Delirium in the Intensive Care Unit: Incidence, Risk Factors, and Impact on Outcome

Delirium in Critically Ill Geriatric Surgical Patients: A Systematic Review of Screening, Risk Factors, Diagnosis, and Management

OBJECTIVE

This systematic review aims to evaluate optimal early screening strategies, significant risk factors, and effective diagnostic and management approaches for delirium in critically ill geriatric surgical patients.

DATA SOURCES

A comprehensive search was conducted across five databases: PubMed, Google Scholar, ProQuest, Embase, and Cochrane.

STUDY SELECTION

Studies were included based on their relevance to early screening, risk factors, diagnostic accuracy, and management strategies for delirium in critically ill geriatric surgical patients. The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

DATA EXTRACTION

A total of 31 studies met the inclusion criteria. Outcomes of interest included effective early screening/prevention strategies, significant risk factors, sensitive diagnosis tools, and effective management strategies.

DATA SYNTHESIS

Early screening strategies, including advanced neural networks and E-PROD-NS, demonstrated high sensitivity and specificity (area under the receiver operating characteristic curve >0.76). Key risk factors included advanced age, renal dysfunction, cognitive impairment, prolonged intensive care unit length of stay (ICU-LOS), and mechanical ventilation time. Diagnostic tools such as the 4A's test and serum biomarkers exhibited superior accuracy compared to the ICU Confusion Assessment Method and Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) criteria. Management strategies effectively reduced delirium duration, including acetaminophen, environmental modifications, and family involvement.

CONCLUSIONS

E-PROD-NS and the 4A's test were associated with early delirium detection and intervention. Risk factors for delirium included advanced age, renal dysfunction, and existing cognitive dysfunction. Mitigating mechanical ventilation and ICU-LOS duration, treatment with acetaminophen, and environmental modifications reduced delirium duration in critically ill geriatric surgical patients.

REGISTRATION

PROSPERO #CRD42025632279.

The Impact of Delirium on Hospitalized Patients With COPD Exacerbation: Insights From the National In-Patient Sample

Background: Delirium in hospitalized patients has been consistently associated with worse clinical outcomes, including increased mortality and prolonged hospital stays. COPD exacerbation is a common reason for hospitalization, and understanding the impact of delirium on this population is crucial for improving patient care and outcomes. Methods: We conducted a retrospective cohort study using the National In-Patient Sample dataset to assess the impact of delirium on patients hospitalized with COPD exacerbation. Subjects were identified using International Classification of Diseases, 10th Revision, codes for COPD exacerbation and delirium. Baseline characteristics and outcomes, including in-patient mortality and the use of invasive mechanical ventilation, were compared between subjects with and without delirium using chi-square analysis. Multivariate regression analysis was used to adjust for potential confounders. Results: A total of 8,062,333 subjects hospitalized with COPD exacerbation were included, of whom 574,005 (7.2%) had a diagnosis of delirium. Most subjects in both groups were white, covered by Medicare, and treated in large urban teaching hospitals. Subjects with delirium had higher rates of dementia, malnutrition, and chronic kidney disease. The rates of in-patient mortality (13.85% vs 4.29%, P < .01) and use of invasive mechanical ventilation (26.7% vs 7.79%, P < .01) were significantly higher in the delirium group. Delirium was associated with higher odds of mortality (adjusted odds ratio [aOR] 2.48, P < .01) and use of mechanical ventilation (aOR 3.92, P < .01). Subjects with delirium had longer and more costly hospital stays. Conclusions: Delirium was associated with worse outcomes in subjects hospitalized with COPD exacerbation.

Unraveling Ventilator-Induced Diaphragmatic Dysfunction: A Comprehensive Narrative Review on Pathogenesis, Diagnosis and Management of Ventilator-Induced Diaphragmatic Dysfunction

INTRODUCTION

Mechanical ventilation (MV) is a crucial intervention for patients with respiratory failure to ensure optimal gas exchange. However, there is strong evidence that MV exerts significant structural and functional alterations on the diaphragm, leading to a notable decline in its contractile force and the consequent atrophy of its muscle fibers. This condition, referred to as ventilator-induced diaphragmatic dysfunction (VIDD), is an integral factor contributing to challenges in weaning patients off MV, a reduction in their quality of life, and escalated Mortality Risks.

OBJECTIVES

This review highlights the complications of MV, with a focus on VIDD and its clinical implications. It explores bedside diagnostic tools for VIDD and examines exercise-based interventions aimed at preventing or reversing daiphragmatic weakness.

DISCUSSION

Rehabilitation programs, including early mobilization and inspiratory muscle training (IMT) for critically ill patients, have the potential to prevent or mitigate the adverse effects of prolonged Mechanical ventilator and improve clinical outcomes. Numerous studies have demonstrated that these interventions are both safe and feasible, offering benefits such as enhanced physical functioning, reduced duration of mechanical ventilation, and shorter stays in intensive care and hospital settings. However, despite these demonstrated advantages, the implementation of rehabilitation programs remains infrequent in routine clinical practice, often hindered by various perceived barriers.

CONCLUSION

Recognizing and addressing respiratory muscle weakness is crucial, as it represents a reversible and treatable factor that can significantly improve patient outcomes.

The effectiveness of family participation interventions for the prevention of delirium in intensive care units: A systematic review

AIM

To review the effect of family participation interventions in preventing delirium in Intensive Care Units (ICU).

METHODS

The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and the "Synthesis Without Meta-analysis" guidelines. The search was performed using the MEDLINE, CINAHL, Cochrane Database of Systematic Reviews, Web of Science, Scopus, Cochrane Central Register of Controlled Trials and ClinicalTrials.gov databases in April 2024. Eligibility criteria included patients admitted to Intensive Care Units, aged 18 or older exposed to risk factors for delirium, and with family members present; studies about family intervention to prevent delirium, that considered family as a partner in care and included interventions; studies that quantitatively assessed the effect of measures on the incidence and duration of delirium; interventional studies. Two authors independently applied these criteria using the Rayyan® application, assessing study quality with Critical Appraisal Skills Programme tools.

RESULTS

Fourteen studies were included, involving 33,232 patients. A meta-analysis was not feasible due to the highly heterogeneous results, but we concluded that the family participation interventions for delirium prevention were grouped into single-component and multi-component interventions. The single-component interventions, such as familiar voice messages, flexible visitation, and family presence, showed a favorable response in reducing delirium. The multicomponent interventions suggesting a positive effect included family visitation with professional-guided orientation; familiar voice messages for reorientation, newspaper reading, and nighttime eye patch use; sensory stimulation program; the ABCDEF bundle; the DyDel program; family education, emotional support, orientation training, cognitive stimulation, and ICU life care participation.

CONCLUSIONS

Several family participation interventions, both single-component and multicomponent, have shown positive effects on outcomes in preventing delirium in ICU patients, particularly in reducing its incidence and duration.

IMPLICATIONS FOR CLINICAL PRACTICE

Identifying the family participation interventions that can prevent delirium allows the development of measures to minimize its occurrence in ICU.

Patients' and family members' dyadic experience of post-operative delirium in the intensive care unit: A qualitative study

BACKGROUND

Post-operative delirium is a complication with long-lasting consequences for both patients and their families. This is particularly true for those transferred to the intensive care unit after surgery, where the incidence of post-operative delirium is high, and patient outcomes are often poor. Despite the acknowledged role of family engagement in delirium management, previous research has mainly focused on patients, with limited exploration of the shared experiences between patients and family members.

AIM

This study aims to explore the experiences of patients and family members during episodes of post-operative delirium in the intensive care unit to better understand their unmet needs.

STUDY DESIGN

A qualitative descriptive study was conducted at a tertiary general hospital. Eighteen pairs of patients, their family members and two other family members were interviewed. Data were collected through face-to-face semi-structured interviews within the first week after patients' discharge from the intensive care unit and analysed using thematic analysis.

RESULTS

Four major themes emerged: (1) the dyadic relationship between patients and family members must be understood in the context of their shared emotional and behavioural experiences; (2) family's history may predispose patients to post-operative delirium; (3) family engagement may prevent the development of post-operative delirium; and (4) inadequate communication between health care providers and patients or families may negatively affect post-operative delirium outcomes.

CONCLUSIONS

Post-operative delirium presents significant emotional and physical challenges for both patients and their families. Addressing these challenges requires improved communication between health care providers and families, as well as strategies that emphasize early family support and collaboration in care.

RELEVANCE TO CLINICAL PRACTICE

Patients and their families should be considered a unit during post-operative delirium management, and earlier family engagement is essential. Health care systems should adapt intensive care unit practices to meet the dynamic needs of families, promoting more comprehensive support during critical care.

Beyond the Lungs: Extrapulmonary Effects of Non-Invasive and Invasive Ventilation Strategies

Background/Objectives: Non-invasive respiratory support and invasive mechanical ventilation are critical interventions that can induce significant changes not only in the lungs but also in extra-pulmonary organs, which are often overlooked. Understanding the extra-pulmonary effects of non-invasive respiratory support and invasive mechanical ventilation is crucial since it can help prevent or mitigate complications and improve outcomes. This narrative review explores these consequences in detail and highlights areas that require further research. Main Text: Non-invasive respiratory support and invasive mechanical ventilation can significantly impact various extrapulmonary organs. For instance, some ventilation strategies can affect venous return from the brain, which may lead to neurological sequelae. In the heart, regardless of the chosen ventilation method, increased intrathoracic pressure (ITP) can also reduce venous return to the heart. This reduction in turn can decrease cardiac output, resulting in hypotension and diminished perfusion of vital organs. Conversely, in certain situations, both ventilation strategies may enhance cardiac function by decreasing the work of breathing and lowering oxygen consumption. In the kidneys, these ventilation methods can impair renal perfusion and function through various mechanisms, including hemodynamic changes and the release of stress hormones. Such alterations can lead to acute kidney injury or exacerbate pre-existing renal conditions. Conclusions: This review emphasizes the critical importance of understanding the extensive mechanisms by which non-invasive respiratory support and invasive mechanical ventilation affect extrapulmonary organs, including neurological, cardiovascular, and renal systems. Such knowledge is essential for optimizing patient care and improving outcomes in critical care settings.

Effects of Sensory-Based Interventions on Delirium Prevention in Critically Ill Patients: A Systematic Review and Meta-Analysis

OBJECTIVE

To identify, appraise and synthesize current evidence on different sensory-based interventions on delirium prevention in critically ill patients.

DATA SOURCES

A comprehensive electronic literature search was performed in the PubMed, Embase, Cumulative Index of Nursing and Allied Health Literature, Cochrane Library, China Biology Medicine, China National Knowledge Infrastructure, Wanfang and WeiPu databases from inception to 2 June 2022. The data were updated on 24 December 2022. The study was registered on PROSPERO (CRD 42021254328).

REVIEW METHODS

Randomized controlled trials were included. Participants in the included studies were critically ill patients aged 18 years or older, and the interventions involved care by sensory-based intervention. And the outcome was the incidence of delirium rated by the Confusion Assessment Method for the ICU Tool.

RESULTS

The 14 studies included in the systematic review indicated a reduction in the effectiveness of sensory-based intervention on the incidence of delirium. Subgroup analyses showed significant effects for auditory stimulation (OR, 0.46; 95% confidence interval [CI], 0.27-0.79; p = 0.005) and tactile stimulation (OR, 0.53; 95% CI, 0.33-0.87; p = 0.01) but not for the effectiveness of visual intervention on the incidence of delirium (OR, 0.71; 95% CI, 0.38-1.30; p = 0.27).

CONCLUSIONS

Sensory-based interventions significantly reduce the incidence of delirium in critical patients. It is suggested that when choosing sensory-based interventions, auditory intervention should be preferred.

Dose-response analysis of music intervention for improving delirium in intensive care unit patients: A systematic review and meta-analysis

BACKGROUND

Delirium is a common and severe condition among adult intensive care unit (ICU) patients. Music intervention, as a non-pharmacological approach, has the potential to reduce delirium, but the optimal dosage and type of intervention remain unclear.

AIM

To explore the effects of music intervention at different doses and types on reducing delirium in ICU patients.

STUDY DESIGN

This study was conducted as a systematic review and meta-analysis. Databases including Cochrane Library, EBSCO, Embase, PubMed, Web of Science, Airiti Library, China National Knowledge Infrastructure and Wanfang Data were searched until 29 February 2024. Study quality was assessed using the Cochrane Risk of Bias 2.0 criteria. Data were analysed using RevMan 5.4.1 and Comprehensive Meta-Analysis 3.0.

RESULTS

Fourteen studies involving 1434 ICU patients were included. Four studies were of good quality (low risk of bias), seven were of moderate quality (unclear risk) and three were of low quality (high risk). Pooled analysis showed that music interventions significantly reduced the risk of delirium (12 studies, RR = .49, 95% confidence interval [CI] [.40, .61]). Slow-tempo music had the strongest effect (11 studies, RR = .46, 95% CI [.37, .57]). The optimal intervention dosage involves conducting music interventions twice daily (12 studies, RR = .46, 95% CI [.34, .63]), with each session lasting 30 min (12 studies, RR = .41, 95% CI [.30, .55]). Additionally, a pooled analysis showed that a 7-day music intervention (6 studies, RR = .43, 95% CI [.26, .71]) was the most effective in reducing the risk of delirium.

CONCLUSIONS

Music intervention reduces delirium in ICU patients, especially with two 30-min sessions daily for 7 days. However, the certainty of evidence is low, highlighting the need for further high-quality research.

RELEVANCE TO CLINICAL PRACTICE

Music intervention is a simple, non-invasive method that may help reduce delirium in ICU patients. However, given the low certainty of the current evidence, it should be used cautiously, and further research is needed to validate its effectiveness before routine implementation.

A Critical Reappraisal of Haloperidol for Delirium Management in the Intensive Care Unit: Perspective from Psychiatry

Delirium is a complex neuropsychiatric syndrome with multifactorial pathophysiology, encompassing a wide range of neuropsychiatric symptoms, and its management remains a significant challenge in critical care. Although often managed with antipsychotics, like haloperidol, current research has predominantly focused on dopamine dysregulation as the primary driver of delirium, overlooking its broader neuroanatomical and neurochemical underpinnings. This has led to a majority of research focusing on haloperidol as a treatment for intensive care unit (ICU) delirium. Our review critically evaluates the role of haloperidol in ICU delirium management, particularly in light of recent large-scale randomized controlled trials (RCTs) that have primarily focused on delirium-free days and mortality as the primary endpoints. These studies highlight an limited understanding of the true nature of delirium treatment, which requires a broader, neuropsychiatric approach. We argue that future research should shift focus to neuropsychiatric symptoms such as agitation and psychosis and explore the clinical and functional benefits of reducing these distressing symptoms. Additionally, the stratification of delirium by subtypes and etiology, the enhancement of detection tools, and the adoption of multi-intervention and multi-disciplinary care approaches should be prioritized. Despite the methodological flaws in these studies, the findings support the safety of haloperidol in the ICU setting, with minimal risk of adverse events, particularly cardiac and neuropsychiatric. Moving forward, delirium research must integrate modern neuroscientific understanding and adopt more multi-disciplinary input and nuanced, patient-centered approaches to truly advance clinical care and outcomes.

Co-designing a digital family-led intervention for delirium prevention and management in adult critically ill patients: An application of the double diamond design process

BACKGROUND

Co-designing healthcare interventions is gaining recognition as a novel and collaborative method. Co-design involves end-users from the start, ensuring that an intervention best meets their needs. Despite its potential benefits, this approach is not yet widely used in developing clinical interventions within intensive care units where the perspectives of patients, family members, and clinicians are crucial.

OBJECTIVE

To describe the application, benefits and challenges of the Double Diamond model to co-design a digital family-led voice reorientation intervention for delirium prevention and management in critically ill adult patients.

METHODS

The co-design process was guided by the Double Diamond model over a period of 12 months. Development involved patients, family members, and nursing and medical staff as co-designers and decision-makers in the iterative development of the intervention. Data from field notes and group meetings were audio recorded, transcribed verbatim, and content analysed at each phase, which were then presented to the co-designers for verification and refinement.

FINDINGS

Co-designers included people with lived experience of the ICU as patients (n = 5) and family members (n = 1) and clinical experts (nursing staff n = 3; medical staff n = 3). Co-designers were highly engaged and reported positive experiences and collaboration in the co-design process. Sharing the diversity of their own personal ICU experiences was found to be beneficial as it not only validated individual feelings but also strengthened intervention development. Differences in interpretations and meanings of the voice messages proposed as part of the intervention were challenging. Maintaining sufficient focus on each phase of the Double Diamond was difficult due to the complexity of the context in which the intervention was being co-designed and the resulting challenges of maintaining the engagement of the co-designers throughout the process.

CONCLUSIONS

There were benefits and challenges of engaging people with lived experience in an intensive care unit as co-designers through the Double Diamond design process to develop a digital family-led intervention for delirium prevention and management. Overall, applying the Double Diamond to co-design a clinical intervention is recommended, whereby the collaboration process benefits patients, family members, and clinical staff.

REGISTRATION NUMBER

ACTRN12622001568707; ANZCTR - Registration.

Reliability and Validity of Hindi Version of the Confusion Assessment Method for Intensive Care Unit (CAM-ICU) for Diagnosis of Delirium: A Cohort Study

Background

The confusion assessment method for the intensive care unit (CAM-ICU) is a bedside tool to diagnose delirium in critically ill patients. This study aims to determine the reliability and validity of the Hindi version of CAM-ICU against the Diagnostic and Statistical Manual (DSM), fourth edition text revision (DSM-IV-TR), and DSM, fifth edition (DSM-5) criteria for diagnosis of delirium.

Methods

Seventy-five Hindi-speaking consenting patients ≥18-year-old with Richmond Agitation Sedation Scale ≥-3 and an anticipated ICU stay > 48 hours were included. Patients with known severe mental illnesses, visual/hearing loss, neurological injury, burns, drug overdose, and Glasgow Coma Scale <9 at the time of screening were excluded. After 48 hours of ICU stay and ensuring at least 2 hours of sedative interruption, within a 4-hour period, two examiners independently assessed delirium using the Hindi version of the scale and an experienced psychiatrist assessed the patients independently and applied the DSM-IV-TR and DSM-5 criteria for diagnosing delirium. Time taken for CAM-ICU assessment, inter-observer reliability, sensitivity, specificity, and positive and negative predictive values were calculated.

Results

The Cohen's κ value was 0.944 (p < 0.001). The Cronbach's α for observer 1 and observer 2 was 0.961 and 0.968, respectively. The sensitivity and negative predictive value of the tool was 100% with both DSM-IV-TR and DSM-5. The specificity was 90.2% and 92% and the positive predictive value was 82.8 and 86.2% with DSM-IV-TR and DSM-5, respectively.

Conclusions

The Hindi version of CAM-ICU is a reliable and valid tool for the diagnosis of delirium in an ICU setting.

Trial registration

The study was registered with the Clinical Trials Registry, India (CTRI) as per the research guidelines laid down by the Indian Council of Medical Research before enrolling the participants. (CTRI number- CTRI/2021/01/030471). The registration date was 14th January 2021. URL of registry is http://ctri.nic.in.

Highlights

Delirium in the ICU is often undiagnosed due to unfamiliarity, lack of understanding of symptoms, non-availability of psychiatric consultation, and validated diagnostic tools in the native language of the patient. This study aims to find the reliability and validity of the Hindi version of CAM-ICU.

How to cite this article

Salhotra R, Bose A, Srivastava S, Mohta M, Pandarinathan K, Rautela RS. Reliability and Validity of Hindi Version of the Confusion Assessment Method for Intensive Care Unit (CAM-ICU) for Diagnosis of Delirium: A Cohort Study. Indian J Crit Care Med 2024;28(10):958-962.

Practices of the ABCDEF care bundle in intensive care units as reported by nurses: A cross-sectional study from Turkey

BACKGROUND

Recent critical care guidelines recommended the evidence-based ABCDEF care bundle for intensive care unit (ICU) patients. However, limited information is available on the implementation of the bundle in Turkish ICUs.

AIM

To assess the current practices of the ABCDEF care bundle as reported by ICU nurses.

STUDY DESIGN

A cross-sectional study using a web-based survey was conducted. Researchers invited nurses with at least 1 year of ICU experience to participate by sending the link to the research questionnaires they created in Google Forms to the one ICU nurse association and one communication group of which they are members.

RESULTS

A total of 342 ICU nurses completed the survey. Although 92% of the participants performed pain assessments in their ICUs, 52.7% reported not using protocols. Based on the responses of the nurses, spontaneous awakening and breathing trials are performed in 88.8% and 92.4%, respectively, of ICUs. Fewer than half of the participants reported following a sedation protocol in their ICUs. Only 54.7% of ICU nurses surveyed reported routinely monitoring patients for delirium. It was reported that early mobilization was practised in 68.7% of ICUs, but non-ventilated patients were mobilized more frequently (70.2%), and 9.7% of ICUs had mobilization teams. Family members were actively involved in 95% of ICUs; however, 9.7% used dedicated staff to support families and 3.5% reported that their unit was open 24 h/day for visits.

CONCLUSIONS

While the implementation of most pain and sedation evaluations in ICUs were reported by nurses, many of them did not use structured delirium assessments. There is a need to encourage early mobilization programs and family participation.

RELEVANCE TO CLINICAL PRACTICE

Health institutions can improve patient care and outcomes by establishing and standardizing a protocol for each component of the ABCDEF care bundle in ICUs.

Intensive care nurses' perceptions and awareness of delirium and delirium prevention guidelines

BACKGROUND

Delirium is an acute and fluctuating disturbance of cognition and is a common occurrence in critically ill patients. It is a manifestation of an acute brain dysfunction often attributed to higher survival rates and a subsequently aging population. Intensive Care Unit (ICU) treatment and survival often contributes towards development of delirium, and lack of or inappropriate management can translate into the development of long-term psychological effects that last even after discharge. While a lot is already known about this topic, and several assessment tools exist, these are not being consistently used by ICU nurses and as a result delirium often goes unrecognized, with unwarranted consequences.

AIMS

The study aimed to explore the perception of delirium among ICU nurses, and the extent of their awareness about guidelines to assess and prevent delirium in ICU patients. It also sought to understand the application of delirium guidelines in ICU practice.

STUDY DESIGN

A quantitative, exploratory, self-reporting survey was conducted among 145 ICU nurses from one critical care unit in the Republic of Ireland.

RESULTS

The overall response rate was 71% (103/145). Most nurses (85%) who participated in this survey believed delirium was expected. However, only 45% acknowledged it is a complication. Only 31% of nurses monitored delirium using a validated scale and few observed this as a part of routine care. Most nurses had received education; however, this did not translate to their clinical practice.

CONCLUSIONS

Guidelines on managing delirium may not be routinely implemented in the ICU settings of hospitals in the Republic of Ireland.

RELEVANCE TO CLINICAL PRACTICE

As the findings suggest, a gap exists between theory and practice, necessary revision of policy or creating a new policy, supplemental educational sessions such as bedside sessions, e-learning module, study day or seminars need to be organized to improve nurses' awareness related to delirium and delirium prevention guidelines.

A Case Report and Review of the Literature of ICU Delirium

This case report focuses on what patients and family members may experience when a neurological trauma transpires and resultant intensive care (ICU) delirium occurs. It is the personal account of the patient (A.B.) and spouse's (R.G.B.) perspectives when the patient (A.B) suffered a vertebral artery aneurysm and hemorrhage and experienced intensive care unit (ICU) delirium after being in the ICU for 22 days. This case report provides the patient's and spouse's perspectives regarding delirium, i.e., A.B.'s inability to discern reality, loss of memory, paranoia and hallucinations, agency and recovery, post-ICU syndrome, and post-traumatic stress disorder (PTSD). Clinical diagnosis by the neurosurgeon indicated delirium, with treatment consisting of sleep sedation and uninterrupted sleep. A.B. was able to regain consciousness yet experienced post-traumatic stress disorder up to one year afterward. Consistent family participation in the patient's delirium care is crucial. Family member care and family-centered strategies are provided with implications for future research and health care.

Nursing Intervention to Prevent and Manage Delirium in Critically Ill Patients: A Scoping Review

Delirium is an acute neuropsychiatric syndrome of multifactorial etiology with a high incidence in people admitted to intensive care units. In addition to reversible impairment of cognitive processes, it may be associated with changes in thinking and perception. If, in the past, it was considered an expected complication of severe disease, nowadays, delirium is associated with a poor short-term and long-term prognosis. Knowing that its prevention and early identification can reduce morbidity, mortality, and health costs, it is vital to investigate nursing interventions focused on delirium in critically ill patients. This study aimed to identify nursing interventions in the prevention and management of delirium in critically ill adults. The method used to answer the research question was a scoping review. The literature search was performed in the Medline (via PubMed), CINAHL (via EBSCOhost), Scopus, Web of Science, and JBI databases. The final sample included 15 articles. Several categories of non-pharmacological interventions were identified, addressing the modifiable risk factors that contribute to the development of delirium, and for which nurses have a privileged position in their minimization. No drug agent can, by itself, prevent or treat delirium. However, psychoactive drugs are justified to control hyperactive behaviors through cautious use. Early diagnosis, prevention, or treatment can reduce symptoms and improve the individual's quality of life. Therefore, nursing professionals must ensure harmonious coordination between non-pharmacological and pharmacological strategies.

A Comparison of Efficacy between Low-dose Dexmedetomidine and Propofol for Prophylaxis of Postoperative Delirium in Elderly Patients Undergoing Hip Fracture Surgery: A Randomized Controlled Trial

AIMS AND BACKGROUND

The efficacy of dexmedetomidine and propofol in preventing postoperative delirium is controversial. This study aims to evaluate the efficacy of dexmedetomidine and propofol for preventing postoperative delirium in extubated elderly patients undergoing hip fracture surgery.

MATERIALS AND METHODS

This randomized controlled trial included participants undergoing hip fracture surgery. Participants were randomly assigned to receive dexmedetomidine, propofol, or placebo intravenously during intensive care unit (ICU) admission (8 p.m. to 6 a.m.). The drug dosages were adjusted to achieve the Richmond Agitation Sedation Scale (RASS) of 0 to -1. The primary outcome was postoperative delirium. The secondary outcomes were postoperative complications, fentanyl consumption, and length of hospital stay.

RESULTS

108 participants were enrolled (n = 36 per group). Postoperative delirium incidences were 8.3%, 22.2%, and 5.6% in the dexmedetomidine, propofol, and placebo groups, respectively. The hazard ratios of dexmedetomidine and propofol compared with placebo were 1.49 (95% CI, 0.25, 8.95; p = 0.66) and 4.18 (95% CI, 0.88, 19.69; p = 0.07). The incidence of bradycardia was higher in the dexmedetomidine group compared with others (13.9%; p = 0.01) but not for hypotension (8.3%; p = 0.32). The median length of hospital stays (8 days, IQR: 7, 11) and fentanyl consumption (240 µg, IQR: 120, 400) were not different among groups.

CONCLUSION

This study did not successfully demonstrate the impact of nocturnal low-dose dexmedetomidine and propofol in preventing postoperative delirium among elderly patients undergoing hip fracture surgery. While not statistically significant, it is noteworthy that propofol exhibited a comparatively higher delirium rate.

HOW TO CITE THIS ARTICLE

Ekkapat G, Kampitak W, Theerasuwipakorn N, Kittipongpattana J, Engsusophon P, Phannajit J, et al. A Comparison of Efficacy between Low-dose Dexmedetomidine and Propofol for Prophylaxis of Postoperative Delirium in Elderly Patients Undergoing Hip Fracture Surgery: A Randomized Controlled Trial. Indian J Crit Care Med 2024;28(5):467-474.

Efficacy of melatonin in decreasing the incidence of delirium in critically ill adults: a randomized controlled trial

OBJECTIVE

To determine whether enteral melatonin decreases the incidence of delirium in critically ill adults.

METHODS

In this randomized controlled trial, adults were admitted to the intensive care unit and received either usual standard care alone (Control Group) or in combination with 3mg of enteral melatonin once a day at 9 PM (Melatonin Group). Concealment of allocation was done by serially numbered opaque sealed envelopes. The intensivist assessing delirium and the investigator performing the data analysis were blinded to the group allocation. The primary outcome was the incidence of delirium within 24 hours of the intensive care unit stay. The secondary outcomes were the incidence of delirium on Days 3 and 7, intensive care unit mortality, length of intensive care unit stay, duration of mechanical ventilation and Glasgow outcome score (at discharge).

RESULTS

We included 108 patients in the final analysis, with 54 patients in each group. At 24 hours of intensive care unit stay, there was no difference in the incidence of delirium between Melatonin and Control Groups (29.6 versus 46.2%; RR = 0.6; 95%CI 0.38 - 1.05; p = 0.11). No secondary outcome showed a statistically significant difference.

CONCLUSION

Enteral melatonin 3mg is not more effective at decreasing the incidence of delirium than standard care is in critically ill adults.

Close relatives' perspective of critical illness due to COVID-19: Keeping in touch at a distance

AIM

To elucidate the meaning of being a close relative of a critically ill person cared for in intensive care during the initial phase of the COVID-19 pandemic.

DESIGN

A narrative inquiry design following the COREQ guidelines.

METHODS

Individual interviews with fifteen close relatives of patients critically ill with COVID-19 were analysed using phenomenological hermeneutics.

RESULTS

The surreal existence of not being allowed to be near was emotionally difficult. While distancing due to restrictions was challenging, physicians' phone calls served as a connection to their relatives and brought a sense of security. Keeping notes helped them remember what happened and brought order to a chaotic situation.

CONCLUSION

Close relatives feel secure when they receive regular information about their critically ill relative, not just when their condition worsens. They wish to be physically near to their critically ill person; when this is impossible, digital technology can provide support, but further accessibility developments are needed.

Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) for the diagnosis of delirium in adults in critical care settings

BACKGROUND

Delirium is an underdiagnosed clinical syndrome typified by an acute alteration of mental state. It is an important problem in critical care and intensive care units (ICU) due to its high prevalence and its association with adverse outcomes. Delirium is a very distressing condition for patients, with a huge impact on their well-being. Diagnosis of delirium in the critical care setting is challenging. This is especially true for patients who are mechanically ventilated and are therefore unable to engage in a verbal interview. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is a tool specifically designed to assess for delirium in the context of ICU patients, including those on mechanical ventilation. CAM-ICU can be administered by non-specialists to give a dichotomous delirium present/absent result.

OBJECTIVES

To determine the diagnostic accuracy of the CAM-ICU for the diagnosis of delirium in adult patients in critical care units.

SEARCH METHODS

We searched MEDLINE (Ovid SP, 1946 to 8 July 2022), Embase (Ovid SP, 1982 to 8 July 2022), Web of Science Core Collection (ISI Web of Knowledge, 1945 to 8 July 2022), PsycINFO (Ovid SP, 1806 to 8 July 2022), and LILACS (BIREME, 1982 to 8 July 2022). We checked the reference lists of included studies and other resources for additional potentially relevant studies. We also searched the Health Technology Assessment database, the Cochrane Library, Aggressive Research Intelligence Facility database, WHO ICTRP, ClinicalTrials.gov, and websites of scientific associations to access any annual meetings and abstracts of conference proceedings in the field.

SELECTION CRITERIA

We included diagnostic studies enrolling adult ICU patients assessed using the CAM-ICU tool, regardless of language or publication status and reporting sufficient data on delirium diagnosis for the construction of 2 x 2 tables. Eligible studies evaluated the diagnostic performance of the CAM-ICU versus a clinical reference standard based on any iteration of the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria applied by a clinical expert.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected and collated study data. We assessed the methodological quality of studies using the QUADAS-2 tool. We used two univariate fixed-effect or random-effects models to determine summary estimates of sensitivity and specificity. We performed sensitivity analyses that excluded studies considered to be at high risk of bias and high concerns in applicability, due mainly to the target population included (e.g. patients with traumatic brain injury). We also investigated potential sources of heterogeneity, assessing the effect of reference standard diagnosis and proportion of patients ventilated.

MAIN RESULTS

We included 25 studies (2817 participants). The mean age of participants ranged from 48 to 69 years; 15 of the studies included critical care units admitting mixed populations (e.g. medical, trauma, surgery patients). The percentage of patients receiving mechanical ventilation ranged from 11.8% to 100%. The prevalence of delirium in the studies included ranged from 12.5% to 83.9%. Presence of delirium was determined by the application of DSM-IV criteria in 13 out of 25 included studies. We assessed 13 studies as at low risk of bias and low applicability concerns for all QUADAS-2 domains. The most common issue of concern was flow and timing of the tests, followed by patient selection. Overall, we estimated a pooled sensitivity of 0.78 (95% confidence interval (CI) 0.72 to 0.83) and a pooled specificity of 0.95 (95% CI 0.92 to 0.97). Sensitivity analysis restricted to studies at low risk of bias and without any applicability concerns (n = 13 studies) gave similar summary accuracy indices (sensitivity 0.80 (95% CI 0.72 to 0.86), specificity 0.95 (95% CI 0.93 to 0.97)). Subgroup analyses based on diagnostic assessment found summary estimates of sensitivity and specificity for studies using DSM-IV of 0.79 (95% CI 0.72 to 0.85) and 0.94 (95% CI 0.90 to 0.96). For studies that used DSM-5 criteria, summary estimates of sensitivity and specificity were 0.75 (95% CI 0.67 to 0.82) and 0.98 (95% CI 0.95 to 0.99). DSM criteria had no significant effect on sensitivity (P = 0.421), but the specificity for detection of delirium was higher when DSM-5 criteria were used (P = 0.024). The relative specificity comparing DSM-5 versus DSM-IV criteria was 1.05 (95% CI 1.02 to 1.08). Summary estimates of sensitivity and specificity for studies recruiting < 100% of patients with mechanical ventilation were 0.81 (95% CI 0.75 to 0.85) and 0.95 (95% CI 0.91 to 0.98). For studies that exclusively recruited patients with mechanical ventilation, summary estimates of sensitivity and specificity were 0.91 (95% CI 0.76 to 0.97) and 0.98 (95% CI 0.92 to 0.99). Although there was a suggestion of differential performance of CAM-ICU in ventilated patients, the differences were not significant in sensitivity (P = 0.316) or in specificity (P = 0.493).

AUTHORS' CONCLUSIONS

The CAM-ICU tool may have a role in the early identification of delirium, in adult patients hospitalized in intensive care units, including those on mechanical ventilation, when non-specialized, properly trained clinical personnel apply the CAM-ICU. The test is most useful for exclusion of delirium. The test may miss a proportion of patients with incident delirium, therefore in situations where detection of all delirium cases is desirable, it may be best to repeat the test or combine CAM-ICU with another assessment. Future studies should compare different screening tests proposed for bedside assessment of delirium, as this approach will reveal which tool yields superior accuracy. In addition, future studies should consider and report the flow and timing of the tests and clearly report key characteristics related to patient selection. Finally, future research should focus on the impact of CAM-ICU screening on patient outcomes.

Effect of using eye masks and earplugs in preventing delirium in intensive care patients: A single-blinded, randomized, controlled trial

BACKGROUND

Delirium, which is frequently encountered in intensive care patients, can be prevented with multicomponent nursing interventions, and thus the negative consequences can be reduced.

AIM

To examine the effect of using eye masks and earplugs in preventing delirium in intensive care units (ICUs).

STUDY DESIGN

A randomized, controlled, single-blind intervention study. This study was conducted in the medical and surgical ICUs of a tertiary hospital, and nurses were given pre-study training on delirium risks, diagnosis, prevention, and management. Data were collected using the patient information form, the Nursing Delirium Screening Scale, the Richard-Campbell Sleep Scale, and the daily follow-up form. Various environmental modifications were made in the ICUs for all patients, and evidence-based nonpharmacological nursing interventions were applied to the patients in both groups during the day and night shifts for 3 days. In addition, the patients in the intervention group were provided with eye masks and earplugs for three nights.

RESULTS

The study included a total of 60 patients (30 in the intervention group and 30 in the control group). There was a statistically significant difference in the development of delirium between the intervention and control groups (night of the 2nd day, p = .019; day of the 3rd day p < .001; night of the 3rd day p ≤ .001). The average total sleep quality score of the intervention group was found to be significantly higher than the control group (p ≤ .001 for three nights). Staying in the internal medicine ICU affected (odds ratio [OR], 11.84; 95% confidence interval [CI], 3.00-46.66; p = .017) more on the development of delirium than in coronary ICU, being in the age group of 65 and over, having a hearing impairment, coming to ICU from the operating room, and education level had an effect.

CONCLUSIONS

The earplugs and eye masks used by the intensive care patients overnight were found to be effective in increasing sleep quality and preventing delirium.

RELEVANCE TO CLINICAL PRACTICE

The use of eye masks and earplugs is recommended for ICUs in preventing delirium.

Incidence, Subtypes, Risk factors, and Outcome of Delirium: A Prospective Observational Study from Indian Intensive Care Unit

Background

Delirium is a common, under-recognized, and often fatal condition in critically ill patients, characterized by acute disorder of attention and cognition. The global prevalence varies with a negative impact on outcomes. A paucity of Indian studies exists that have systematically assessed delirium.

Objective

A prospective observational study designed to determine the incidence, subtypes, risk factors, complications, and outcome of delirium in Indian intensive care units (ICUs).

Patients and methods

Among 1198 adult patients screened during the study period (December 2019-September 2021), 936 patients were included. The confusion assessment method score (CAM-ICU) and Richmond agitation sedation scale (RASS) were used, with additional confirmation of delirium by the psychiatrist/neurophysician. Risk factors and related complications were compared with a control group.

Results

Delirium occurred in 22.11% of critically ill patients. The hypoactive subtype was the most common (44.9%). The risk factors recognized were higher age, increased acute physiology and chronic health evaluation (APACHE-II) score, hyperuricemia, raised creatinine, hypoalbuminemia, hyperbilirubinemia, alcoholism, and smoking. Precipitating factors included patients admitted on noncubicle beds, proximity to the nursing station, requiring ventilation, as well as the use of sedatives, steroids, anticonvulsants, and vasopressors. Complications observed in the delirium group were unintentional removal of catheters (35.7%), aspiration (19.8%), need for reintubation (10.6%), decubitus ulcer formation (18.4%), and high mortality (21.3% vs 5%).

Conclusion

Delirium is common in Indian ICUs with a potential effect on length of stay and mortality. Identification of incidence, subtype, and risk factors is the first step toward prevention of this important cognitive dysfunction in the ICU.

How to cite this article

Tiwari AM, Zirpe KG, Khan AZ, Gurav SK, Deshmukh AM, Suryawanshi PB, et al. Incidence, Subtypes, Risk factors, and Outcome of Delirium: A Prospective Observational Study from Indian Intensive Care Unit. Indian J Crit Care Med 2023;27(2):111-118.

Incidence, Associated Factors, and Outcome of Delirium among Patients Admitted to ICUs in Oman

Background

The incidence of delirium is high up to 46.3% among patients admitted to ICU. Delirium is linked to negative patient outcomes like increased duration of mechanical ventilation use, prolonged ICU stay, increased mortality rate, and healthcare costs. Despite the importance of delirium and its consequences that are significant, there is a scarcity of studies which explored delirium in Oman.

Objectives

This study was conducted to assess the incidence of delirium, the association between the selected predisposing factors and precipitating factors with delirium, determine the predicators of delirium, and evaluate its impacts on ICU mortality and ICU length of stay among ICU patients in Oman.

Methods

A multicenter prospective observational design was used. A total of 153 patients were assessed two-times a day by bedside ICU nurses through the Intensive Care Delirium Screening Checklist (ICDSC).

Results

The results revealed that the delirium incidence was 26.1%. Regression analysis showed that sepsis, metabolic acidosis, nasogastric tube use, and APACHE II score were independent predictors for delirium among ICU patients in Oman and delirium had significant impacts on ICU length of stay and mortality rate.

Conclusion

Delirium is common among ICU patients and it is associated with negative consequences. Multidisciplinary prevention strategies should be implemented to identify and treat the modifiable risk factors.

Evaluation of progressive early rehabilitation training mode in intensive care unit patients with mechanical ventilation

BACKGROUND

Mechanical ventilation is a common resuscitation method in the intensive care unit (ICU). Unfortunately, this treatment process prolongs the ICU stay of patients with an increased incidence of delirium, which ultimately affects the prognosis.

AIM

To evaluate the effect of progressive early rehabilitation training on treatment and prognosis of patients with mechanical ventilation in ICU.

METHODS

The convenience sampling method selected 190 patients with mechanical ventilation admitted to the Fourth Hospital of Hebei Medical University from March 2020 to March 2021. According to the random number table method, they were divided into the control and intervention groups. The control group received routine nursing and rehabilitation measures, whereas the intervention group received progressive early rehabilitation training. In addition, the incidence and duration of delirium were compared for the two groups along with mechanical ventilation time, ICU hospitalization time, functional independence measure (FIM) score, Barthel index, and the incidence of complications (deep venous thrombosis, pressure sores, and acquired muscle weakness).

RESULTS

In the intervention group, the incidence of delirium was significantly lower than in the control group (28% vs 52%, P < 0.001). In the intervention group, the duration of delirium, mechanical ventilation time, and ICU stay were shorter than in the control group (P < 0.001). The FIM and Barthel index scores were significantly higher in the intervention group than the control group (P < 0.001). The total incidence of complications in the intervention group was 3.15%, which was lower than 17.89% in the control group (P < 0.001).

CONCLUSION

Progressive early rehabilitation training reduced the incidence of delirium and complications in ICU patients with mechanical ventilation, which improved prognosis and quality of life.

The Effect of Scenario-Based Learning on the Performance of Nurses Regarding Delirium in Cardiac Surgery Intensive Care Units: A Quasi-Experimental Study

Background

Delirium is one of the most common complications of cardiac surgery, and only a small percentage of nurses are able to diagnose and manage it. The aim of this study was to determine the effect of Scenario-Based Learning (SBL) on the performance of nurses in the management of delirium in Cardiovascular Intensive Care Units (CICUs).

Materials and Methods

A quasi-experimental research with a pretest-post-test design was conducted on 36 nurses of the cardiac surgery ICUs of Isfahan's therapeutic-educational center from October 2019 to January 2020. The SBL↱ was held in the form of a 2-day workshop. The study data collection tools included a demographic questionnaire, researcher-made knowledge questionnaire, and performance checklist. The data were analysed using descriptive statistics (frequency, mean, and standard deviation), and inferential statistics (repeated measures one-way analysis of variance ANOVA and Fisher's Least Significant Difference (LSD post hoc test).

Results

The mean score of performance of nurses differed significantly different between the three study stages (before the intervention, immediately, and 3 weeks after the intervention) (F_2,30 = 139.41; p < 0.001). LSD post hoc test showed that the mean score of performance was significantly higher immediately after the training program compared to before the intervention and 3 weeks after the SBL (p < 0.001).

Conclusions

Based on the results of this study, it can be concluded that SBL↱ improved the delirium care performance levels of nurses in the cardiac surgery ICU. Thus, it is recommended that SBL be used as a method for training nurses.

Development of a Delirium Risk Predication Model among ICU Patients in Oman

Background

Delirium is a common disorder among patients admitted to intensive care units. Identification of the predicators of delirium is very important to improve the patient's quality of life.

Methods

This study was conducted in a prospective observational design to build a predictive model for delirium among ICU patients in Oman. A sample of 153 adult ICU patients from two main hospitals participated in the study. The Intensive Care Delirium Screening Checklist (ICDSC) was used to assess the participants for delirium twice daily.

Result

The results showed that the incidence of delirium was 26.1%. Multiple logistic regression analysis showed that sepsis (odds ratio (OR) = 9.77; 95% confidence interval (CI) = 1.91–49.92; P < 0.006), metabolic acidosis (odds ratio (OR) = 3.45; 95% confidence interval [CI] = 1.18–10.09; P=0.024), nasogastric tube use (odds ratio (OR) 9.74; 95% confidence interval (CI) = 3.48–27.30; P ≤ 0.001), and APACHEII score (OR = 1.22; 95% CI = 1.09–1.37; P ≤ 0.001) were predictors of delirium among ICU patients in Oman (R²=0.519, adjusted R²=0.519, P ≤ 0.001).

Conclusion

To prevent delirium in Omani hospitals, it is necessary to work on correcting those predictors and identifying other factors that had effects on delirium development. Designing of a prediction model may help on early delirium detection and implementation of preventative measures.

Delirium in elderly patients with COPD combined with respiratory failure undergoing mechanical ventilation: a prospective cohort study

Background

COPD combined with respiratory failure is very common in intensive care unit (ICU). We aimed to evaluate the current status and influencing factors of delirium in elderly COPD patients with undergoing mechanical ventilation.

Methods

Patients with COPD combined with respiratory failure and mechanically ventilated who were admitted to the ICU of our hospital were selected. The characteristics of included patients were assessed. Pearson correlation analysis was performed to evaluate the characteristics of patients and delirium. Logistic regression analysis was conducted to identify the risk factors of delirium in elderly patients with COPD combined with respiratory failure undergoing mechanical ventilation.

Results

A total of 237 COPD combined with respiratory failure patients were included, the incidence of delirium was 21.94%. Pearson correlation analysis indicated that age (r = 0.784), BMI (r = 0.709), hypertension (r = 0.696), APACHE II score (r = 0.801), CPOT (r = 0.513), sedation(r = 0.626) and PaO₂ (r = 0.611) were all correlated with the occurrence of delirium (all p < 0.05). Logistic regression analysis indicated that age ≥ 75y (OR 3.112, 95% CI 2.144–4.602), BMI ≤ 19 kg/m² (OR 2.742, 95% CI 1.801–3.355), hypertension(OR 1.909, 95% CI 1.415–2.421), APACHE II score ≥ 15 (OR 2.087, 95% CI 1.724–2.615), CPOT ≥ 5 (OR 1.778, 95% CI 1.206–2.641), sedation(OR 3.147, 95% CI 2.714–3.758), PaO₂ ≤ 75 mmHg(OR 2.196, 95%CI 1.875–3.088) were the risk factors of delirium in elderly patients with COPD combined with respiratory failure undergoing mechanical ventilation (all p < 0.05).

Conclusions

Delirium is common in patients with COPD and respiratory failure undergoing mechanical ventilation, and there are many related influencing factors. Medical staff should pay more attention to patients with risk factors and take intervention measures as soon as possible to reduce the incidence of delirium.

Prevention and treatment of delirium in intensive care: Hermeneutics of experiences of the nursing team

OBJECTIVE

To understand the experiences in nursing care in the prevention and treatment of delirium in people hospitalized in intensive care units.

METHODOLOGY

Hermeneutic phenomenological qualitative study. The selection of participants was by intentional sampling: seven nursing assistants and eight nurses. Theoretical saturation was achieved. The phenomenological interview was applied to collect data from a central question and the analysis was carried out following the approaches of Heidegger's hermeneutical circle.

RESULTS

Four significant themes emerged from the analysis: (1) delirium prevention, (2) pharmacological treatment, (3) non-pharmacological treatment, and (4) barriers to non-pharmacological treatment. These themes were accompanied by 35 interrelated units of meaning: in the first theme, the most repetitive units were communication, orientation, and family bonding; in the second was the use of pharmacological treatment only in the acute phase; in the third was the modification of the environment according to the patient's preference (where the family is a priority and strategies that provide cognitive and social stimulation can be reinforced), and in the fourth was the work overload for the nursing team.

CONCLUSIONS

The experiences of the nursing team in the prevention and treatment of delirium in critically ill patients highlight that communication allows an approach to the patient as a human being immersed in a reality, with a personal history, needs and preferences. Therefore, family members must be involved in these scenarios, as they can complement and support nursing care.

Effects of nonpharmacological interventions on sleep improvement and delirium prevention in critically ill patients: A systematic review and meta-analysis

OBJECTIVE

Sleep disturbance and delirium are common problems experienced by critically ill patients in the intensive care unit (ICU). These interrelated issues increase the length of stay in the ICU but might also negatively affect long-term health outcomes. The objective of this study was to identify the nonpharmacological interventions provided to improve sleep or prevent delirium in ICU patients or both and integrate their effect sizes.

REVIEW METHODS

This study was a registered systematic review and meta-analysis. We searched MEDLINE, CINAHL, EMBASE, Web of Science, and Cochrane Library from their inception until December 2021. We included randomised controlled trials and nonrandomised controlled trials-(RCT) that provided nonpharmacological interventions and reported sleep or delirium as outcome variables. Studies not published in English or whose full text was not available were excluded. The quality of the evidence was assessed with version 2 of the Cochrane risk-of-bias tool for RCTs and the Risk Of Bias In Non-randomised Studies of Interventions (ROBINS-I).

RESULTS

The systematic review included 118 studies, and the meta-analysis included 100 studies. Overall nonpharmacological interventions had significant effects on subjective sleep quality (standardised mean difference = 0.30, 95% confidence interval [CI] = 0.05 to 0.56), delirium incidence (odds ratio = 0.62, 95% CI = 0.53 to 0.73), and delirium duration (standardised mean difference = -0.68, 95% CI = -0.93 to -0.43). In individual interventions, aromatherapy, music, and massage effectively improved sleep. Exercise, family participation, information giving, cognitive stimulation, bright light therapy, architectural intervention, and bundles/protocols effectively reduced delirium. Light/noise blocking was the only intervention that ensured both sleep improvement and delirium prevention.

CONCLUSIONS

Our results suggest nonpharmacological interventions improve sleep and prevent delirium in ICU patients. We recommend that ICU nurses use nonpharmacological interventions that promote person-environment compatibility in their clinical practice. The results of our review can guide nurses in adopting interventions related to sleep and delirium.

PROSPERO REFERENCE NUMBER

CRD42021230815.

Postoperative delirium is an independent factor influencing the length of stay of elderly patients in the intensive care unit and in hospital

Purpose

Postoperative delirium (POD) is an often unrecognized adverse event in older people after surgery. The aim of this subgroup analysis of the PRe-Operative Prediction of postoperative DElirium by appropriate SCreening (PROPDESC) trial in patients aged 70 years and older was to identify preoperative risk factors and the impact of POD on length of stay (LOS) in intensive care unit (ICU) and hospital.

Methods

Of the total 1097 patients recruited at a German university hospital (from September 2018 to October 2019) in the PROPDESC prospective observational study, 588 patients aged 70 years and older (mean age 77.2 ± 4.7 years) were included for subgroup analysis. The primary endpoint POD was considered positive if one of the following tests were positive on any of the five postoperative visit days: Confusion Assessment Method for ICU (CAM-ICU), Confusion Assessment Method (CAM), 4'A's (4AT) and Delirium Observation Scale (DOS). Trained doctoral students carried out these visitations and additionally the nursing staff were interviewed for completion of the DOS. To evaluate the independent effect of POD on LOS in ICU and in hospital, a multi-variable linear regression analysis was performed.

Results

The POD incidence was 25.9%. The results of our model showed POD as an independent predictor for a prolonged LOS in ICU (36%; 95% CI 4–78%; < 0.001) and in hospital (22%; 95% CI 4–43%; < 0.001).

Conclusion

POD has an independent impact on LOS in ICU and in hospital. Based on the effect of POD for the elderly, a standardized risk screening is required.

Trail registration

German Registry for Clinical Studies: DRKS00015715.

Incidence and Risk Factors of Ventilator-Associated Pneumonia among Patients with Delirium in the Intensive Care Unit: A Prospective Observational Study

INTRODUCTION

The incidence and risk factors for ventilator-related pneumonia (VAP) in patients with delirium are deficient, and there is a lack of in-depth knowledge of the impact of VAP on outcomes in this population. We investigated the incidence, risk factors, and outcomes of VAP in patients with delirium.

MATERIALS AND METHODS

This prospective observational study was performed in a surgical ICU at Be'sat Hospital in Hamadan, Iran, between 2018 and 2019. A total of 108 patients with delirium were identified using the Confusion Assessment Method (CAM) for the ICU and Intensive Care Delirium Screening Checklist (ICDSC) and enrolled in this study. The association between VAP and delirium, risk factors, and outcomes (ICU length of stay and ICU mortality) for VAP were investigated using the Cox proportional hazards model and logistic and simple linear regression analyses with a 95% confidence interval.

RESULTS

Of 108 delirium patients, 86 patients (79.6%) underwent mechanical ventilation (MV) and 16 patients (18.6%) experienced VAP during ICU stay. The median onset of VAP was 6.5 (IQR 4.2-7.7) days after intubation. Delirium patients with VAP stayed longer in the ICU (21.68 ± 4.26 vs.12.93 ± 1.71, P < 0.001) and also had higher ICU mortality (31.25% vs. 0%, P < 0.001) than subjects without VAP. According to multivariate cox regression, the expected HR for VAP was 53.5% lower for patients with early-onset delirium than in patients with late-onset delirium (HR: 0.465, 95% CI: 0.241-0.894, P=0.022). However, the expected hazard for VAP was 1.854 times and 4.604 times higher in patients with longer ICU stay (HR: 1.854, 95% CI: 1.689-3.059, P=0.032) and in patients with a prolonged MV duration (HR: 4.604, 95%CI: 1.567-6.708, P=0.023).

CONCLUSION

According to the results, there seems to be an inverse relationship between early onset of delirium and VAP. This finding cannot be conclusively cited, and more studies in this filed should be conducted with a larger sample size. Furthermore, VAP in delirium patients is associated with increases in poor outcomes (higher ICU mortality) and the use of medical resources (longer stay in the ICU and MV duration).

Risk factors, time to onset and recurrence of delirium in a mixed medical-surgical ICU population: A secondary analysis using Cox and CHAID decision tree modeling

A retrospective secondary analysis of 4,200 patients was collected from two academic medical centers. Delirium was assessed using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) in all patients. Univariate and multivariate Cox models, logistic regression analysis, and Chi-square Automatic Interaction Detector (CHAID) decision tree modeling were used to explore delirium risk factors. Increased delirium risk was associated with exposed only to artificial light (AL) hazard ratio (HR) 1.84 (95 % CI: 1.66-2.044, P<0.001), physical restraint application 1.11 (95 % CI: 1.001-1.226, P=0.049), and high nursing care requirements (>8 hours per 8-hour shift) 1.18 (95 % CI: 1.048-1.338, P=0.007). Delirium incidence was inversely associated with greater family engagement 0.092 (95 % CI: 0.014-0.596, P=0.012), low staff burnout and anticipated turnover scores 0.093 (95 % CI: 0.014-0.600, P=0.013), non-ICU length-of-stay (LOS)<15 days 0.725 (95 % CI: 0.655-0.804, P<0.001), and ICU LOS ≤15 days 0.509 (95 % CI: 0.456-0.567, P<0.001). CHAID modeling indicated that AL exposure and age <65 years were associated with a high risk of delirium incidence, whereas SOFA score ≤11, APACHE IV score >15 and natural light (NL) exposure were associated with moderate risk, and female sex was associated with low risk. More rapid time to delirium onset correlated with baseline sleep disturbance (P=0.049), high nursing care requirements (P=0.019), and prolonged ICU and non-ICU hospital LOS (P<0.001). Delirium recurrence correlated with age >65 years (HR 2.198; 95 % CI: 1.101-4.388, P=0.026) and high nursing care requirements (HR 1.978, 95 % CI: 1.096-3.569), with CHAID modeling identifying AL exposure (P<0.001) and age >65 years (P=0.032) as predictive variables. Development of ICU delirium correlated with application of physical restraints, high nursing care requirements, prolonged ICU and non-ICU LOS, exposure exclusively to AL (rather than natural), less family engagement, and greater staff burnout and anticipated turnover scores. ICU delirium occurred more rapidly in patients with baseline sleep disturbance, and recurrence correlated with the presence of delirium on ICU admission, exclusive AL exposure, and high nursing care requirements.

Incidence of delirium in the critical care unit and risk factors in the Central Region, Saudi Arabia

Objectives:

To determine the incidence and risk factors of delirium in the cardiac care unit (CCU) and intensive care unit (ICU).

Methods:

This multicenter prospective observational study was conducted between July 2019 and November 2019 in the central region of Saudi Arabia. All patients admitted to the critical care units were enrolled, and their demographic data and risk factors of delirium were reported.

Results:

A total of 165 patients were included: 76 (46.1%) admitted to the CCU and 89 (53.9%) admitted to the ICU. The mean age was 55.1±18 years, and 45 (27.3%) were women. We found that 24/165 (14.5%) patients developed delirium during admission. Importantly, variables significantly associated with delirium group were female gender: (24.5% versus 10.8%, p=0.028), malnutrition (29.2% versus 5%, p<0.001), the presence of urinary catheter (75% versus 30.5%, p=0.001), septicemia (50% versus 14.9%, p<0.001), intubation (41.7% versus 10.6%, p=0.001), low hemoglobin (10.79±2.91 versus 12.05±2.77, p=048), and prolonged prothrombin time (PT) (15.87±5.17 versus 13.60±3.28, p=0.011).

Conclusion:

The incidence of delirium was 14.5% among patients admitted to critical care units in the central region of Saudi Arabia. Septicemia, prolonged PT, malnutrition, and urinary catheter are significant predictors of delirium.

Prevention and treatment of delirium in intensive care: Hermeneutics of experiences of the nursing team

OBJECTIVE

To understand the experiences in nursing care in the prevention and treatment of delirium in people hospitalized in intensive care units.

METHODOLOGY

Hermeneutic phenomenological qualitative study. The selection of participants was by intentional sampling: seven nursing assistants and eight nurses. Theoretical saturation was achieved. The phenomenological interview was applied to collect data from a central question and the analysis was carried out following the approaches of Heidegger's hermeneutical circle.

RESULTS

Four significant themes emerged from the analysis: 1) Delirium prevention, 2) Pharmacological treatment, 3) Non-pharmacological treatment, and 4) Barriers to non-pharmacological treatment. These themes were accompanied by 35 interrelated units of meaning: in the first theme, the most repetitive units were communication, orientation, and family bonding; in the second was the use of pharmacological treatment only in the acute phase; in the third was the modification of the environment according to the patient's preference (where the family is a priority and strategies that provide cognitive and social stimulation can be reinforced), and in the fourth was the work overload for the nursing team.

CONCLUSIONS

The experiences of the nursing team in the prevention and treatment of delirium in critically ill patients highlight that communication allows an approach to the patient as a human being immersed in a reality, with a personal history, needs and preferences. Therefore, family members must be involved in these scenarios, as they can complement and support nursing care.

Factors Related to Delirium of Intensive Care Unit Patients in Korea: A Systematic Review

BACKGROUND

The delirium in Intensive Care Units (ICU) patients is a major cause of unplanned extubation, increased length of hospital day. This study aimed to review systematically risk factors associated with the occurrence of delirium among ICU patients in South Korea.

METHODS

Data collection was done with domestic literature search databases including KMbase, KoreaMed, KISS, and KisTi and also with hand searching, from February 17 to May 19, 2019. Two researchers independently selected research literatures, and three researchers summarized and identified related variables based on data extraction methods.

RESULTS

Overall, 140 articles were identified, 18 articles met the inclusion criteria for review. According to the results of the methodological quality, one article was found to have a high level of quality, while the remaining 17 articles belonged to the medium level. Those factors were highly associated with delirium by more than 9 out of the 18 selected studies were listed as follows; age, the application of ventilator, APACHE II score, comorbidity, the application of restraint, and educational level. In addition, catheter insertion and the application of artificial airway had significant relevance with the occurrence of delirium.

CONCLUSION

For management of delirium among ICU patients, it is necessary to eliminate and prevent delirium-associated risk factors, and also to detect and treat the delirium early through regular monitoring using an appropriate screening tool for delirium.

Effects of case-based confusion assessment methods for intensive care unit training on delirium knowledge and delirium assessment accuracy of intensive care units: A quasi-experimental study

BACKGROUND

Delirium evaluation is important because the development of delirium in critically ill patients negatively affects their progress and prognosis. Although delirium assessment tools have been developed, nurses have insufficient experience using these tools in clinical practice.

OBJECTIVES

This study examined the effects of case-based confusion assessment methods for intensive care unit education on delirium knowledge and assessment accuracy for intensive care nurses.

DESIGN

This study adopted a pre- and post-test non-equivalent control group design.

SETTINGS AND PARTICIPANTS

The study participants were 122 general nurses (61 participants each in the experimental and control groups) working in the intensive care unit of one university hospital in South Korea.

METHODS

Case-based confusion assessment methods for intensive care unit education comprised lectures on delirium and confusion assessment methods for intensive care unit tools and delirium assessment education using standardized patients. The experimental group received 80-min case-based confusion assessment methods for intensive care unit training, whereas the control group received no intervention.

RESULTS

Differences in the degree of pre- and post-knowledge in subcategories between the experimental and control groups were the cause, symptom, and management. The delirium assessment accuracy score of the experimental group changed from 2.89 ± 1.61 points before training to 8.11 ± 1.23 points after training, whereas that of the control group changed from 2.92 ± 1.94 points before training to 3.05 ± 2.99 points after training (Z = -9.668, p < .001).

CONCLUSIONS

The case-based confusion assessment methods for intensive care unit educational program developed in this study is effective for improving delirium knowledge and delirium assessment accuracy in intensive care nurses. Based on the study results, various cases can be developed for the education of intensive care nurses.

Delirium in Ventilated Patients: Is ABCDEF Bundle the Solution?

How to cite this article: Rangappa R. Delirium in Ventilated Patients: Is ABCDEF Bundle the Solution? Indian J Crit Care Med 2021;25(7):743-744.

The Effect of Patient-controlled Intravenous Analgesia (PCIA) on Postoperative Delirium in Patients with Liver Transplantation: a Propensity Score Matching Analysis

Objectives Postoperative opioid use and pain are related to postoperative delirium. This study aims to compare the incidence of delirium in patients with and without patient-controlled intravenous analgesia (PCIA) among liver transplant recipients. Methods The medical records of 253 patients who received liver transplantation (LT) from January 2010 to July 2017 in a single university hospital were retrospectively reviewed. Patients were divided into two groups: the patients who had used PCIA (P group, n = 71) and those who did not use PCIA (C group, n = 182) after LT in intensive care unit (ICU). The patient data were collected, which included demographic data, and details about perioperative management and postoperative complications. Results There was no difference in the model for end-stage liver disease (MELD) score between the two groups. Postoperative delirium occurred in 10 / 71 (14.08 %) in the P group and 26 / 182 (14.29 %) in the C group after LT, respectively (P = 0.97). After propensity score matching, no differences were observed in the incidence of delirium (P = 0.359) and the time from surgery to discharge (P = 0.26) between the two groups. Conclusions Patients with PCIA after LT exhibited no relationship with postoperative delirium. Therefore, it is necessary to actively control postoperative pain using PCIA.

Delirium and Associated Length of Stay and Costs in Critically Ill Patients

Purpose

Delirium frequently affects critically ill patients in the intensive care unit (ICU). The purpose of this study is to evaluate the impact of delirium on ICU and hospital length of stay (LOS) and perform a cost analysis.

Materials and Methods

Prospective studies and randomized controlled trials of patients in the ICU with delirium published between January 1, 2015, and December 31, 2020, were evaluated. Outcome variables including ICU and hospital LOS were obtained, and ICU and hospital costs were derived from the respective LOS.

Results

Forty-one studies met inclusion criteria. The mean difference of ICU LOS between patients with and without delirium was significant at 4.77 days (p < 0.001); for hospital LOS, this was significant at 6.67 days (p < 0.001). Cost data were extractable for 27 studies in which both ICU and hospital LOS were available. The mean difference of ICU costs between patients with and without delirium was significant at $3,921 (p < 0.001); for hospital costs, the mean difference was $5,936 (p < 0.001).

Conclusion

ICU and hospital LOS and associated costs were significantly higher for patients with delirium, compared to those without delirium. Further research is necessary to elucidate other determinants of increased costs and cost-reducing strategies for critically ill patients with delirium. This can provide insight into the required resources for the prevention of delirium, which may contribute to decreasing healthcare expenditure while optimizing the quality of care.

Prospective Randomized Controlled Pilot Study of High-Intensity Lightbox Phototherapy to Prevent ICU-Acquired Delirium Incidence

Background

This study aimed to evaluate the role of disturbed circadian rhythm in potentiating intensive care unit (ICU)-acquired delirium.Previous studies have demonstrated bright light therapy (BLT) as an effective modality to improve sleeping patterns and cognitive function in non-critically ill patients. However, its benefit in the ICU has not been clearly established. In this study, we aimed to evaluate the application of daily high-intensity phototherapy at the bedside to deter ICU delirium incidence and duration.

Methodology

This was a single center, prospective study conducted in ICUs at the Carilion Roanoke Memorial Hospital in Roanoke, VA. Adults patients admitted to the ICU from July 9, 2018 to March 20, 2020 were included in the study. The patients were subjected to 30-minute BLT session (10,000 lux) at the bedside starting at 0700 while in the ICU. Patients were randomized into either the control group (standard hospital lighting) or phototherapy group. Data were analyzed using Wilcoxon rank sum test for continuous variables, Pearson chi-square test for categorical variables, and logistic regression for multivariable analysis that examined significant risk factors for ICU delirium.

Results

Delirium incidence between BLT (18%) and control (17.5%) groups was non-significant. Total number of delirium-free, coma-free days, as determined by Confusion Assessment Method for the ICU, demonstrated no differences between groups with a median of 28 days (p = 0.516). In multivariable analysis, patients with a Sequential Organ Failure Assessment Score >3 also showed no significant change in ICU delirium incidence when provided bedside BLT compared to those with standard hospital lighting (odds ratio: 0.08; 95% confidence interval: 0.002-1.40; p = 0.867).

Conclusions

In this randomized control pilot study, daily morning 10,000 lux BLT of 30-minute duration alone was not associated with a significant decrease in ICU-acquired delirium incidence or duration compared to standard hospital lighting. Future studies should consider a nuanced approach to better elucidate the role of disturbed circadian rhythm in influencing ICU-acquired delirium by not only undertaking BLT during the day but also minimizing nighttime light exposure.

Incidence and risk factors of delirium in surgical intensive care unit

Background

To evaluate the incidence and modifiable risk factors of delirium in surgical intensive care unit (SICU) of tertiary care hospital in a low-income and middle-income country.

Methods

We conducted a single cohort observational study in patients over 18 years of age who were admitted to the SICU for >24 hours in Aga Khan University Hospital from January to December 2016. Patients who had pre-existing cognitive dysfunction were excluded. Intensive Care Delirium Screening Checklist was used to assess delirium. Incidence of delirium was computed, and univariate and multivariable analyses were performed to observe the relationship between outcome and associated factors.

Results

The average patient age was 43.29±17.38 and body mass index was 26.25±3.57 kg/m². Delirium was observed in 19 of 87 patients with an incidence rate of 21.8%. Multivariable analysis showed chronic obstructive pulmonary disease, pain score >4 and hypernatremia were strong predictors of delirium. Midazolam (adjusted OR (aOR)=7.37; 95% CI 2.04 to 26.61) and propofol exposure (aOR=7.02; 95% CI 1.92 to 25.76) were the strongest independent predictors of delirium while analgesic exposures were not statistically significant to predict delirium in multivariable analysis.

Conclusion

Delirium is a significant risk factor of poor outcome in SICU. There was an independent association between pain, sedation, COPD, hypernatremia and fever in developing delirium.

Level of evidence

IV.

A Quality Improvement Evaluation of a Primary As-Needed Light Sedation Protocol in Mechanically Ventilated Adults

Objectives

First, to implement successfully a light-sedation protocol, favoring initial as-needed (prioritizing as-needed) boluses over continuous infusion sedation, and second, to evaluate if this protocol was associated with differences in patient-level sedative requirements, clinical outcomes, and unit-level longitudinal changes in pharmacy charges for sedative medications.

Design

Retrospective review comparing patients who received the prioritizing as-needed sedation protocol to similar patients eligible for the prioritizing as-needed protocol but treated initially with continuous infusion sedation.

Setting

Thirty-two bed medical ICUs in a large academic medical center.

Patients

A total of 254 mechanical ventilated patients with a target Riker Sedation-Agitation Scale goal of 3 or 4 were evaluated over a 2-year period. Of the evaluable patients, 114 received the prioritizing as-needed sedation protocol and 140 received a primary continuous infusion approach.

Interventions

A multidisciplinary leadership team created and implemented a light-sedation protocol, focusing on avoiding initiation of continuous sedative infusions and prioritizing prioritizing as-needed sedation.

Measurements and Main Results

Overall, 42% of patients in the prioritizing as-needed group never received continuous infusion sedation. Compared with the continuous infusion sedation group, patients treated with the prioritizing as-needed protocol received significantly less opioid, propofol, and benzodiazepine. Patients in the prioritizing as-needed group experienced less delirium, shorter duration of mechanical ventilation, and shorter ICU length of stay. Adverse events were similar between the two groups. At the unit level, protocol implementation was associated with reductions in the use of continuous infusion sedative medications.

Conclusions

Implementation and use of a prioritizing as-needed protocol targeting light sedation appear to be safe and effective. These single-ICU retrospective findings require wider, prospective validation.

Platelet-to-lymphocyte ratio as a predictive index for delirium in critically ill patients: A retrospective observational study

Delirium is a neuropsychiatric syndrome commonly encountered in critically ill patients, and systemic inflammation has been strongly implicated to underlie its pathophysiology. This study aimed to investigate the predictive value of the platelet-to-lymphocyte ratio (PLR) for delirium in the intensive care unit (ICU).In this retrospective observational study, we analyzed the clinical and laboratory data of 319 ICU patients from October 2016 to December 2017. Using the Locally Weighted Scatterplot Smoothing technique, a PLR knot was detected at a value of approximately 100. Logistic regression was used to investigate the association between the PLR and delirium.Of the 319 patients included in this study, 29 (9.1%) were diagnosed with delirium. In the delirium group, the duration of mechanical ventilation was significantly longer than that in the no-delirium group (40.2 ± 65.5 vs. 19.9 ± 26.5 hours, respectively; P < .001). A multiple logistic regression analysis showed that PLR > 100 (odds ratio [OR]: 1.003, 95% confidence interval [CI]: 1.001-1.005), age (OR: 2.76, 95% CI: 1.110-6.861), and the ratio of arterial oxygen partial pressure to the inspired oxygen fraction (OR: 0.996, 95% CI: 0.992-0.999) were independent predictors of delirium.In our study, a high PLR value on ICU admission was associated with a higher incidence of delirium. Owing to easy calculability, the PLR could be a useful delirium predictive index in ICUs, thereby enabling early interventions to be implemented.

[Pandemic COVID-19 and mental disorders international experience and therapeutic approaches]

The article considers the COVID-19 pandemic impact on the population mental health, the main psychogenic and somatogenic mental disorders associated with COVID-19 are distinguished. The comorbid PTSD clinical features are described. The mental health risk factors for health workers are presented. The psychotherapeutic and psychopharmaceutical approaches are proposed.

Single assessment of delirium severity during postacute intensive care of chronically critically ill patients and its associated factors: post hoc analysis of a prospective cohort study in Germany

OBJECTIVES

To assess the delirium severity (DS), its risk factors and association with adverse patient outcomes in chronically critically ill (CCI) patients.

DESIGN

A prospective cohort study.

SETTING

A tertiary care hospital with postacute intensive care units (ICUs) in Germany.

PARTICIPANTS

N=267 CCI patients with critical illness polyneuropathy and/or critical illness myopathy, aged 18-75 years, who had undergone elective tracheotomy for weaning failure.

INTERVENTIONS

None.

MEASURES

Primary outcomes: DS was assessed using the Confusion Assessment Method for the Intensive Care Unit-7 delirium severity score, within 4 weeks (t1) after the transfer to a tertiary care hospital. In post hoc analyses, univariate linear regressions were employed, examining the relationship of DS with clinical, sociodemographic and psychological variables. Secondary outcomes: additionally, correlations of DS with fatigue (using the Multidimensional Fatigue Inventory-20), quality of life (using the Euro-Quality of Life) and institutionalisation/mortality at 3 (t2) and 6 (t3) months follow-up were computed.

RESULTS

Of the N=267 patients analysed, 9.4% showed severe or most severe delirium symptoms. 4.1% had a full-syndromal delirium. DS was significantly associated with the severity of illness (p=0.016, 95% CI -0.1 to -0.3), number of medical comorbidities (p<0.001, 95% CI .1 to .3) and sepsis (p<0.001, 95% CI .3 to 1.0). Patients with a higher DS at postacute ICU (t1), showed a higher mental fatigue at t2 (p=0.008, 95% CI .13 to .37) and an increased risk for institutionalisation/mortality (p=0.043, 95% CI 1.1 to 28.9/p=0.015, 95% CI 1.5 to 43.2).

CONCLUSIONS

Illness severity is positively associated with DS during postacute care in CCI patients. An adequate management of delirium is essential in order to mitigate functional and cognitive long-term sequelae following ICU.

TRIAL REGISTRATION NUMBER

DRKS00003386.

A pilot study of high frequency accelerometry-based sedation and agitation monitoring in critically ill patients

OBJECTIVE

The degree of sedation or agitation in critically ill patients is typically assessed with the Richmond Agitation and Sedation Scale (RASS). However, this approach is intermittent and subject to unrecognised variation between assessments. High frequency accelerometry may assist in achieving a quantitative and continuous assessment of sedation while heralding imminent agitation.

DESIGN

We undertook a prospective, observational pilot study.

SETTING

An adult tertiary intensive care unit in Melbourne, Australia.

PARTICIPANTS

20 patients with an admission diagnosis of trauma.

MAIN OUTCOME MEASURES

Accelerometers were applied to patients' wrists and used to continuously record patient movement. Video data of patient behaviour were simultaneously collected, and observers blinded to accelerometry data were adjudicated the RASS score every 30 seconds. Exploratory analyses were undertaken.

RESULTS

Patients were enrolled for a median duration of 9.7 hours (interquartile range [IQR], 0-22.8) and a total of 160 hours. These patients had a median RASS score of 0 (IQR, -4 to 0). A 2-minute moving window of amplitude variance was seen to reflect contemporaneous fluctuations in motor activity and was proportional to the RASS score. Furthermore, the moving window of amplitude variance was observed to spike immediately before ≥ 2 point increases in the RASS score.

CONCLUSIONS

We describe a novel approach to the analysis of wrist accelerometry data in critically ill patients. This technique not only appears to provide novel and continuous information about the depth of sedation or degree of agitation, it is also notable in its aptitude to anticipate impending transitions to higher RASS values.

A pilot study of high frequency accelerometry-based sedation and agitation monitoring in critically ill patients

OBJECTIVE

The degree of sedation or agitation in critically ill patients is typically assessed with the Richmond Agitation and Sedation Scale (RASS). However, this approach is intermittent and subject to unrecognised variation between assessments. High frequency accelerometry may assist in achieving a quantitative and continuous assessment of sedation while heralding imminent agitation.

DESIGN

We undertook a prospective, observational pilot study.

SETTING

An adult tertiary intensive care unit in Melbourne, Australia.

PARTICIPANTS

20 patients with an admission diagnosis of trauma.

MAIN OUTCOME MEASURES

Accelerometers were applied to patients' wrists and used to continuously record patient movement. Video data of patient behaviour were simultaneously collected, and observers blinded to accelerometry data were adjudicated the RASS score every 30 seconds. Exploratory analyses were undertaken.

RESULTS

Patients were enrolled for a median duration of 9.7 hours (interquartile range [IQR], 0-22.8) and a total of 160 hours. These patients had a median RASS score of 0 (IQR, -4 to 0). A 2-minute moving window of amplitude variance was seen to reflect contemporaneous fluctuations in motor activity and was proportional to the RASS score. Furthermore, the moving window of amplitude variance was observed to spike immediately before ≥ 2 point increases in the RASS score.

CONCLUSIONS

We describe a novel approach to the analysis of wrist accelerometry data in critically ill patients. This technique not only appears to provide novel and continuous information about the depth of sedation or degree of agitation, it is also notable in its aptitude to anticipate impending transitions to higher RASS values.

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.

Steroid-Induced Sleep Disturbance and Delirium: A Focused Review for Critically Ill Patients

OBJECTIVE

Insomnia and delirium have gained much attention since the publication of recent guidelines for the management in critically ill adults. Neurologic effects such as sleep disturbance, psychosis, and delirium are commonly cited adverse effects (AEs) of corticosteroids. Steroid use is considered a modifiable risk factor in intensive care unit patients; however, reported mechanisms are often lacking. This focused review will specifically evaluate the effects of steroids on sleep deprivation, psychosis, delirium, and what is known about these effects in a critically ill population.

OBSERVATIONS

The medical literature proposes 3 pathways primarily responsible for neurocognitive AEs of steroids: behavior changes through modification of the hypothalamic-pituitary-adrenal axis, changes in natural sleep-wake cycles, and hyperarousal caused by modification in neuroinhibitory pathways. Initial search fields produced 285 articles. Case reports, reviews, letters, and articles pertaining to primary care or palliative populations were excluded, leaving 8 relevant articles for inclusion.

CONCLUSIONS

Although steroid therapy often cannot be altered in the critically ill population, research showed that steroid overuse is common in intensive care units. Minimizing dosage and duration are important ways clinicians can mitigate AEs.