic drugs, a 50% reduction of the length of ICU stay, a 28% decrease in aortic clamping duration and a 35% decrease of postoperative insulin requirement.

Current Evidence Regarding Biomarkers Used to Aid Postoperative Delirium Diagnosis in the Field of Cardiac Surgery-Review

Postoperative cognitive disorders after cardiac surgery may manifest as postoperative delirium (POD) or later as postoperative cognitive dysfunction (POCD). The incidence of POD after cardiac surgery ranges from 16% to 73%. In contrast to POD, POCD is usually diagnosed after the discharge from hospital, with an incidence of 30 to 70% of cases, very often noticed only by close relative or friends, decreasing after six (20–30%) and twelve (15–25%) months after surgery. Perioperative cognitive disorders are associated with adverse short- and long-term effects, including increased morbidity and mortality. Due to the complexity of delirium pathomechanisms and the difficulties in the diagnosis, researchers have not yet found a clear answer to the question of which patient will be at a higher risk of developing delirium. The risk for POD and POCD in older patients with numerous comorbidities like hypertension, diabetes, and previous ischemic stroke is relatively high, and the predisposing cognitive profile for both conditions is important. The aim of this narrative review was to identify and describe biomarkers used in the diagnosis of delirium after cardiac surgery by presenting a search through studies regarding this subject, which have been published during the last ten years. The authors discussed brain-derived biomarkers, inflammation-related biomarkers, neurotransmitter-based biomarkers, and others. Work based on inflammation-related biomarkers, which are characterized by the low cost of implementation and the effectiveness of delirium diagnosis, seems to be the closest to the goal of discovering an inexpensive and effective marker. Currently, the use of a panel of tests, and not a single biomarker, brings us closer to the discovery of a test, or rather a set of tests ideal for the diagnosis of delirium after cardiac surgery.

Management of psychiatric conditions and delirium during the COVID-19 pandemic across continents: lessons learned and recommendations

Background

With the uncertainties of COVID-19, people infected with coronavirus present with diverse psychiatric presentations. Some institutions have had to manage their patients with existing protocols, others have had to create them. In this article we aimed to report the challenges and good practices in the management of psychiatric conditions and delirium coexisting with COVID-19 across continents.

Methods

Early Career Psychiatrists (ECPs) from across five continents were approached to share their experiences on the management of psychiatric conditions in patients with COVID-19 during the current pandemic.

Results

We collected information about the experiences from sixteen countries. Commonalities were similar psychiatric presentations and poor preparedness across countries. Differences were varying adjustments made in the management of psychiatric conditions coexisting with COVID-19 and different innovations. Good practices which can be adopted by other countries are novel approaches such as telepsychiatry, proactive consultation-liaison units and enhanced community services targeted at circumventing challenges faced when providing mental health services.

Conclusions

These findings highlight the need for global preparedness in the mental health sector during outbreaks of infectious diseases, and the need for concerted efforts targeted at global and locally sensitive adaptation of existing protocols and the development of new guidelines for the management of psychiatric conditions for the present pandemic and subsequent occurrences.

•

ECPs provided their perspective on the management of psychiatric conditions in patients with COVID-19.

•

We found commonalities and differences in the management of psychiatric conditions coexisting with COVID-19.

•

There are shared similarities and differences, likewise modifications in pre-existing protocols for management of delirium.

•

A common factor is the need to adapt guidelines and protocols for the management of psychiatric conditions.

Pathomechanisms of Non-Traumatic Acute Brain Injury in Critically Ill Patients

Delirium, an acute alteration in mental status characterized by confusion, inattention and a fluctuating level of arousal, is a common problem in critically ill patients. Delirium prolongs hospital stay and is associated with higher mortality. The pathophysiology of delirium has not been fully elucidated. Neuroinflammation and neurotransmitter imbalance seem to be the most important factors for delirium development. In this review, we present the most important pathomechanisms of delirium in critically ill patients, such as neuroinflammation, neurotransmitter imbalance, hypoxia and hyperoxia, tryptophan pathway disorders, and gut microbiota imbalance. A thorough understanding of delirium pathomechanisms is essential for effective prevention and treatment of this underestimated pathology in critically ill patients.

Risk factors associated with postoperative intensive care unit delirium in patients undergoing invasive mechanical ventilation following acute exacerbation of chronic obstructive pulmonary disease

OBJECTIVE

This study was performed to determine the risk factors associated with intensive care unit delirium (ICUD) in patients undergoing invasive mechanical ventilation (IMV) secondary to acute exacerbation of chronic obstructive pulmonary disease (COPD).

METHODS

Data involving 620 patients undergoing IMV secondary to acute exacerbation of COPD from 2009 to 2019 at the First Hospital of Hebei Medical University were retrospectively analysed. The primary endpoint was the risk factors associated with developing ICUD. Univariable and multivariable logistic regression analyses were used to identify these risk factors.

RESULTS

Of 620 patients, 93 (15.0%) developed ICUD. In the multivariable analysis, risk factors that were significantly associated with ICUD were increased age, male sex, alcoholism with active abstinence, current smoking, stage 3 acute kidney injury (AKI), and an American Society of Anesthesiologists (ASA) physical status of III.

CONCLUSION

This study showed that increasing age, male sex, alcoholism with active abstinence, current smoking, stage 3 AKI, and an ASA physical status of III might be associated with a risk of developing ICUD. Even if these risk factors are unaltered, they provide a target population for quality improvement initiatives.

Postoperative Delirium in Patients with Chronic Obstructive Pulmonary Disease after Coronary Artery Bypass Grafting

Background and Objectives: The incidence of postoperative delirium (POD) in patients with chronic obstructive pulmonary disease (COPD) is unclear. It seems that postoperative respiratory problems that may occur in COPD patients, including prolonged mechanical ventilation or respiratory-tract infections, may contribute to the development of delirium. The aim of the study was to identify a relationship between COPD and the occurrence of delirium after cardiac surgery and the impact of these combined disorders on postoperative mortality. Materials and Methods: We performed an analysis of data collected from 4151 patients undergoing isolated coronary artery bypass grafting (CABG) in a tertiary cardiac-surgery center between 2012 and 2018. We included patients with a clinical diagnosis of COPD according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria. The primary endpoint was postoperative delirium; Confusion Assessment Method in the Intensive Care Unit (CAM-ICU) was used for delirium assessment. Results: Final analysis included 283 patients with COPD, out of which 65 (22.97%) were diagnosed with POD. Delirious COPD patients had longer intubation time (p = 0.007), more often required reintubation (p = 0.019), had significantly higher levels of C-reactive protein (CRP) three days after surgery (p = 0.009) and were more often diagnosed with pneumonia (p < 0.001). The CRP rise on day three correlated positively with the occurrence of postoperative pneumonia (r = 0.335, p = 0.005). The probability of survival after CABG was significantly lower in COPD patients with delirium (p < 0.001). Conclusions: The results of this study confirmed the relationship between chronic obstructive pulmonary disease and the incidence of delirium after cardiac surgery. The probability of survival in COPD patients undergoing CABG who developed postoperative delirium was significantly decreased.

COVID-19: ICU delirium management during SARS-CoV-2 pandemic

The novel coronavirus, SARS-CoV-2-causing Coronavirus Disease 19 (COVID-19), emerged as a public health threat in December 2019 and was declared a pandemic by the World Health Organization in March 2020. Delirium, a dangerous untoward prognostic development, serves as a barometer of systemic injury in critical illness. The early reports of 25% encephalopathy from China are likely a gross underestimation, which we know occurs whenever delirium is not monitored with a valid tool. Indeed, patients with COVID-19 are at accelerated risk for delirium due to at least seven factors including (1) direct central nervous system (CNS) invasion, (2) induction of CNS inflammatory mediators, (3) secondary effect of other organ system failure, (4) effect of sedative strategies, (5) prolonged mechanical ventilation time, (6) immobilization, and (7) other needed but unfortunate environmental factors including social isolation and quarantine without family. Given early insights into the pathobiology of the virus, as well as the emerging interventions utilized to treat the critically ill patients, delirium prevention and management will prove exceedingly challenging, especially in the intensive care unit (ICU). The main focus during the COVID-19 pandemic lies within organizational issues, i.e., lack of ventilators, shortage of personal protection equipment, resource allocation, prioritization of limited mechanical ventilation options, and end-of-life care. However, the standard of care for ICU patients, including delirium management, must remain the highest quality possible with an eye towards long-term survival and minimization of issues related to post-intensive care syndrome (PICS). This article discusses how ICU professionals (e.g., physicians, nurses, physiotherapists, pharmacologists) can use our knowledge and resources to limit the burden of delirium on patients by reducing modifiable risk factors despite the imposed heavy workload and difficult clinical challenges posed by the pandemic.

The Impact of Acute Kidney Injury in the Perioperative Period on the Incidence of Postoperative Delirium in Patients Undergoing Coronary Artery Bypass Grafting-Observational Cohort Study

Recent data indicate that acute kidney damage leads to inflammation in the brain and other distant organs. The purpose of this study was to investigate the effect of acute kidney injury (AKI) according to the Kidney Disease Improving Global Outcome (KDIGO) criteria on the occurrence of postoperative delirium in patients undergoing coronary artery bypass grafting (CABG). We performed a retrospective cohort analysis that included all consecutive patients undergoing elective CABG. The CAM-ICU (Confusion Assessment Method for Intensive Care Unit) was used for delirium assessment. Patients were divided into four groups, depending on the occurrence of AKI in the perioperative period according to KDIGO criteria. Overall, 902 patients were included in the final analysis, the mean age was 65.95 ± 8.01 years, and 76.83% were males (693/957). The majority of patients presented with normal kidney function-baseline creatinine level of 0.91 ± 0.21 (mg/dL). The incidence of AKI in the perioperative setting was 22.17% (200/902). Postoperative delirium was diagnosed in 115/902 patients (12.75%). Compared with no AKI, the odds of developing POD were increased for KDIGO stage 1 (OR 2.401 (95% confidence interval 1.484–3.884), p < 0.001); KDIGO stage 2 (OR 3.387 (95% confidence interval 1.459–7.866), p = 0.005); and highest for KDIGO stage 3 (OR equal to 9.729 (95% confidence interval 2.675–35.382), p = 0.001). Acute kidney injury, based on AKI staging, should be regarded as an independent risk factor for postoperative delirium after cardiac surgery.

COVID-19: What do we need to know about ICU delirium during the SARS-CoV-2 pandemic?

In March 2020, the World Health Organisation announced the COVID-19 pandemic caused by the SARS-CoV-2 virus. As well as respiratory failure, the SARS-CoV-2 may cause central nervous system (CNS) involvement, including delirium occurring in critically ill patients (ICU delirium). Due attention must be paid to this subject in the face of the COVID-19 pandemic. Delirium, the detection of which takes less than two minutes, is frequently underestimated during daily routine ICU care, but it may be a prodromal symptom of infection or hypoxia associated with severe respiratory failure. During the COVID-19 pandemic, systematic delirium monitoring using validated tests (CAM-ICU or ICDSC) may be sacrificed. This is likely to be due to the fact that the main emphasis is placed on organisational issues, i.e. the lack of ventilators, setting priorities for limited mechanical ventilation options, and a shortage of personal protective equipment. Early identification of patients with delirium is critical in patients with COVID-19 because the occurrence of delirium may be an early symptom of worsening respiratory failure or of infectious spread to the CNS mediated by potential neuroinvasive mechanisms of the coronavirus. The purpose of this review is to identify problems related to the development of delirium during the COVID-19 epidemic, which are presented in three areas: i) factors contributing to delirium in COVID-19, ii) potential pathophysiological factors of delirium in COVID-19, and iii) long-term consequences of delirium in COVID-19. This article discusses how healthcare workers can reduce the burden of delirium by identifying potential risk factors and difficulties during challenges associated with SARS-CoV-2 infection.

The Design and validation of a Nursing Plan for Elderly Patients with Postoperative Delirium

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.

Development and validation of a postoperative delirium prediction model for patients admitted to an intensive care unit in China: a prospective study

OBJECTIVES

We aimed to develop and validate a postoperative delirium (POD) prediction model for patients admitted to the intensive care unit (ICU).

DESIGN

A prospective study was conducted.

SETTING

The study was conducted in the surgical, cardiovascular surgical and trauma surgical ICUs of an affiliated hospital of a medical university in Heilongjiang Province, China.

PARTICIPANTS

This study included 400 patients (≥18 years old) admitted to the ICU after surgery.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was POD assessment during ICU stay.

RESULTS

The model was developed using 300 consecutive ICU patients and was validated using 100 patients from the same ICUs. The model was based on five risk factors: Physiological and Operative Severity Score for the enumeration of Mortality and morbidity; acid-base disturbance and history of coma, diabetes or hypertension. The model had an area under the receiver operating characteristics curve of 0.852 (95% CI 0.802 to 0.902), Youden index of 0.5789, sensitivity of 70.73% and specificity of 87.16%. The Hosmer-Lemeshow goodness of fit was 5.203 (p=0.736). At a cutoff value of 24.5%, the sensitivity and specificity were 71% and 69%, respectively.

CONCLUSIONS

The model, which used readily available data, exhibited high predictive value regarding risk of ICU-POD at admission. Use of this model may facilitate better implementation of preventive treatments and nursing measures.

Characteristics, Risk Factors And Outcome Of Early-Onset Delirium In Elderly Patients With First Ever Acute Ischemic Stroke - A Prospective Observational Cohort Study

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.

Could Neutrophil-to-Lymphocyte Ratio (NLR) Serve as a Potential Marker for Delirium Prediction in Patients with Acute Ischemic Stroke? A Prospective Observational Study

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.