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Wan X, Yu H, Yang M, Hou W, Xie J, Xu K, Ma Y, Ma R, Wang F, Xu P. Study on the causal relationship between educational attainment and delirium: A two-sample Mendelian randomization study. Heliyon 2024; 10:e28697. [PMID: 38571646 PMCID: PMC10988048 DOI: 10.1016/j.heliyon.2024.e28697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 01/26/2024] [Accepted: 03/22/2024] [Indexed: 04/05/2024] Open
Abstract
This study aimed to investigate whether there is a causal relationship between educational attainment and delirium at the genetic level using the Mendelian randomization method, and provide new evidence for studies in this field. We found a causal relationship between educational attainment and delirium at the genetic level after excluding confounders using Mendelian randomization. The inverse variance weighting method of random effects was the main analysis method. The weighted median and Mendelian Randomization-Egger methods, as well as simple, and weighted modes were used as supplementary analysis methods. Additionally, horizontal pleiotropy tests were conducted, including the Mendelian Randomization-Egger intercept test and Mendelian Randomization Pleiotropy RESidual Sum and Outlier. Cochran's Q statistic was used to assess the size of heterogeneity. We retrieved all second single nucleotide polymorphism features and performed multivariate Mendelian randomization to adjust for the effect of potential confounders on our results. The inverse variance weighting suggested a negative correlation between genetically predicted educational attainment and delirium (0.67[0.49-0.92], p = 0.013); Mendelian Randomization Pleiotropy RESidual Sum and Outlier (0.67[0.49-0.92], p = 0.013) and multivariate Mendelian randomization (0.52[0.33-0.82], p = 0.005) results were generally consistent with the inverse variance weighting method. The Mendelian Randomization-Egger, simple, and weighted mode results were consistent with the inverse variance weighting results. Our results were not affected by pleiotropy or heterogeneity (p > 0.05, for both pleiotropy and heterogeneity). In addition, the "leave-one-out" analysis showed that the results of our Mendelian randomization analysis were not influenced by individual single nucleotide polymorphisms. Studies have found a causal relationship between educational attainment and delirium at the genetic level; higher educational attainment may be a protective factor against delirium. Clinically, more attention should be paid to patients at a high risk of delirium with low educational attainment.
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Affiliation(s)
| | | | - Mingyi Yang
- Department of Joint Surgery, HongHui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, 710054, China
| | - Weikun Hou
- Department of Joint Surgery, HongHui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, 710054, China
| | - Jiale Xie
- Department of Joint Surgery, HongHui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, 710054, China
| | - Ke Xu
- Department of Joint Surgery, HongHui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, 710054, China
| | - Yujie Ma
- Department of Joint Surgery, HongHui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, 710054, China
| | - Rui Ma
- Department of Joint Surgery, HongHui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, 710054, China
| | - Fan Wang
- Department of Joint Surgery, HongHui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, 710054, China
| | - Peng Xu
- Department of Joint Surgery, HongHui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, 710054, China
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Paredes S, Harb A, Rössler J, Nikoo MZ, Ruetzler K, Turan A, Pu X, Sessler DI. Metformin Use in Type 2 Diabetics and Delirium After Noncardiac Surgery: A Retrospective Cohort Analysis. Anesth Analg 2024:00000539-990000000-00800. [PMID: 38517762 DOI: 10.1213/ane.0000000000006863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2024]
Abstract
INTRODUCTION The cause of postoperative delirium is unknown, but it is thought to result at least in part from inflammation. Metformin, besides its hypoglycemic properties, demonstrates anti-inflammatory effects systemically and in the brain. We tested the primary hypothesis that chronic metformin use in adults with type 2 diabetes is associated with less delirium during the first 5 days after major noncardiac surgery. Secondary outcomes were a composite of serious complications (myocardial infarction, cardiac arrest, stage 2-3 acute kidney injury [AKI], and mortality) and time to discharge alive. METHODS We considered adults with type 2 diabetes who did or did not routinely use metformin daily and had noncardiac surgery. Delirium was assessed by Confusion Assessment Method for Intensive Care Unit (CAM-ICU) or brief Confusion Assessment Method (bCAM) for 5 postoperative days. Postoperative AKI was defined by Kidney Disease Improving Global Guidelines. Logistic regression and generalized estimating equation models accounted for within-patient correlation across multiple surgeries and explored the association between metformin use and postoperative delirium and complications. Inverse propensity score weighting and propensity score calibration (PSC) adjusted for confounding variables. RESULTS No significant difference was observed in the incidence of postoperative delirium between the 2 groups, with 260 of 4744 cases (5.5%) among metformin users and 502 of 5918 cases (8.5%) cases in nonmetformin users, for an odds ratio of 0.88 (95% confidence interval [CI], 0.73-1.05; P = .155), number-needed-to-expose = 118 patients. Similarly, there were fewer composite complications in metformin users (3.3%) than in nonusers (11.7%); However, the common-effect odds ratio of 0.67 was not statistically significant (97.5% CI, 0.39-1.17; P = .106). Discharge from the hospital was significantly faster in patients who took metformin (3 [interquartile range, IQR, 1-5] days for metformin users and 3 [IQR, 2-6] days for nonmetformin users), with a hazard ratio of 1.07 for early discharge, and tight CIs (1.01-1.13). CONCLUSIONS Chronic metformin use was associated with slightly and nonsignificantly less delirium. However, patients who used metformin had clinically meaningfully fewer major complications, mostly stage 2 to 3 kidney injury. While not statistically significant, the reduction was substantial and warrants further investigation because there is currently no effective preventive measure for perioperative renal injury. Benefit would be especially meaningful if it could be produced by acute perioperative treatment. Finally, metformin was associated with faster hospital discharge, although not by a clinically meaningful amount.
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Affiliation(s)
- Stephania Paredes
- From the Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Ayoub Harb
- From the Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
- Ohio University Heritage College of Osteopathic Medicine, Cleveland, Ohio
| | - Julian Rössler
- From the Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | | | - Kurt Ruetzler
- From the Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
- Department of General Anesthesia, Cleveland Clinic, Cleveland, Ohio
| | - Alparslan Turan
- From the Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
- Department of General Anesthesia, Cleveland Clinic, Cleveland, Ohio
| | - Xuan Pu
- From the Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Daniel I Sessler
- From the Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
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García-Montoto F, Paz-Martín D, Pestaña D, Soro M, Marcos Vidal JM, Badenes R, Suárez de la Rica A, Bardi T, Pérez-Carbonell A, García C, Cervantes JA, Martínez MP, Guerrero JL, Lorente JV, Veganzones J, Murcia M, Belda FJ. Guidelines for inhaled sedation in the ICU. Rev Esp Anestesiol Reanim (Engl Ed) 2024; 71:90-111. [PMID: 38309642 DOI: 10.1016/j.redare.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 07/29/2023] [Indexed: 02/05/2024]
Abstract
INTRODUCTION AND OBJECTIVES Sedation is used in intensive care units (ICU) to improve comfort and tolerance during mechanical ventilation, invasive interventions, and nursing care. In recent years, the use of inhalation anaesthetics for this purpose has increased. Our objective was to obtain and summarise the best evidence on inhaled sedation in adult patients in the ICU, and use this to help physicians choose the most appropriate approach in terms of the impact of sedation on clinical outcomes and the risk-benefit of the chosen strategy. METHODOLOGY Given the overall lack of literature and scientific evidence on various aspects of inhaled sedation in the ICU, we decided to use a Delphi method to achieve consensus among a group of 17 expert panellists. The processes was conducted over a 12-month period between 2022 and 2023, and followed the recommendations of the CREDES guidelines. RESULTS The results of the Delphi survey form the basis of these 39 recommendations - 23 with a strong consensus and 15 with a weak consensus. CONCLUSION The use of inhaled sedation in the ICU is a reliable and appropriate option in a wide variety of clinical scenarios. However, there are numerous aspects of the technique that require further study.
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Affiliation(s)
- F García-Montoto
- UCI de Anestesia, Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de Cáceres, Cáceres, Spain.
| | - D Paz-Martín
- UCI, Departamento de Anestesia y Cuidados Intensivos, Clínica Universidad de Navarra, Pamplona, Navarra, Spain
| | - D Pestaña
- UCI de Anestesia, Servicio de Anestesiología y Reanimación, Hospital Universitario Ramon y Cajal, Madrid, Spain; Universidad de Alcalá de Henares, Alcalá de Henares, Madrid, Spain
| | - M Soro
- UCI, Servicio de Anestesiología y Cuidados Intensivos, Hospital IMED, Valencia, Spain
| | - J M Marcos Vidal
- Unidad de Reanimación, Servicio de Anestesiología y Reanimación, Complejo Asistencial Universitario de León, León, Spain
| | - R Badenes
- Departamento Cirugía, Facultad de Medicina, Universidad de Valencia, Valencia, Spain; UCI de Anestesia, Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Clínico Universitario de Valencia, Valencia, Spain; INCLIVA Instituto de Investigación Sanitaria, Valencia, Spain
| | - A Suárez de la Rica
- Unidad de Reanimación, Servicio de Anestesiología y Reanimación, Hospital Universitario de La Princesa, Madrid, Spain
| | - T Bardi
- UCI de Anestesia, Servicio de Anestesiología y Reanimación, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - A Pérez-Carbonell
- UCI Quirúrgica, Servicio de Anestesiología, UCI Quirúrgica y Unidad del Dolor, Hospital General Universitario de Elche, Elche, Alicante, Spain
| | - C García
- UCI Quirúrgica, Servicio de Anestesiología y Reanimación, Hospital General Universitario Dr. Balmis, Alicante, Spain
| | - J A Cervantes
- Unidad de Reanimación, Servicio de Anestesiología y Reanimación, Hospital Universitario Torrecárdenas, Almería, Spain
| | - M P Martínez
- Unidad de Reanimación, Servicio de Anestesiología y Reanimación, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - J L Guerrero
- Unidad de Reanimación, Servicio de Anestesiología y Reanimación, Hospital Universitario Virgen de la Victoria, Málaga, Spain; Universidad de Málaga, Málaga, Spain; Instituto Biomédico de Málaga, Málaga, Spain
| | - J V Lorente
- Unidad de Reanimación, Servicio de Anestesiología y Reanimación, Hospital Juan Ramón Jiménez, Huelva, Spain
| | - J Veganzones
- Unidad de Reanimación, Servicio de Anestesiología y Reanimación, Hospital Universitario La Paz, Madrid, Spain
| | - M Murcia
- UCI, Servicio de Anestesiología y Cuidados Intensivos, Hospital IMED, Valencia, Spain
| | - F J Belda
- Departamento Cirugía, Facultad de Medicina, Universidad de Valencia, Valencia, Spain
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Sadlonova M, Beach SR, Funk MC, Rosen JH, Ramirez Gamero AF, Karlson RA, Huffman JC, Celano CM. Risk Stratification of QTc Prolongation in Critically Ill Patients Receiving Antipsychotics for the Management of Delirium Symptoms. J Intensive Care Med 2023:8850666231222470. [PMID: 38130132 DOI: 10.1177/08850666231222470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
BACKGROUND Patients experiencing significant agitation or perceptual disturbances related to delirium in an intensive care setting may benefit from short-term treatment with an antipsychotic medication. Some antipsychotic medications may prolong the QTc interval, which increases the risk of potentially fatal ventricular arrhythmias. In this targeted review, we describe the evidence regarding the relationships between antipsychotic medications and QTc prolongation and practical methods for monitoring the QTc interval and mitigating arrhythmia risk. METHODS Searches of PubMed and Cochrane Library were performed to identify studies, published before February 2023, investigating the relationships between antipsychotic medications and QTc prolongation or arrhythmias. RESULTS Most antipsychotic medications commonly used for the management of delirium symptoms (eg, intravenous haloperidol, olanzapine, quetiapine) cause a moderate degree of QTc prolongation. Among other antipsychotics, those most likely to cause QTc prolongation are iloperidone and ziprasidone, while aripiprazole and lurasidone appear to have minimal risk for QTc prolongation. Genetic vulnerabilities, female sex, older age, pre-existing cardiovascular disease, electrolyte abnormalities, and non-psychiatric medications also increase the risk of QTc prolongation. For individuals at risk of QTc prolongation, it is essential to measure the QTc interval accurately and consistently and consider medication adjustments if needed. CONCLUSIONS Antipsychotic medications are one of many risk factors for QTc prolongation. When managing agitation related to delirium, it is imperative to assess an individual patient's risk for QTc prolongation and to choose a medication and monitoring strategy commensurate to the risks. In intensive care settings, we recommend regular ECG monitoring, using a linear regression formula to correct for heart rate. If substantial QTc prolongation (eg, QTc > 500 msec) is present, a change in pharmacologic treatment can be considered, though a particular medication may still be warranted if the risks of discontinuation (eg, extreme agitation, removal of invasive monitoring devices) outweigh the risks of arrhythmias. AIMS This review aims to summarize the current literature on relationships between antipsychotic medications and QTc prolongation and to make practical clinical recommendations towards the approach of antipsychotic medication use for the management of delirium-related agitation and perceptual disturbances in intensive care settings.
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Affiliation(s)
- Monika Sadlonova
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
- Department of Psychosomatic Medicine and Psychotherapy, University of Göttingen Medical Center, Göttingen, Germany
- Department of Cardiovascular and Thoracic Surgery, University of Göttingen Medical Center, Göttingen, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Göttingen, Göttingen, Germany
| | - Scott R Beach
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Margo C Funk
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA, USA
| | - Jordan H Rosen
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA, USA
| | - Andres F Ramirez Gamero
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Rebecca A Karlson
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Jeff C Huffman
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Christopher M Celano
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
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Piccirillo A, Perri F, Vittori A, Ionna F, Sabbatino F, Ottaiano A, Cascella M. Evaluating Nutritional Risk Factors for Delirium in Intensive-Care-Unit Patients: Present Insights and Prospects for Future Research. Clin Pract 2023; 13:1577-1592. [PMID: 38131687 PMCID: PMC10742123 DOI: 10.3390/clinpract13060138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 11/30/2023] [Accepted: 12/06/2023] [Indexed: 12/23/2023] Open
Abstract
Malnutrition, hypercatabolism, and metabolic changes are well-established risk factors for delirium in critically ill patients. Although the exact mechanisms are not fully understood, there is mounting evidence suggesting that malnutrition can cause a variety of changes that contribute to delirium, such as electrolyte imbalances, immune dysfunction, and alterations in drug metabolism. Therefore, a comprehensive metabolic and malnutrition assessment, along with appropriate nutritional support, may help to prevent or ameliorate malnutrition, reduce hypercatabolism, and improve overall physiological function, ultimately lowering the risk of delirium. For this aim, bioelectrical impedance analysis can represent a valuable strategy. Further research into the underlying mechanisms and nutritional risk factors for delirium is crucial to developing more effective prevention strategies. Understanding these processes will allow clinicians to personalize treatment plans for individual patients, leading to improved outcomes and quality of life in the intensive-care-unit survivors.
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Affiliation(s)
- Arianna Piccirillo
- Otolaryngology and Maxillo-Facial Surgery Unit, Istituto Nazionale Tumori—IRCCS Fondazione G. Pascale, 80131 Naples, Italy
| | - Francesco Perri
- Medical and Experimental Head and Neck Oncology Unit, Istituto Nazionale Tumori—IRCCS Fondazione G. Pascale, 80131 Naples, Italy
| | - Alessandro Vittori
- Department of Anesthesia and Critical Care, ARCO ROMA, Ospedale Pediatrico Bambino Gesù IRCCS, Piazza S. Onofrio 4, 00165 Rome, Italy
| | - Franco Ionna
- Otolaryngology and Maxillo-Facial Surgery Unit, Istituto Nazionale Tumori—IRCCS Fondazione G. Pascale, 80131 Naples, Italy
| | | | - Alessandro Ottaiano
- SSD Innovative Therapies for Abdominal Metastases, Abdominal Oncology, Istituto Nazionale Tumori di Napoli, IRCCS “G. Pascale”, 80131 Naples, Italy;
| | - Marco Cascella
- Unit of Anesthesiology, Intensive Care Medicine, and Pain Medicine, Department of Medicine, Surgery, and Dentistry, University of Salerno, Via Salvador Allende, 43, 84081 Baronissi, Italy
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Itai Bendavid I, Assi S, Sasson N, Statlender L, Hellerman M, Fishman G, Singer P, Kagan I. The EyeControl-Med device, an alternative tool for communication in ventilated critically ill patients: A pilot study examining communication capabilities and delirium. J Crit Care 2023; 78:154351. [PMID: 37348187 DOI: 10.1016/j.jcrc.2023.154351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 05/16/2023] [Accepted: 05/26/2023] [Indexed: 06/24/2023]
Abstract
INTRODUCTION Communication with ventilated patients in the Intensive care unit (ICU) is challenging. This may lead to anxiety and frustration, potentially contributing to the development of delirium. Various technologies, such as eye-tracking devices, have been employed to facilitate communication with varying grades of success. The EyeControl-Med device is a novel technology that delivers audio content and allows patients to interact by eye movements and could potentially allow for better communication in this setting. The aim of this exploratory concept study was to assess communication capabilities and delirium incidence using the EyeControl-Med device in critically ill patients unable to generate speech. MATERIAL AND METHODS A single-arm pilot study of patients in a mixed ICU. Patients were approached for consent if they were invasively ventilated and/or tracheotomized, hence unable to generate speech, but had no severe cognitive or sensory impairment that could prevent proper usage. Patients underwent at least 3 sessions with the EyeControl-Med device administered by a speech-language pathologist. Communication and consciousness were assessed using the Loewenstein Communication Scale (LCS) tool during the first and last sessions. Delirium was assessed using a computerized CAM-ICU questionnaire. RESULTS 15 patients were included, 40% of whom were diagnosed with COVID-19. All patients completed three to seven usage sessions. The mean LCS score improved by 19.3 points (p < 0.0001), with each of its five components showing significant improvements as well. The mean number of errors on the CAM-ICU questionnaire decreased from 6.5 to 2.5 (p = 0.0006), indicating a lower incidence of delirium. No adverse effects were observed. CONCLUSION The EyeControl-Med device may facilitate communication and reduce the manifestations and duration of delirium in ventilated critically ill patients. Controlled studies are required to establish this effect.
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Affiliation(s)
- I Itai Bendavid
- Department of General Intensive Care and Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel.
| | - Saja Assi
- Department of speech, language, swallowing, hearing & communication disorders, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Noga Sasson
- Department of speech, language, swallowing, hearing & communication disorders, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Liran Statlender
- Department of General Intensive Care and Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Moran Hellerman
- Department of General Intensive Care and Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Guy Fishman
- Department of General Intensive Care and Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Pierre Singer
- Department of General Intensive Care and Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Ilya Kagan
- Department of General Intensive Care and Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
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Marcos-Vidal JM, González R, Merino M, Higuera E, García C. Sedation for Patients with Sepsis: Towards a Personalised Approach. J Pers Med 2023; 13:1641. [PMID: 38138868 PMCID: PMC10744994 DOI: 10.3390/jpm13121641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 11/17/2023] [Accepted: 11/21/2023] [Indexed: 12/24/2023] Open
Abstract
This article looks at the challenges of sedoanalgesia for sepsis patients, and argues for a personalised approach. Sedation is a necessary part of treatment for patients in intensive care to reduce stress and anxiety and improve long-term prognoses. Sepsis patients present particular difficulties as they are at increased risk of a wide range of complications, such as multiple organ failure, neurological dysfunction, septic shock, ARDS, abdominal compartment syndrome, vasoplegic syndrome, and myocardial dysfunction. The development of any one of these complications can cause the patient's rapid deterioration, and each has distinct implications in terms of appropriate and safe forms of sedation. In this way, the present article reviews the sedative and analgesic drugs commonly used in the ICU and, placing special emphasis on their strategic administration in sepsis patients, develops a set of proposals for sedoanalgesia aimed at improving outcomes for this group of patients. These proposals represent a move away from simplistic approaches like avoiding benzodiazepines to more "objective-guided sedation" that accounts for a patient's principal pathology, as well as any comorbidities, and takes full advantage of the therapeutic arsenal currently available to achieve personalised, patient-centred treatment goals.
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Affiliation(s)
- José Miguel Marcos-Vidal
- Department of Anesthesiology and Critical Care, Universitary Hospital of Leon, 24071 Leon, Spain; (R.G.); (M.M.); (E.H.); (C.G.)
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Hong Y, Chen P, Gao J, Lin Y, Chen L, Shang X. Sepsis-associated encephalopathy: From pathophysiology to clinical management. Int Immunopharmacol 2023; 124:110800. [PMID: 37619410 DOI: 10.1016/j.intimp.2023.110800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 07/20/2023] [Accepted: 08/11/2023] [Indexed: 08/26/2023]
Abstract
Sepsis-associated encephalopathy, which presents as delirium and coma, is a significant complication of sepsis characterized by acute brain dysfunction. The presence of inflammatory pathological changes in the brain of sepsis patients and animal models has been recognized since the 1920 s, initially attributed to the entry of microbial toxins into the brain. In the early 2000 s, attention shifted towards the impact of oxidative stress, the cholinergic system, and cytokines on brain function following sepsis onset. More recently, sepsis-associated encephalopathy has been defined as a diffuse brain dysfunction not directly caused by pathogenic infection of the brain. Currently, there is no evidence-based standard for diagnosing sepsis-associated encephalopathy, and clinical management is primarily focused on symptomatic and supportive measures. This review aims to explore the pathophysiology of sepsis-associated encephalopathy and establish the connection between pathophysiological mechanisms and clinical characteristics. We hope that this work will spark the interest of researchers from various fields and contribute to the advancement of sepsis-associated encephalopathy research.
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Affiliation(s)
- Yixiao Hong
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China; The Third Department of Critical Care Medicine, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fujian Provincial Center for Critical Care Medicine, Fujian Provincial Key Laboratory of Critical Care Medicine, Fuzhou, China
| | - Peiling Chen
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China; The Third Department of Critical Care Medicine, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fujian Provincial Center for Critical Care Medicine, Fujian Provincial Key Laboratory of Critical Care Medicine, Fuzhou, China
| | - Jingqi Gao
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China; The Third Department of Critical Care Medicine, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fujian Provincial Center for Critical Care Medicine, Fujian Provincial Key Laboratory of Critical Care Medicine, Fuzhou, China
| | - Yingying Lin
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China; The Third Department of Critical Care Medicine, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fujian Provincial Center for Critical Care Medicine, Fujian Provincial Key Laboratory of Critical Care Medicine, Fuzhou, China
| | - Linfang Chen
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China; The Third Department of Critical Care Medicine, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fujian Provincial Center for Critical Care Medicine, Fujian Provincial Key Laboratory of Critical Care Medicine, Fuzhou, China
| | - Xiuling Shang
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China; The Third Department of Critical Care Medicine, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fujian Provincial Center for Critical Care Medicine, Fujian Provincial Key Laboratory of Critical Care Medicine, Fuzhou, China.
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Huang J, Zheng H, Zhu X, Zhang K, Ping X. The efficacy and safety of haloperidol for the treatment of delirium in critically ill patients: a systematic review and meta-analysis of randomized controlled trials. Front Med (Lausanne) 2023; 10:1200314. [PMID: 37575982 PMCID: PMC10414537 DOI: 10.3389/fmed.2023.1200314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 07/18/2023] [Indexed: 08/15/2023] Open
Abstract
Purpose Delirium is common during critical illness and is associated with poor outcomes. Therefore, we conducted this meta-analysis to investigate the efficacy and safety of haloperidol for the treatment of delirium in critically ill patients. Methods Randomized controlled trials enrolling critically ill adult patients to compare haloperidol with placebo were searched from inception through to February 20th, 2023. The primary outcome were delirium-free days and overall mortality, secondary outcomes were length of intensive care unit stay, length of hospital stay, and adverse events. Results Nine trials were included in our meta-analysis, with a total of 3,916 critically ill patients. Overall, the pooled analyses showed no significant difference between critically ill patients treated with haloperidol and placebo for the delirium-free days (MD -0.01, 95%CI -0.36 to 0.34, p = 0.95, I2 = 30%), overall mortality (OR 0.89, 95%CI 0.76 to 1.04, p = 0.14, I2 = 0%), length of intensive care unit stay (MD -0.06, 95%CI -0.16 to 0.03, p = 0.19, I2 = 0%), length of hospital stay (MD -0.06, 95%CI -0.61 to 0.49, p = 0.83, I2 = 0%), and adverse events (OR 0.90, 95%CI 0.60 to 1.37, p = 0.63, I2 = 0%). Conclusion Among critically ill patients, the use of haloperidol as compared to placebo has no significant effect on delirium-free days, overall mortality, length of intensive care unit and/or hospital stay. Moreover, the use of haloperidol did not increase the risk of adverse events.
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Affiliation(s)
- Jian Huang
- Department of Critical Care Medicine, Hangzhou Ninth People’s Hospital, Hangzhou, China
| | - Hui Zheng
- Department of Emergency Medicine, Hangzhou Ninth People’s Hospital, Hangzhou, China
| | - Xianfeng Zhu
- Department of Critical Care Medicine, Hangzhou Ninth People’s Hospital, Hangzhou, China
| | - Kai Zhang
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaofeng Ping
- Department of Critical Care Medicine, Hangzhou Ninth People’s Hospital, Hangzhou, China
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Al Farsi RS, Al Alawi AM, Al Huraizi AR, Al-Saadi T, Al-Hamadani N, Al Zeedy K, Al-Maqbali JS. Delirium in Medically Hospitalized Patients: Prevalence, Recognition and Risk Factors: A Prospective Cohort Study. J Clin Med 2023; 12:3897. [PMID: 37373591 DOI: 10.3390/jcm12123897] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 05/12/2023] [Accepted: 06/05/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Delirium is a common neuropsychiatric syndrome in hospitalized elderly patients and is associated with poor clinical outcomes. We aimed to determine the prevalence, recognition, risk factors, and course of delirium among hospitalized elderly (65 years of age or older) patients at Sultan Qaboos University Hospital (SQUH). METHODS A prospective cohort study included 327 elderly patients (65 years of age or older) admitted to the medical wards at SQUH. Patients were screened for delirium using the 3-Minute Diagnostic Confusion Assessment Method (3D-CAM). Additionally, medical records were reviewed to identify possible associated factors. RESULTS The prevalence of delirium was 55.4% (95% CI 49.9-60.7), and 35.4% of patients with delirium were not recognized by the treating team. Hypoactive delirium is the most common type of delirium. The logistic regression analyzes demonstrated that pre-existing cognitive impairment (OR = 4.0); poor functional status (OR = 1.9); the use of medications that are known to precipitate delirium (OR = 2.3); polypharmacy (OR = 5.7); urinary catheterization (OR = 2.2); dehydration (OR = 3.1); and electrolytes derangements (OR = 2.0) were independent risk factors for delirium. Furthermore, 56.9% of patients with delirium continued to have delirium upon discharge from the hospital. CONCLUSIONS Delirium is common among elderly patients hospitalized in general medical wards. Implementing effective preventive strategies for delirium during the hospital stay, including early recognition using standard sensitive and specific screening tools (i.e., 3D-CAM) and developing geriatric wards, is crucial.
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Affiliation(s)
- Rajaa Saleh Al Farsi
- Oman Medical Specialty Board, Internal Medicine Residency Training Program, Muscat 130, Oman
| | | | | | - Taif Al-Saadi
- School of Medicine, Royal College of Surgeons in Ireland, D02 YN77 Dublin, Ireland
| | - Noof Al-Hamadani
- School of Medicine, Royal College of Surgeons in Ireland, D02 YN77 Dublin, Ireland
| | - Khalfan Al Zeedy
- Department of Medicine, Sultan Qaboos University Hospital, Muscat 123, Oman
| | - Juhaina Salim Al-Maqbali
- Department of Pharmacy, Sultan Qaboos University Hospital, Muscat 123, Oman
- Department of Pharmacology and Clinical Pharmacy, College of Medicine and Health Science, Sultan Qaboos University, Muscat 123, Oman
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11
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Yu H, Wan X, Yang M, Xie J, Xu K, Wang J, Wang G, Xu P. A large-scale causal analysis of gut microbiota and delirium: A Mendelian randomization study. J Affect Disord 2023; 329:64-71. [PMID: 36842654 DOI: 10.1016/j.jad.2023.02.078] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/16/2023] [Accepted: 02/18/2023] [Indexed: 02/27/2023]
Abstract
BACKGROUND Several studies have linked gut microbiota to human brain activity. This study used Mendelian randomization (MR) to investigate the causal relationship between gut microbes and delirium. METHODS MR was used to select SNPs from large-scale GWAS summary data on 211 gut microbiota taxa and delirium. Inverse variance weighting (IVW), weighted median, and MR-Egger methods were used for statistical analyses. Outliers were assessed using the leave-one-out method. To avoid horizontal pleiotropy, we performed the MR-PRESSO and MR-Egger intercept tests. Cochran's Q and I2 values for IVW and MR-Egger were used to assess heterogeneity. RESULTS IVW suggested that genetic prediction of the family Desulfovibrionaceae (1.784 (1.267-2.512), P = 0.001), order Desulfovibrionales (1.501 (1.058-2.128), P = 0.023), and genus Candidatus Soleaferrea (1.322 (1.052-1.659), P = 0.016) increased the risk of delirium, but the family Oxalobacteraceae (0.841 (0.722-0.981), P = 0.027), and genera Holdemania (0.766 (0.620-0.946), P = 0.013), Ruminococcus gnavus (0.806 (0.661-0.982), P = 0.033), and Eggerthella (0.815 (0.667-0.997), P = 0.047) reduced the risk of delirium. LIMITATIONS (1) Limited sample size, (2) inability to assess gut microbiota interactions, and (3) limited to European populations. CONCLUSION Our results suggest that presence of the microbial family Desulfovibrionaceae, order Desulfovibrionales, and genus Candidatus Soleaferrea increased the risk of delirium, whereas the Oxalobacteraceae family, and the genera Holdemania, Ruminococcus gnavus, and Eggerthella decreased the risk of delirium. However, the potential of gut probiotic interventions in the prevention of perioperative delirium should be emphasized.
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Affiliation(s)
- Hui Yu
- Department of Joint Surgery, HongHui Hospital, Xi'an Jiaotong University, Xi'an, Shanxi 710054, China
| | - Xianjie Wan
- Department of Joint Surgery, HongHui Hospital, Xi'an Jiaotong University, Xi'an, Shanxi 710054, China
| | - Mingyi Yang
- Department of Joint Surgery, HongHui Hospital, Xi'an Jiaotong University, Xi'an, Shanxi 710054, China
| | - Jiale Xie
- Department of Joint Surgery, HongHui Hospital, Xi'an Jiaotong University, Xi'an, Shanxi 710054, China
| | - Ke Xu
- Department of Joint Surgery, HongHui Hospital, Xi'an Jiaotong University, Xi'an, Shanxi 710054, China
| | - Jiachen Wang
- Department of Joint Surgery, HongHui Hospital, Xi'an Jiaotong University, Xi'an, Shanxi 710054, China
| | - Guoqiang Wang
- Department of Joint Surgery, HongHui Hospital, Xi'an Jiaotong University, Xi'an, Shanxi 710054, China
| | - Peng Xu
- Department of Joint Surgery, HongHui Hospital, Xi'an Jiaotong University, Xi'an, Shanxi 710054, China.
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Matsuoka A, Sogawa R, Murakawa-Hirachi T, Mizoguchi Y, Monji A, Shimanoe C, Shinada K, Koami H, Sakamoto Y. Evaluation of the delirium preventive effect of dual orexin receptor antagonist (DORA) in critically ill adult patients requiring ventilation with tracheal intubation at an advanced emergency center: A single-center, retrospective, observational study. Gen Hosp Psychiatry 2023; 83:123-129. [PMID: 37182281 DOI: 10.1016/j.genhosppsych.2023.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 03/01/2023] [Accepted: 03/22/2023] [Indexed: 05/16/2023]
Abstract
OBJECTIVE ICU delirium reportedly contributes to increased mortality attributed to underlying diseases, long-term cognitive decline, and increased healthcare costs. Dual orexin receptor antagonists (DORAs), suvorexant and lemborexant, have been suggested for preventing ICU delirium. Although ventilator management is a risk factor for delirium, no study has examined the efficacy of suvorexant and lemborexant in preventing delirium in critically ill patients requiring ventilation. Thus, we retrospectively evaluated the efficacy of DORA in preventing delirium in critically ill adult patients requiring ventilatory management in the emergency room. METHOD This retrospective study included patients aged ≥18 years who were admitted to the emergency room and received ventilator support between January 2015 and April 2022. The HR (95% CI) for delirium development in patients taking DORA was estimated using a Cox proportional hazards model, which was adjusted for the patient background and concomitant medications. HRs were calculated for patients taking suvorexant and those taking lemborexant using a stratified analysis. RESULTS Of the 297 patients included in the study, 67 were in the DORA group; 50 were on suvorexant and 17 were on lemborexant. The DORA group had a lower incidence of delirium than the control group (p < 0.0001). The risk of delirium was lower in the DORA group compared the control group (HR, 0.22; 95% CI 0.12-0.40).The risk of developing delirium was lower with suvorexant (HR 0.22; 95% CI 0.11-0.41) and lemborexant (HR 0.25; 95% CI 0.08-0.81). CONCLUSION DORA is a promising drug that could have the potential to prevent delirium, and its efficacy in preventing delirium should be tested in randomized controlled trials in the future.
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Affiliation(s)
- Ayaka Matsuoka
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga City, Saga Prefecture 849-8501, Japan.
| | - Rintaro Sogawa
- Department of Pharmacy, Saga University Hospital, 5-1-1 Nabeshima, Saga City, Saga Prefecture 849-8501, Japan.
| | - Toru Murakawa-Hirachi
- Department of Psychiatry, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga City, Saga Prefecture 849-8501, Japan.
| | - Yoshito Mizoguchi
- Department of Psychiatry, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga City, Saga Prefecture 849-8501, Japan.
| | - Akira Monji
- Department of Psychiatry, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga City, Saga Prefecture 849-8501, Japan; Wakahisa Hospital, 5-3-1, Wakahisa, Minami-ku, Fukuoka 815-0042, Japan.
| | - Chisato Shimanoe
- Department of Pharmacy, Saga University Hospital, 5-1-1 Nabeshima, Saga City, Saga Prefecture 849-8501, Japan.
| | - Kota Shinada
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga City, Saga Prefecture 849-8501, Japan
| | - Hiroyuki Koami
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga City, Saga Prefecture 849-8501, Japan.
| | - Yuichiro Sakamoto
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga City, Saga Prefecture 849-8501, Japan.
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Denk A, Müller K, Schlosser S, Heissner K, Gülow K, Müller M, Schmid S. Liver diseases as a novel risk factor for delirium in the ICU-Delirium and hepatic encephalopathy are two distinct entities. PLoS One 2022; 17:e0276914. [PMID: 36413529 PMCID: PMC9681112 DOI: 10.1371/journal.pone.0276914] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 10/15/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Delirium prevalence is high in critical care settings. We examined the incidence, risk factors, and outcome of delirium in a medical intensive care unit (MICU) with a particular focus on liver diseases. We analyzed this patient population in terms of delirium risk prediction and differentiation between delirium and hepatic encephalopathy. METHODS We conducted an observational study and included 164 consecutive patients admitted to an MICU of a university hospital. Patients were assessed for delirium using the Confusion Assessment Method for ICUs and the Richmond Agitation-Sedation Scale (RASS). On admission and at the onset of delirium Sequential Organ Failure Assessment (SOFA) score was determined. A population of patients with liver disease was compared to a population with gastrointestinal diseases. In the population with liver diseases, hepatic encephalopathy was graded according to the West Haven classification. We analyzed the incidence, subtype, predisposing, precipitating, and health-care setting-related factors, treatment, outcome of delirium and the association between delirium and hepatic encephalopathy in patients with liver diseases. RESULTS The incidence of delirium was 32.5% (n = 53). Univariable binary regression analyses adjusted by the Holm-Bonferroni method showed that the development of delirium was significantly determined by 10 risk factors: Alcohol abuse (p = 0.016), severity of disease (Simplified Acute Physiology Score (SAPS) II, p = 0.016), liver diseases (p = 0.030) and sepsis (p = 0.016) compared to the control group (gastrointestinal (GI) diseases and others), increased sodium (p = 0.016), creatinine (p = 0.030), urea (p = 0.032) or bilirubin (p = 0.042), decreased hemoglobin (p = 0.016), and mechanical ventilation (p = 0.016). Of note, we identified liver diseases as a novel and relevant risk factor for delirium. Hepatic encephalopathy was not a risk factor for delirium. Delirium and hepatic encephalopathy are both life-threatening but clearly distinct conditions. The median SOFA score for patients with delirium at delirium onset was significantly higher than the SOFA score of all patients at admission (p = 0.008). Patients with delirium had five times longer ICU stays (p = 0.004) and three times higher in-hospital mortality (p = 0.036). Patients with delirium were five times more likely to be transferred to an intensive medical rehabilitation unit for post-intensive care (p = 0.020). Treatment costs per case were more than five times higher in patients with delirium than in patients without delirium (p = 0.004). CONCLUSIONS The 10 risk factors identified in this study should be assessed upon admission to ICU for effective detection, prevention, and treatment of delirium. Liver diseases are a novel risk factor for delirium with a level of significance comparable to sepsis as an established risk factor. Of note, in patients with liver diseases delirium and hepatic encephalopathy should be recognized as distinct entities to initiate appropriate treatment. Therefore, we propose a new algorithm for efficient diagnosis, characterization, and treatment of altered mental status in the ICU. This algorithm integrates the 10 risk factor prediction-model for delirium and prompts grading of the severity of hepatic encephalopathy using the West Haven classification if liver disease is present or newly diagnosed.
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Affiliation(s)
- Alexander Denk
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious diseases, University Hospital Regensburg, Regensburg, Germany
| | - Karolina Müller
- Center for Clinical Studies, University Hospital Regensburg, Regensburg, Germany
| | - Sophie Schlosser
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious diseases, University Hospital Regensburg, Regensburg, Germany
| | - Klaus Heissner
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious diseases, University Hospital Regensburg, Regensburg, Germany
| | - Karsten Gülow
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious diseases, University Hospital Regensburg, Regensburg, Germany
| | - Martina Müller
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious diseases, University Hospital Regensburg, Regensburg, Germany
| | - Stephan Schmid
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious diseases, University Hospital Regensburg, Regensburg, Germany
- * E-mail:
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Scruth EA. Decreasing Delirium Through Family Presence: It Is a Complex Equation. Crit Care Med 2022; 50:1683-5. [PMID: 36227042 DOI: 10.1097/CCM.0000000000005663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Li HC, Yeh TYC, Wei YC, Ku SC, Xu YJ, Chen CCH, Inouye S, Boehm LM. Association of Incident Delirium With Short-term Mortality in Adults With Critical Illness Receiving Mechanical Ventilation. JAMA Netw Open 2022; 5:e2235339. [PMID: 36205994 PMCID: PMC9547314 DOI: 10.1001/jamanetworkopen.2022.35339] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Intensive care unit (ICU)-acquired delirium and/or coma have consequences for patient outcomes. However, contradictory findings exist, especially when considering short-term (ie, in-hospital) mortality and length of stay (LOS). OBJECTIVE To assess whether incident delirium, days of delirium, days of coma, and delirium- and coma-free days (DCFDs) are associated with 14-day mortality, in-hospital mortality, and hospital LOS among patients with critical illness receiving mechanical ventilation. DESIGN, SETTING, AND PARTICIPANTS This single-center prospective cohort study was conducted in 6 ICUs of a university-affiliated tertiary hospital in Taiwan. A total of 267 delirium-free patients (aged ≥20 years) with critical illness receiving mechanical ventilation were consecutively enrolled from August 14, 2018, to October 1, 2020. EXPOSURES Participants were assessed daily for the development of delirium and coma status over 14 days (or until death or ICU discharge) using the Confusion Assessment Method for the Intensive Care Unit and the Richmond Agitation-Sedation Scale, respectively. MAIN OUTCOMES AND MEASURES Mortality rates (14-day and in-hospital) and hospital LOS using electronic health records. RESULTS Of 267 participants (median [IQR] age, 65.9 [57.4-75.1] years; 171 men [64.0%]; all of Taiwanese ethnicity), 149 patients (55.8%) developed delirium for a median (IQR) of 3.0 (1.0-5.0) days at some point during their first 14 days of ICU stay, and 105 patients (39.3%) had coma episodes also lasting for a median (IQR) of 3.0 (1.0-5.0) days. The 14-day and in-hospital mortality rates were 18.0% (48 patients) and 42.1% (112 of 266 patients [1 patient withdrew from the study]), respectively. The incidence and days of delirium were not associated with either 14-day mortality (incident delirium: adjusted hazard ratio [aHR], 1.37; 95% CI, 0.69-2.72; delirium by day: aHR, 1.00; 95% CI, 0.91-1.10) or in-hospital mortality (incident delirium: aHR, 1.00; 95% CI, 0.64-1.55; delirium by day: aHR, 1.02; 95% CI, 0.97-1.07), whereas days spent in coma were associated with an increased hazard of dying during a given 14-day period (aHR, 1.16; 95% CI, 1.10-1.22) and during hospitalization (aHR, 1.10; 95% CI, 1.06-1.14). The number of DCFDs was a protective factor; for each additional DCFD, the risk of dying during the 14-day period was reduced by 11% (aHR, 0.89; 95% CI, 0.84-0.94), and the risk of dying during hospitalization was reduced by 7% (aHR, 0.93; 95% CI, 0.90-0.97). Incident delirium was associated with longer hospital stays (adjusted β = 10.80; 95% CI, 0.53-21.08) when compared with no incident delirium. CONCLUSIONS AND RELEVANCE In this study, despite prolonged LOS, ICU delirium was not associated with short-term mortality. However, DCFDs were associated with a lower risk of dying, suggesting that future research and intervention implementation should refocus on maximizing DCFDs to potentially improve the survival of patients receiving mechanical ventilation.
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Affiliation(s)
- Hsiu-Ching Li
- Department of Nursing, Chang Gung University of Science and Technology, Taoyuan, Taiwan
| | - Tony Yu-Chang Yeh
- Department of Anaesthesiology, National Taiwan University College of Medicine and National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Chung Wei
- Graduate Institute of Statistics and Information Science, National Changhua University of Education, Changhua, Taiwan
| | - Shih-Chi Ku
- Department of Internal Medicine, National Taiwan University College of Medicine and National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Juan Xu
- Department of Nursing, National Taiwan University College of Medicine and National Taiwan University Hospital, Taipei, Taiwan
| | - Cheryl Chia-Hui Chen
- Department of Nursing, National Taiwan University College of Medicine and National Taiwan University Hospital, Taipei, Taiwan
| | - Sharon Inouye
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Marcus Institute for Aging Research, Hebrew Senior Life, Boston, Massachusetts
- Associate Editor, JAMA Network Open
| | - Leanne M. Boehm
- Vanderbilt University School of Nursing, Nashville, Tennessee
- Critical Illness, Brain dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
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