Improving management of ARDS: uniting acute management and long-term recovery

Acute Respiratory Distress Syndrome (ARDS) is an important global health issue with high in-hospital mortality. Importantly, the impact of ARDS extends beyond the acute phase, with increased mortality and disability for months to years after hospitalization. These findings underscore the importance of extended follow-up to assess and address the Post-Intensive Care Syndrome (PICS), characterized by persistent impairments in physical, cognitive, and/or mental health status that impair quality of life over the long-term. Persistent muscle weakness is a common physical problem for ARDS survivors, affecting mobility and activities of daily living. Critical illness and related interventions, including prolonged bed rest and overuse of sedatives and neuromuscular blocking agents during mechanical ventilation, are important risk factors for ICU-acquired weakness. Deep sedation also increases the risk of delirium in the ICU, and long-term cognitive impairment. Corticosteroids also may be used during management of ARDS, particularly in the setting of COVID-19. Corticosteroids can be associated with myopathy and muscle weakness, as well as prolonged delirium that increases the risk of long-term cognitive impairment. The optimal duration and dosage of corticosteroids remain uncertain, and there's limited long-term data on their effects on muscle weakness and cognition in ARDS survivors. In addition to physical and cognitive issues, mental health challenges, such as depression, anxiety, and post-traumatic stress disorder, are common in ARDS survivors. Strategies to address these complications emphasize the need for consistent implementation of the evidence-based ABCDEF bundle, which includes daily management of analgesia in concert with early cessation of sedatives, avoidance of benzodiazepines, daily delirium monitoring and management, early mobilization, and incorporation of family at the bedside. In conclusion, ARDS is a complex global health challenge with consequences extending beyond the acute phase. Understanding the links between critical care management and long-term consequences is vital for developing effective therapeutic strategies and improving the quality of life for ARDS survivors.

Carried Along

As a physician, the hardest days in medicine are when I endure great distance from the Lord in my bedside interactions with patients and families. They make me feel like driftwood without vocational direction. Given the enormity of what critically ill patients are experiencing, emotional detachment from Jesus and those I am serving creates swells of grief for me as a Catholic physician. In the intensive care unit, I tend to gravitate to big and bold occurrences. Unfortunately, one tendency I have is to think that small events yield small outcomes, while big events yield big outcomes. Such is not the case with God, whom I tend to force into finite scales when, in truth, the Creator of the universe has no limits. This essay highlights an experience in which God brought a deeper understanding of His grace from a seemingly monotonous patient encounter. I am reminded that because of God's presence in my relationship with each person, "Nothing shall be impossible." (Lk 1:37).

Nutrition therapy in the intensive care unit during the COVID-19 pandemic: Findings from the ISIIC point prevalence study

BACKGROUND & AIMS

Nutrition therapy for Intensive Care Unit (ICU) patients involves complex decision-making, especially during the COVID-19 pandemic. We investigated the use of nutrition therapy in ICU patients with and without COVID-19 infections.

METHODS

Nutrition therapy was evaluated during a world-wide one-day prevalence study focused on implementation of the ABCDEF bundle (A: regular pain assessment, B: both spontaneous awakening and breathing trials, C: regular sedation assessment, D: regular delirium assessment, E: early mobility and exercise, and F: family engagement and empowerment) during the COVID-19 pandemic. Basic ICU and patient demographics including nutrition therapy delivery were collected on the survey day. Physical activity for patients with and without COVID infections was categorized using the ICU mobility scale (IMS). Multivariable regression analysis of nutrition was conducted using ICU parameters.

RESULTS

The survey included 627 non-COVID and 602 COVID patients. A higher proportion of COVID-19 patients received energy ≥20 kcal/kg/day (55% vs. 45%; p = 0.0007) and protein ≥1.2 g/kg/day (45% vs. 35%; p = 0.0011) compared to non-COVID patients. Enteral nutrition was provided to most COVID patients even with prone positioning (91%). Despite nutrition therapy, IMS was extremely low in both groups; median IMS was 1 in non-COVID patients and 0 in COVID patients. The rate of energy delivery ≥20 kcal/kg/day was significantly higher in patients with COVID-19 infections in the subgroup of ICU days ≤5 days and IMS ≤2. Having a dedicated ICU nutritionist/dietitian was significantly associated with appropriate energy delivery in patients both with and without COVID-19 infections, but not with protein delivery.

CONCLUSION

During the COVID-19 pandemic, patients with COVID-19 infections received higher energy and protein delivery. Generally low mobility levels highlight the need to optimize early mobilization with nutrition therapy in all ICU patients.

Oxygen as an Essential Medicine

Supplemental oxygen is an essential medication in critical care. The optimal oxygen dose delivery system remains unclear, however. The "dose" and "delivery" of oxygen carry significant importance for resource-limited settings, such as low- and middle-income countries (LMICs). Regrettably, LMICS often experience significant inequities in oxygen supply and demand, with major impacts on preventable mortality. These inequities have become particularly prominent during the global COVID-19 pandemic, highlighting the need for additional investment and research into the best methods to utilize supplemental oxygen and ensure stable access to medical oxygen.

Mobilization and Rehabilitation Practice in ICUs During the COVID-19 Pandemic

BACKGROUND

Mobilization and acute rehabilitation are essential in the intensive care unit (ICU), with substantial evidence supporting their benefits. This study aimed to characterize ICU mobilization practices during the COVID-19 pandemic for patients with and without COVID-19.

METHODS

This was a secondary analysis of an international point prevalence study. All ICUs across the world were eligible to participate and were required to enroll all patients in each ICU on the survey date, 27 January 2021. The primary outcome was the achievement of mobilization at the level of sitting over the edge of the bed. Independent factors associated with mobilization, including COVID-19 infection, were analyzed by multivariable analysis.

RESULTS

A total of 135 ICUs in 33 countries participated, for inclusion of 1229 patients. Among patients who were not receiving mechanical ventilation (MV), those with COVID-19 infection were mobilized more than those without COVID-19 (60% vs. 34%, p < 0.001). Among patients who were receiving MV, mobilization was low in both groups (7% vs. 9%, p = .56). These findings were consistent irrespective of ICU length of stay. Multivariable analysis showed that COVID-19 infection was associated with achievement of mobilization in patients without (adjusted odds ratio [aOR] = 4.48, 95% confidence interval [CI] = 2.71-7.42) and with MV (aOR = 2.13, 95% CI = 1.00-4.51). Factors that prevented mobilization were prone positioning in patients without MV and continuous use of neuromuscular blockade and sedation agents in patients with MV, whereas facilitating factors were the presence of targets/goals in both groups.

CONCLUSION

Mobilization rates for ICU patients across the globe are severely low, with the greatest immobility observed in mechanically ventilated patients. Although COVID-19 is not an independent barrier to the mobilization of patients with or without MV, this study has highlighted the current lack of mobility practice for all ICU patients during the COVID-19 pandemic.(299 words).

Stakeholder perspectives of a pilot multicomponent delirium prevention intervention for adult patients with advanced cancer in palliative care units: A behaviour change theory-based qualitative study

BACKGROUND

Theory-based and qualitative evaluations in pilot trials of complex clinical interventions help to understand quantitative results, as well as inform the feasibility and design of subsequent effectiveness and implementation trials.

AIM

To explore patient, family, clinician and volunteer ('stakeholder') perspectives of the feasibility and acceptability of a multicomponent non-pharmacological delirium prevention intervention for adult patients with advanced cancer in four Australian palliative care units that participated in a phase II trial, the 'PRESERVE pilot study'.

DESIGN

A trial-embedded qualitative study via semi-structured interviews and directed content analysis using Michie's Behaviour Change Wheel and the Theoretical Domains Framework.

SETTING/PARTICIPANTS

Thirty-nine people involved in the trial: nurses (n = 17), physicians (n = 6), patients (n = 6), family caregivers (n = 4), physiotherapists (n = 3), a social worker, a pastoral care worker and a volunteer.

RESULTS

Participants' perspectives aligned with the 'capability', 'opportunity' and 'motivation' domains of the applied frameworks. Of seven themes, three were around the alignment of the delirium prevention intervention with palliative care (intervention was considered routine care; intervention aligned with the compassionate and collaborative culture of palliative care; and differing views of palliative care priorities influenced perspectives of the intervention) and four were about study processes more directly related to adherence to the intervention (shared knowledge increased engagement with the intervention; impact of the intervention checklist on attention, delivery and documentation of the delirium prevention strategies; clinical roles and responsibilities; and addressing environmental barriers to delirium prevention).

CONCLUSION

This theory-informed qualitative study identified multiple influences on the delivery and documentation of a pilot multicomponent non-pharmacological delirium prevention intervention in four palliative care units. Findings inform future definitive studies of delirium prevention in palliative care.Australian New Zealand Clinical Trials Registry, ACTRN12617001070325; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373168.

Sunset and the Birth of New Ideas

We met each other through academic medicine, in search for answers, and found friendship. Its value in my life was abundant, unearned grace. In Dr. Curtis, I learned the truth of the words of Thomas Mann, "Illness was merely transformed love."

Practices in sedation, analgesia, mobilization, delirium, and sleep deprivation in adult intensive care units (SAMDS-ICU): an international survey before and during the COVID-19 pandemic

Background

Since the publication of the 2018 Clinical Guidelines about sedation, analgesia, delirium, mobilization, and sleep deprivation in critically ill patients, no evaluation and adequacy assessment of these recommendations were studied in an international context. This survey aimed to investigate these current practices and if the COVID-19 pandemic has changed them.

Methods

This study was an open multinational electronic survey directed to physicians working in adult intensive care units (ICUs), which was performed in two steps: before and during the COVID-19 pandemic.

Results

We analyzed 1768 questionnaires and 1539 (87%) were complete. Before the COVID-19 pandemic, we received 1476 questionnaires and 292 were submitted later. The following practices were observed before the pandemic: the Visual Analog Scale (VAS) (61.5%), the Behavioral Pain Scale (BPS) (48.2%), the Richmond Agitation Sedation Scale (RASS) (76.6%), and the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) (66.6%) were the most frequently tools used to assess pain, sedation level, and delirium, respectively; midazolam and fentanyl were the most frequently used drugs for inducing sedation and analgesia (84.8% and 78.3%, respectively), whereas haloperidol (68.8%) and atypical antipsychotics (69.4%) were the most prescribed drugs for delirium treatment; some physicians regularly prescribed drugs to induce sleep (19.1%) or ordered mechanical restraints as part of their routine (6.2%) for patients on mechanical ventilation; non-pharmacological strategies were frequently applied for pain, delirium, and sleep deprivation management. During the COVID-19 pandemic, the intensive care specialty was independently associated with best practices. Moreover, the mechanical ventilation rate was higher, patients received sedation more often (94% versus 86.1%, p < 0.001) and sedation goals were discussed more frequently in daily rounds. Morphine was the main drug used for analgesia (77.2%), and some sedative drugs, such as midazolam, propofol, ketamine and quetiapine, were used more frequently.

Conclusions

Most sedation, analgesia and delirium practices were comparable before and during the COVID-19 pandemic. During the pandemic, the intensive care specialty was a variable that was independently associated with the best practices. Although many findings are in accordance with evidence-based recommendations, some practices still need improvement.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-022-00985-y.

Implementation of the ABCDEF Bundle for Critically Ill ICU Patients During the COVID-19 Pandemic: A Multi-National 1-Day Point Prevalence Study

Background: Data regarding delivery of evidence-based care to critically ill patients in Intensive Care Units (ICU) during the COVID-19 pandemic is crucial but lacking. This study aimed to evaluate the implementation rate of the ABCDEF bundle, which is a collection of six evidence-based ICU care initiatives which are strongly recommended to be incorporated into clinical practice, and ICU diaries for patients with and without COVID-19 infections in ICUs, and to analyze the impact of COVID-19 on implementation of each element of the bundle and independent associated factors.

Methods: A world-wide 1-day point prevalence study investigated the delivery of the ABCDEF bundle and ICU diary to patients without or with COVID-19 infections on 27 January 2021 via an online questionnaire. Multivariable logistic regression analysis with adjustment for patient demographics evaluated the impact of COVID-19 and identified factors in ICU administrative structures and policies independently associated with delivery.

Results: From 54 countries and 135 ICUs, 1,229 patients were eligible, and 607 (49%) had COVID-19 infections. Implementation rates were: entire bundle (without COVID-19: 0% and with COVID-19: 1%), Element A (regular pain assessment: 64 and 55%), Element B (both spontaneous awakening and breathing trials: 17 and 10%), Element C (regular sedation assessment: 45 and 61%), Element D (regular delirium assessment: 39 and 35%), Element E (exercise: 22 and 25%), Element F (family engagement/empowerment: 16 and 30%), and ICU diary (17 and 21%). The presence of COVID-19 was not associated with failure to implement individual elements. Independently associated factors for each element in common between the two groups included presence of a specific written protocol, application of a target/goal, and tele-ICU management. A lower income status country and a 3:1 nurse-patient ratio were significantly associated with non-implementation of elements A, C, and D, while a lower income status country was also associated with implementation of element F.

Conclusions: Regardless of COVID-19 infection status, implementation rates for the ABCDEF bundle, for each element individually and an ICU diary were extremely low for patients without and with COVID-19 infections during the pandemic. Strategies to facilitate implementation of and adherence to the complete ABCDEF bundle should be optimized and addressed based on unit-specific barriers and facilitators.

Association of postoperative delirium with cognitive outcomes: A meta-analysis

STUDY OBJECTIVE

To determine the association between postoperative delirium (POD) and cognitive outcomes at least 1 month after surgery in elderly patients, and synthesize the dynamic risk trajectory of cognition impairment after POD.

DESIGN

Meta-analysis searching PubMed, Cochrane and EMBASE from inception to November 1, 2020. The terms postoperative delirium, delirium after surgery, postsurgical delirium, postoperative cogniti*, postoperative cognitive dysfunction, postoperative cognition decline, cognitive decline, cognitive impair* and dement* were searched alone or in combination.

MEASUREMENTS

Inclusion criteria were prospective cohort studies investigating the association between POD and cognitive outcomes in patients aged ≥60 years underwent surgery. The primary outcome was the association between POD and cognitive outcomes at 1 or more months after surgery. We considered cognitive outcomes measured up to 12 months after surgery as short-term and beyond 12 months as long-term. Two authors performed the study screening, data extraction and quality assessments. Effect sizes were calculated as Hedges g or Odds ratio (OR) based on random- and fixed-effects models. Meta-regression was conducted to analyze the role of potential contributors to heterogeneity.

MAIN RESULTS

Eighteen studies were included. Our result showed a significant and medium association between POD and cognitive outcomes after at least 1 month postoperatively (g = 0.61 95% CI 0.43-0.79; I² = 65.1%), indicating that patients with POD were associated with worse cognitive outcomes. The association of POD with short- and long-term cognitive impairment were also both significant (short-term: g = 0.46 95% CI 0.24-0.68; I² = 53.1%; and long-term: g = 0.82 95% CI 0.57-1.06; I² = 57.1%). A multivariate meta-regression suggested that age and measure of delirium were significant sources of heterogeneity. POD was also associated with the significant risk for dementia (OR = 6.08 95% CI 3.80-9.72; I² = 0) as well as attention (OR = 1.74 95% CI 1.13-2.68; I² = 0), executive (OR = 1.33 95% CI 1.00-1.80; I² = 0) and memory impairment (OR = 1.59 95% CI 1.20-2.10; I² = 43.0%). Additionally, our results showed that the risk trajectory for cognitive decline associated with POD within five years after surgery revealed exponential growth.

CONCLUSIONS

This is the first meta-analysis quantifying the association between POD and cognitive outcomes. Our results showed that POD was significantly associated with worse cognitive outcomes, including short- and long-term cognitive outcomes following surgery.

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

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

Adaptation and Validation of a Chart-Based Delirium Detection Tool for the ICU (CHART-DEL-ICU)

OBJECTIVE

To adapt and validate a chart-based delirium detection tool for use in critically ill adults.

DESIGN

Validation study.

SETTING

Medical-surgical intensive care unit (ICU) in an academic hospital.

MEASUREMENTS

A chart-based delirium detection tool (CHART-DEL) was adapted for use in critically ill adults (CHART-DEL-ICU) and compared with prospective delirium assessments (i.e., clinical assessments (reference standard) by a research nurse trained by a neuropsychiatrist and routine delirium screening tools Confusion Assessment Method (CAM-ICU)) and (Intensive Care Delirium Screening Checklist (ICDSC)). The original CHART-DEL tool was adapted to include physician-reported ICDSC score (for probable delirium) and Richmond-Agitation Sedation Scale score (for altered level of consciousness and agitation). Two trained chart abstractors blinded to all delirium assessments manually abstracted delirium-related information from medical charts and electronic medical records and rated if delirium was present (four levels: uncertain, possible, probable, definite) or absent (no evidence).

RESULTS

Charts were manually abstracted for delirium-related information for 213 patients who were included in a prospective cohort study that included prospective delirium assessments. The CHART-DEL-ICU tool had excellent interrater reliability (kappa = 0.90). Compared to the reference standard, the sensitivity was 66.0% (95% CI = 59.3-72.3%) and specificity was 82.1% (95% CI = 78.0-85.7%), with a cut-point that included definite, probable, possible, and uncertain delirium. The AUC of the CHART-DEL-ICU alone is 74.1% (95% CI = 70.4-77.8%) compared with the addition of the CAM-ICU and ICDSC (CAM-ICU/CHART-DEL-ICU: 80.9% (95% CI = 77.8-83.9%), P = .01; ICDSC/CHART-DEL-ICU: 79.2% (95% CI = 75.9-82.6%), P = .03).

CONCLUSION

A chart-based delirium detection tool has improved diagnostic accuracy when combined with routine delirium screening tools (CAM-ICU and ICDSC), compared to a chart-based method on its own. This presents a potential for retrospective detection of delirium from medical charts for research or to augment routine delirium screening methods to find missed cases of delirium.

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

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

A Tunisian version of the confusion assessment method for the intensive care unit (CAM-ICU): translation and validation

BACKGROUND

Delirium is common in critically ill patients and it is associated with poor outcomes. In Tunisia, however, it is still underdiagnosed as there is no validated screening tool. The aim of this study was to translate and to validate a Tunisian version of the CAM-ICU.

METHODS

For the validation and inter-rater reliability assessment of the Tunisian CAM-ICU, two trained intensivists independently evaluated delirium in the patients admitted to the ICU between October 2017 and June 2018. All the patients consecutively admitted to the ICU for more than 24 h and having a Richmond Agitation-Sedation Scale greater than or equal to "-3" were assessed for delirium excluding those with stroke, dementia, psychosis or persistent coma. The results were compared with the reference evaluation carried out by a psychiatrist using the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) criteria. The inter-rater reliability was calculated using the kappa (κ) statistic. The CAM-ICU concurrent validity was assessed using Cronbach's α coefficient, sensitivity, specificity as well as positive and negative predictive values (PPV and NPV, respectively) for the two Tunisian CAM-ICU raters.

RESULTS

The study involved 137 patients [median (IQR) age: 60 [49-68] years, male sex (n = 102), invasive mechanical ventilation (n = 49)]. Using the DSM-V criteria evaluations, 46 patients were diagnosed with delirium. When applying the Tunisian version of the CAM-ICU, 38(27.7%) patients were diagnosed with delirium for the first rater and 45(32.6%) patients for the second one. The Tunisian CAM-ICU showed a very-high inter-rater reliability for both intensivists (κ = 0.844, p < 0.001). Using the DSM-V rater as the reference standard, the sensitivity of the two intensivists' evaluations was 80.4 vs. 95.7%. Specificity was 98.9% for both. The Cronbach's α of the first and second raters' evaluations using the Tunisian version of the CAM-ICU were 0.886 and 0.887, respectively.

CONCLUSIONS

The Tunisian version of the CAM-ICU showed almost perfect validity and reliability in detecting delirium in critically ill patients. It could therefore be used in Tunisian ICUs or where Tunisian translators are available following appropriate training.

TRIAL REGISTRATION

Not applicable.

A Tunisian version of the Confusion Assessment Method for the intensive care unit (CAM-ICU): translation and validation.. [DOI: 10.21203/rs.2.17611/v3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Background. Delirium is common in critically ill patients and it is associated with poor outcomes. In Tunisia, however, it is still underdiagnosed as there is no validated screening tool. The aim of this study was to translate and to validate a Tunisian version of the CAM-ICU. Methods. For the validation and inter-rater reliability assessment of the Tunisian CAM-ICU, two trained intensivists independently evaluated delirium in the patients admitted to the ICU between October 2017 and June 2018. All the patients consecutively admitted to the ICU for more than 24 hours and having a Richmond Agitation-Sedation Scale greater than or equal to “-3” were assessed for delirium excluding those with stroke, dementia, psychosis or persistent coma. The results were compared with the reference evaluation carried out by a psychiatrist using the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) criteria. The inter-rater reliability was calculated using the kappa (κ) statistic. The CAM-ICU concurrent validity was assessed using Cronbach’s α coefficient, sensitivity, specificity as well as positive and negative predictive values (PPV and NPV, respectively) for the two Tunisian CAM-ICU raters. Results. The study involved 137 patients [median (IQR) age: 60 [49-68] years, male sex (n=102), invasive mechanical ventilation (n=49)]. Using the DSM-V criteria evaluations, 46 patients were diagnosed with delirium. When applying the Tunisian version of the CAM-ICU, 38(27.7%) patients were diagnosed with delirium for the first rater and 45(32.6%) patients for the second one. The Tunisian CAM-ICU showed a very-high inter-rater reliability for both intensivists (κ = 0.844, p<0.001). Using the DSM-V rater as the reference standard, the sensitivity of the two intensivists’ evaluations was 80.4 vs. 95.7%. Specificity was 98.9% for both. The Cronbach’s α of the first and second raters’ evaluations using the Tunisian version of the CAM-ICU were 0.886 and 0.887, respectively. Conclusions. The Tunisian version of the CAM-ICU showed almost perfect validity and reliability in detecting delirium in critically ill patients. It could therefore be used in Tunisian ICUs or where Tunisian translators are available following appropriate training. Trial registration. Not applicable.

A Multicomponent Nonpharmacological Intervention to Prevent Delirium for Hospitalized People with Advanced Cancer: A Phase II Cluster Randomized Waitlist Controlled Trial (The PRESERVE Pilot Study)

Background: Delirium is a common debilitating complication of advanced cancer. Objective: To determine if a multicomponent nonpharmacological delirium prevention intervention was feasible for adult patients with advanced cancer, before a phase III (efficacy) trial. Design: Phase II (feasibility) cluster randomized controlled trial. All sites implemented delirium screening and diagnostic assessment. Strategies within sleep, vision and hearing, hydration, orientation, mobility, and family domains were delivered to enrolled patients at intervention site admission days 1-7. Control sites then implemented the intervention ("waitlist sites"). Setting: Four Australian palliative care units. Measurements: The primary outcome was adherence, with an a priori endpoint of at least 60% patients achieving full adherence. Secondary outcomes were interdisciplinary care delivery, delirium measures, and adverse events, analyzed descriptively and inferentially. Results: Sixty-five enrolled patients (25 control, 20 intervention, and 20 waitlist) had 98% delirium screens and 75% diagnostic assessments completed. Nurses (67%), physicians (16%), allied health (8.4%), family (7%), patients (1%), and volunteers (0.5%) delivered the intervention. There was full adherence for 5% patients at intervention sites, partial for 25%. Both full and partial adherence were higher at waitlist sites: 25% and 45%, respectively. One-third of control site patients (32%) became delirious within seven days of admission compared to one-fifth (20%) at both intervention and waitlist sites (p = 0.5). Mean (standard deviation) Delirium Rating Scale-Revised-1998 scores were 16.8 + 12.0 control sites versus 18.4 + 8.2 (p = 0.6) intervention and 18.7 + 7.8 (p = 0.5) waitlist sites. The intervention caused no adverse events. Conclusion: The intervention requires modification for optimal adherence in a phase III trial.

A Tunisian version of the Confusion Assessment Method for the intensive care unit (CAM-ICU): translation and validation.. [DOI: 10.21203/rs.2.17611/v2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Background. Delirium is common in critically ill patients and it is associated with poor outcomes. In Tunisia, however, it is still underdiagnosed as there is no validated screening tool. The aim of this study was to translate and to validate a Tunisian version of the CAM-ICU. Methods. For the validation and inter-rater reliability assessment of the Tunisian CAM-ICU, two trained intensivists independently evaluated delirium in the patients admitted to the ICU between October 2017 and June 2018. All the patients consecutively admitted to the ICU for more than 24 hours and having a Richmond Agitation-Sedation Scale greater than or equal to “-3” were assessed for delirium excluding those with stroke, dementia, psychosis or persistent coma. The results were compared with the reference evaluation carried out by a psychiatrist using the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) criteria. The inter-rater reliability was calculated using the kappa (κ) statistic. The CAM-ICU concurrent validity was assessed using Cronbach’s α coefficient, sensitivity, specificity as well as positive and negative predictive values (PPV and NPV, respectively) for the two Tunisian CAM-ICU raters. Results. The study involved 137 patients [median (IQR) age: 60 [49-68] years, male sex (n=102), invasive mechanical ventilation (n=49)]. Using the DSM-V criteria evaluations, 46 patients were diagnosed with delirium. When applying the Tunisian version of the CAM-ICU, 38(27.7%) patients were diagnosed with delirium for the first rater and 45(32.6%) patients for the second one. The Tunisian CAM-ICU showed a very-high inter-rater reliability for both intensivists (κ = 0.844, p<0.001). Using the DSM-V rater as the reference standard, the sensitivity of the two intensivists’ evaluations was 80.4 vs. 95.7%. Specificity was 98.9% for both. The Cronbach’s α of the first and second raters’ evaluations using the Tunisian version of the CAM-ICU were 0.886 and 0.887, respectively. Conclusions. The Tunisian version of the CAM-ICU showed almost perfect validity and reliability in detecting delirium in critically ill patients. It could therefore be used in Tunisian ICUs or where Tunisian translators are available following appropriate training.

Delirium in the ICU

Introduction: Delirium, the most prevalent form of acute brain dysfunction in the Intensive Care Unit (ICU) is characterized by inattention, changes in cognition and at times thought and perceptual disturbances (e.g., delusions and hallucinations). Recent estimates of delirium prevalence suggest around 70% of patients on mechanical ventilation will experience delirium during their critical illness and almost a third of days in the ICU are days spent with delirium^1,2. There are at least three distinct motor subtypes of delirium: hypoactive (decreased movement), hyperactive (increased movement and at times agitation) and mixed (features of both). The hypoactive form predominates, is under-diagnosed and is associated with worse outcomes. Recent work has suggested that another psychomotor disturbance, catatonia may co-occur in up to a third of patients with delirium in the ICU³. Risk factors: Risk factors for the development of delirium include: pre-existing dementia, advanced age, hypertension, pre-critical illness emergency surgery or trauma, increased severity of illness, mechanical ventilation, metabolic acidosis, prior delirium or coma and use of certain delirium potentiating drugs such as anti-cholinergic and sedative hypnotic medications. Mechanisms: Exact mechanisms leading to the development of delirium are unknown, however early evidence suggests neural disconnectivity of the dorsolateral prefrontal cortex and the posterior cingulate cortex. Reversible reduction of functional connectivity of subcortical regions and neuroinflammation leading to hippocampal and extra-hippocampal dysfunction, may play potential roles. Overall all brain volume loss and disruption in white matter tracts may be associated with new onset dementia in survivors of critical illness. Due to the heterogeneous phenotype of delirium, there may be multiple causative neurobiological mechanisms contributing to its development, instead of one unifying pathway. Morbidity and mortality: Delirium is associated with significant morbidity and mortality. Much of the critical care literature about delirium has focused on the exposure of delirium and its relationship with acquired disabilities, as well as its effect on in-hospital and post-discharge excess mortality. Delirium is known to be predictive of new-onset dementia⁴, depression, excess mortality, longer lengths of stay, institutionalization at discharge, inability to return to work and increased cost of care in the hospital. Prevention and treatment: Despite scant evidence, antipsychotic medications have historically been the treatment of choice for delirium, however recent findings suggest that typical and atypical antipsychotics have no effect on delirium duration in the ICU⁵. As delirium is characterized by alterations in the sleep wake cycle, some studies have explored the role of melatonin or ramelton in the prevention or treatment of delirium, with early promising results. Non-pharmacological interventions such as complete adherence to the ABCDEF (Assess, prevent, and manage pain; Both spontaneous awakening and breathing trials: Choice of analgesia and sedation; Delirium assess, prevent, and manage; Early mobility and exercise; Family engagement/empowerment) bundle have shown benefit in reducing delirium prevalence in the ICU².

A Tunisian version of the Confusion Assessment Method for the intensive care unit (CAM-ICU): translation and validation.. [DOI: 10.21203/rs.2.17611/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Background Delirium is common in critically ill patients and is associated with poor outcomes. In Tunisia, it remains however underdiagnosed, lacking a validated screening tool. The CAM-ICU is one of the most commonly used tools for detecting delirium in ICUs. The aim of the present study was to translate and validate a Tunisian version of the CAM-ICU. Methods A forward and backward translation was performed according to the guidelines suggested by the translation and cultural adaptation group. For the validation and inter-rater reliability assessment of the Tunisian CAM-ICU, two trained intensivists independently evaluated delirium in ICU patients admitted between October 2017 and June 2018. The results were compared with the reference evaluation carried out by a psychiatrist using the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The inter-rater reliability was calculated using the kappa statistic. Results The related material of the Tunisian translated version of the CAM-ICU is currently available at the website www.icudelirium.org (last access: October 19, 2019). The study enrolled 137 patients. The Tunisian CAM-ICU showed a very high inter-rater reliability for both intensivists in terms of assessing delirium (Kappa=0.844, p<0.001). Using the DSM-5 rater as the reference standard, the sensitivity of the two intensivists’ evaluations were 80.4% vs. 95.7%. Specificity was 98.9% for both respectively. Conclusions The Tunisian version of the CAM-ICU showed excellent validity and reliability in detecting delirium in critically ill patients. It could therefore be used in Tunisian ICUs or where Tunisian translators are available following appropriate training. Trial registration: Not applicable.

Feasibility and acceptability of family administration of delirium detection tools in the intensive care unit: a patient-oriented pilot study

BACKGROUND

Family-administered delirium detection tools may serve as valuable diagnostic adjuncts because family caregivers may be better able than providers to detect changes in patient cognition and behaviour from pre-illness levels of functioning. The aim of this pilot study was to assess the feasibility and acceptability of family-administered tools to detect delirium in critically ill patients.

METHODS

In this single-centre pilot tool validation study conducted in August and September 2017, eligible family caregivers used the Family Confusion Assessment Method (FAM-CAM) and the Sour Seven questionnaire to detect delirium during the patient's intensive care unit (ICU) stay. We calculated descriptive statistics for all study variables. Patients and family caregivers were involved as research partners throughout the study. A patient-orient research approach was taken, engaging patients and family caregivers as full partners.

RESULTS

Of 141 patients admitted to the ICU, 75 were eligible, of whom 53 were approached; 21 patients (40%), 23/38 family caregivers (60%) and 17/38 dyads (i.e., patient and family caregiver enrolled together) (45%) consented to participate. The most common reason for nonenrolment was refusal by the family, who commonly reported feeling overwhelmed. The completion rate for the FAM-CAM and Sour Seven questionnaire was 74% (17/23). Among 13 dyads, family caregivers detected delirium in 5 patients (38%) using the FAM-CAM, and delirium or possible delirium in 8 patients (62%) using the Sour Seven questionnaire, whereas trained research assistants detected delirium in 8 patients (62%) using the Confusion Assessment Method for the Intensive Care Unit 7 and the Richmond Agitation-Sedation Scale (κ coefficient for agreement between the former and the FAM-CAM and Sour Seven questionnaire 0.62 and 0.85, respectively).

INTERPRETATION

Administration of the FAM-CAM and Sour Seven questionnaire by family caregivers to detect delirium in the ICU is feasible and acceptable, although, as with most family engagement strategies, it was not desired by all. Results from this pilot study support a definitive study with a larger sample to enable calculation of inferential statistics, but additional recruitment strategies are necessary to improve the response rate. Trial registration: Clinicaltrials.gov, no. NCT03379129.

Clinical phenotypes of delirium during critical illness and severity of subsequent long-term cognitive impairment: a prospective cohort study

BACKGROUND

Delirium during critical illness results from numerous insults, which might be interconnected and yet individually contribute to long-term cognitive impairment. We sought to describe the prevalence and duration of clinical phenotypes of delirium (ie, phenotypes defined by clinical risk factors) and to understand associations between these clinical phenotypes and severity of subsequent long-term cognitive impairment.

METHODS

In this multicentre, prospective cohort study, we included adult (≥18 years) medical or surgical ICU patients with respiratory failure, shock, or both as part of two parallel studies: the Bringing to Light the Risk Factors and Incidence of Neuropsychological Dysfunction in ICU Survivors (BRAIN-ICU) study, and the Delirium and Dementia in Veterans Surviving ICU Care (MIND-ICU) study. We assessed patients at least once a day for delirium using the Confusion Assessment Method-ICU and identified a priori-defined, non-mutually exclusive phenotypes of delirium per the presence of hypoxia, sepsis, sedative exposure, or metabolic (eg, renal or hepatic) dysfunction. We considered delirium in the absence of hypoxia, sepsis, sedation, and metabolic dysfunction to be unclassified. 3 and 12 months after discharge, we assessed cognition with the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). We used multiple linear regression to separately analyse associations between the duration of each phenotype of delirium and RBANS global cognition scores at 3-month and 12-month follow-up, adjusting for potential confounders.

FINDINGS

Between March 14, 2007, and May 27, 2010, 1048 participants were enrolled, eight of whom could not be analysed. Of 1040 participants, 708 survived to 3 months of follow-up and 628 to 12 months. Delirium was common, affecting 740 (71%) of 1040 participants at some point during the study and occurring on 4187 (31%) of all 13 434 participant-days. A single delirium phenotype was present on only 1355 (32%) of all 4187 participant-delirium days, whereas two or more phenotypes were present during 2832 (68%) delirium days. Sedative-associated delirium was most common (present during 2634 [63%] delirium days), and a longer duration of sedative-associated delirium predicted a worse RBANS global cognition score 12 months later, after adjusting for covariates (difference in score comparing 3 days vs 0 days: -4·03, 95% CI -7·80 to -0·26). Similarly, longer durations of hypoxic delirium (-3·76, 95% CI -7·16 to -0·37), septic delirium (-3·67, -7·13 to -0·22), and unclassified delirium (-4·70, -7·16 to -2·25) also predicted worse cognitive function at 12 months, whereas duration of metabolic delirium did not (1·14, -0·12 to 3·01).

INTERPRETATION

Our findings suggest that clinicians should consider sedative-associated, hypoxic, and septic delirium, which often co-occur, as distinct indicators of acute brain injury and seek to identify all potential risk factors that may impact on long-term cognitive impairment, especially those that are iatrogenic and potentially modifiable such as sedation.

FUNDING

National Institutes of Health and the Department of Veterans Affairs.

Deficits in Self-Reported Initiation Are AssociatedWith Subsequent Disability in ICU Survivors

OBJECTIVE

To determine whether deficits in a key aspect of executive functioning, namely, initiation, were associated with current and future functional disabilities in intensive care unit survivors.

METHODS

A nested substudy within a 2-center prospective observational cohort. We used 3 tests of initiation at 3 and 12 months: the Ruff Total Unique Design, Controlled Oral Word Association, and Behavior Rating Inventory of Executive Function initiation. Disability in instrumental activities of daily living (IADL) was measured with the Functional Activities Questionnaire. We used a proportional odds logistic regression model to evaluate the association between initiation and disability. Covariates in the model included age, education, baseline Functional Activities Questionnaire, pre-existing cognitive impairment, comorbidities, admission severity of illness, episodes of hypoxia, and days of severe sepsis.

RESULTS

In 195 patients, after adjusting for covariates, only the Behavior Rating Inventory of Executive Function initiation was associated with disability at any time point. Comparing the 25th vs the 75th percentile scores (95% confidence interval) of the Behavior Rating Inventory of Executive Function initiation at 3 months, patients with worse initiation scores had 5.062 times the odds (95% confidence interval: 2.539, 10.092) of disability according to the Functional Activities Questionnaire at 3 months, with similar odds at 12 months (odds ratio: 3.476, 95% confidence interval: 1.943, 6.216). Worse Behavior Rating Inventory of Executive Function initiation scores at 3 months were associated with future disability at 12 months odds ratio (95% confidence interval) 5.079 (2.579, 10.000).

CONCLUSIONS

Executive function deficits acquired after a critical illness in the domain of initiation are common in intensive care unit survivors, and when they are identified via self-report tools, they are associated with current and future disability in instrumental activities of daily living.

Validation of the behavioral pain scale to assess pain intensity in adult, intubated postcardiac surgery patients: A cohort observational study - POL-BPS

Patients after cardiac surgery experience significant pain, but cannot communicate effectively due to opioid analgesia and sedation. Identification of pain with validated behavioral observation tool in patients with limited abilities to self-report pain improves quality of care and prevents suffering. Aim of this study was to validate Polish version of behavioral pain scale (BPS) in intubated, mechanically ventilated patients sedated with dexmedetomidine and morphine after cardiac surgery.Prospective observational cohort study included postoperative cardiac surgery patients, both sedated with dexmedetomidine and unsedated, observed at rest, during a nociceptive procedure (position change) and 10 minutes after intervention. Pain control was achieved using morphine infusion and nonopioid coanalgesia. Pain intensity evaluation included self-report by patient using numeric rating scale (NRS) and BPS assessments carried out by 2 blinded observers.A total of 708 assessments were performed in 59 patients (mean age 68 years), predominantly men (44/59, 75%). Results showed very good interrater correlation between raters (interrater correlation scores >0.87). Self-report NRS scores were obtained from all patients. Correlation between NRS and BPS was relatively strong during nociceptive procedures in all patients for rater A and rater B (Spearman R > 0.65, P < .001). Both mean NRS and BPS scores were significantly higher during nociceptive procedures as compared to assessments at rest, in both sedated and unsedated patients (P < .001).The results of this observational study show that the Polish translation of BPS can be regarded as a useful and validated tool for pain assessment in adult intubated patients. This instrument can be used in both unsedated and sedated cardiac surgery patients with limited communication abilities.

ICU delirium - a diagnostic and therapeutic challenge in the intensive care unit

ICU delirium is a common medical problem occurring in patients admitted to the intensive care units (ICUs). Studies have shown that ICU delirium is associated with increased mortality, prolonged hospitalization, prolonged mechanical ventilation, costs and the occurrence of cognitive disoders after discharge from ICU. The tools available for ICU delirium screening and diagnosis are validated tests available for all members if the medical team (physicians, nurses, physiotherapists). Their use for routine patient assessment is recommended by international medical and scientific societies. They have been implemented as Pain, Agitation, Delirium (PAD) Guidelines by the Society of Critical Care Medicine. Apart from monitoring, a strategy of prevention and treatment is recommended, based on non-pharmacological approach (restoration of senses, early mobilization, physiotherapy, improvement in sleep hygiene and family involvement) as well as pharmacological treatment (typical and atypical antipsychotics and dexmedetomidine). In this article, we present the risk factors of ICU delirium, available tools for monitoring, as well as options for prevention and treatment of delirium that can be used to improve care over critically ill patients.

An evaluation of single question delirium screening tools in older emergency department patients

OBJECTIVES

To determine the diagnostic performances of several single question delirium screens. To the patient we asked: "Have you had any difficulty thinking clearly lately?" To the patient's surrogate, we asked: "Is the patient at his or her baseline mental status?" and "Have you noticed the patient's mental status fluctuate throughout the course of the day?"

METHODS

This was a prospective observational study that enrolled English speaking patients 65 years or older. A research assistant (RA) and emergency physician (EP) independently asked the patient and surrogate the single question delirium screens. The reference standard for delirium was a consultation-liaison psychiatrist's assessment using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria. All assessments were performed within 3 h and were all blinded to each other.

RESULTS

Of the 406 patients enrolled, 50 (12%) were delirious. A patient who was unable to answer the question "Have you had any difficulty thinking clearly lately?" was 99.7% (95% CI: 98.0%-99.9%) specific, but only 24.0% (95% CI: 14.3%-37.4%) sensitive for delirium when asked by the RA. The baseline mental status surrogate question was 77.1% (95% CI: 61.0%-87.9%) sensitive and 87.5% (95% CI: 82.8%-91.1%) specific for delirium when asked by the RA. The fluctuating course surrogate question was 77.1% (95% CI: 61.0%-87.9%) sensitive and 80.2% (95% CI: 74.8%-84.7%) specific. When asked by the EP, the single question delirium screens' diagnostic performances were similar.

CONCLUSIONS

The patient and surrogate single question delirium assessments may be useful for delirium screening in the ED.

Are you Ernest Shackleton, the polar explorer? Refining the criteria for delirium and brain dysfunction in sepsis

The Third International Consensus Definitions for Sepsis and Septic Shock has recently defined sepsis as a life-threatening organ dysfunction caused by a dysregulated host response to infection. Organ dysfunctions in this consensus definition were identified as an organ-specific Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score ≥ 2 points. The quick SOFA (qSOFA) considers altered mentation indicating brain dysfunction when the Glasgow Coma Scale (GCS) score is ≤13 or ≤14. However, concern has been expressed that the revised criteria may lead to a failure in recognizing the signs of potentially lethal organ dysfunction and thus sepsis. Patients with delirium have a fluctuating course, and GCS can be normal or only slightly reduced at the time when signs of delirium are already present. We here report an illustrative case showing how an acute, initially unrecognized, urinary tract infection caused acute brain dysfunction with profound behavioral and cognitive dysfunction despite normal GCS, hence not meeting the criteria for sepsis.

Emergence from general anaesthesia and evolution of delirium signs in the post-anaesthesia care unit

BACKGROUND

Emergence from anaesthesia is often accompanied by signs of delirium, including fluctuating mental status and inattention. The evolution of these signs of delirium requires investigation since delirium in the post-anaesthesia care unit (PACU) may be associated with worse outcomes.

METHODS

Adult patients emerging from anaesthesia were assessed for agitated emergence in the operating room using the Richmond Agitation-Sedation Scale (RASS). The Confusion Assessment Method for the Intensive Care Unit was then used to evaluate delirium signs at PACU admission and during PACU stay at 30 min, 1 h, and discharge. Signs consistent with delirium were classified as hyperactive vs hypoactive based upon a positive CAM-ICU assessment and the concomitant RASS score. Multivariable logistic regression was utilized to assess potential risk factors for delirium during PACU stay including age, American Society of Anesthesiologists classification, and opioid and benzodiazepine exposure.

RESULTS

Among 400 patients enrolled, 19% had agitated emergence. Delirium signs were present at PACU admission, 30 min, 1 h, and PACU discharge in 124 (31%), 59 (15%), 32 (8%), and 15 (4%) patients, respectively. In patients with delirium signs, hypoactive signs were present in 56% at PACU admission and in 92% during PACU stay. Perioperative opioids were associated with delirium signs during PACU stay (P=0.02).

CONCLUSIONS

A significant proportion of patients develop delirium signs in the immediate postoperative period, primarily manifesting with a hypoactive subtype. These signs often persist to PACU discharge, suggesting the need for structured delirium monitoring in the PACU to identify patients potentially at risk for worse outcomes in the postoperative period.

Delirium diagnosis methodology used in research: a survey-based study

OBJECTIVE

To describe methodology used to diagnose delirium in research studies evaluating delirium detection tools.

METHODS

The authors used a survey to address reference rater methodology for delirium diagnosis, including rater characteristics, sources of patient information, and diagnostic process, completed via web or telephone interview according to respondent preference. Participants were authors of 39 studies included in three recent systematic reviews of delirium detection instruments in hospitalized patients.

RESULTS

Authors from 85% (N = 33) of the 39 eligible studies responded to the survey. The median number of raters per study was 2.5 (interquartile range: 2-3); 79% were physicians. The raters' median duration of clinical experience with delirium diagnosis was 7 years (interquartile range: 4-10), with 5% having no prior clinical experience. Inter-rater reliability was evaluated in 70% of studies. Cognitive tests and delirium detection tools were used in the delirium reference rating process in 61% (N = 21) and 45% (N = 15) of studies, respectively, with 33% (N = 11) using both and 27% (N = 9) using neither. When patients were too drowsy or declined to participate in delirium evaluation, 70% of studies (N = 23) used all available information for delirium diagnosis, whereas 15% excluded such patients.

CONCLUSION

Significant variability exists in reference standard methods for delirium diagnosis in published research. Increasing standardization by documenting inter-rater reliability, using standardized cognitive and delirium detection tools, incorporating diagnostic expert consensus panels, and using all available information in patients declining or unable to participate with formal testing may help advance delirium research by increasing consistency of case detection and improving generalizability of research results.

Feasibility and safety of early combined cognitive and physical therapy for critically ill medical and surgical patients: the Activity and Cognitive Therapy in ICU (ACT-ICU) trial

PURPOSE

Cognitive impairment after critical illness is common and debilitating. We developed a cognitive therapy program for critically ill patients and assessed the feasibility and safety of administering combined cognitive and physical therapy early during a critical illness.

METHODS

We randomized 87 medical and surgical ICU patients with respiratory failure and/or shock in a 1:1:2 manner to three groups: usual care, early once-daily physical therapy, or early once-daily physical therapy plus a novel, progressive, twice-daily cognitive therapy protocol. Cognitive therapy included orientation, memory, attention, and problem-solving exercises, and other activities. We assessed feasibility outcomes of the early cognitive plus physical therapy intervention. At 3 months, we also assessed cognitive, functional, and health-related quality of life outcomes. Data are presented as median (interquartile range) or frequency (%).

RESULTS

Early cognitive therapy was a delivered to 41/43 (95%) of cognitive plus physical therapy patients on 100% (92-100%) of study days beginning 1.0 (1.0-1.0) day following enrollment. Physical therapy was received by 17/22 (77%) of usual care patients, by 21/22 (95%) of physical therapy only patients, and 42/43 (98%) of cognitive plus physical therapy patients on 17% (10-26%), 67% (46-87%), and 75% (59-88%) of study days, respectively. Cognitive, functional, and health-related quality of life outcomes did not differ between groups at 3-month follow-up.

CONCLUSIONS

This pilot study demonstrates that early rehabilitation can be extended beyond physical therapy to include cognitive therapy. Future work to determine optimal patient selection, intensity of treatment, and benefits of cognitive therapy in the critically ill is needed.

Abstract W P226: Delirium After Intracerebral Hemorrhage Is Common and Independently Predicts Reduced Domain-Specific Quality Of Life

Background: Delirium sypmptoms are common after ischemic stroke and in the medical and surgical ICU, and predictive of increased length of stay and worse outcomes. There are few data in intracerebral hemorrhage (ICH). We tested the hypothesis that delirium symptoms were associated with increased length of stay, worse functional outcomes, and worse domain-specific quality of life (QOL) at follow-up.

Methods: We prospectively identified 114 patients with ICH. Delirium symptoms were assessed by trained nursing staff twice daily with the Confusion Assessment Method for the ICU (CAM-ICU), a validated method. Arousal was measured with the Richmond Agitation Sedation Score. Functional outcomes were measured with the modified Rankin Scale at 1 and 3 months, with poor outcome defined at <=3 (moderately severe disability or worse). QOL was assessed at 1, 3 and 12 months with Neuro-QOL, instruments developed by NIH for neurologic disease and validated for proxy report.

Results: Of 114 patients, 31(27%) patients had delirium symptoms, 67 (59%) were never delirious, and the remainder (14%) had persistent coma. Only 2 (2%) were ever very agitated (both of whom were delirious), so most delirium symptoms were hypoactive. Any benzodiazepine (BZD) use, age, pneumonia, seizure, hematoma volume and NIH Stroke Scale were not associated with delirium symptoms in patients who could be assessed. Delirium symptoms were detected mean 5.9 days after ICH symptom onset and were associated with longer ICU length of stay (mean 3.5 days longer in ever delirious patients, 95%CI 1.5 - 8.3, P=0.004) after correction for age, admit NIH Stroke Scale (NIHSS) and any BZD exposure. Delirium symptoms were associated with increased odds of poor outcome at 28 days (OR 8.7, 95%CI 1.4 - 52.5, P=0.018) after correction for admission NIHSS and age. After correction for NIHSS, age, any BZD use and time of follow-up, delirium symptoms were associated with worse QOL in the domains of applied cognition - executive function (0.6 SD, 95%CI 0.2 - 1.1 SD, P=0.045) and fatigue (0.7 SD, 95%CI 0.17-1.3 SD, P=0.01).

Conclusions: Delirium symptoms (encephalopathy) were not predictable on admission, common after ICH, and independently predictive of longer length of stay, worse functional outcomes and reduced QOL.

Long-term cognitive impairment after critical illness

BACKGROUND

Survivors of critical illness often have a prolonged and disabling form of cognitive impairment that remains inadequately characterized.

METHODS

We enrolled adults with respiratory failure or shock in the medical or surgical intensive care unit (ICU), evaluated them for in-hospital delirium, and assessed global cognition and executive function 3 and 12 months after discharge with the use of the Repeatable Battery for the Assessment of Neuropsychological Status (population age-adjusted mean [±SD] score, 100±15, with lower values indicating worse global cognition) and the Trail Making Test, Part B (population age-, sex-, and education-adjusted mean score, 50±10, with lower scores indicating worse executive function). Associations of the duration of delirium and the use of sedative or analgesic agents with the outcomes were assessed with the use of linear regression, with adjustment for potential confounders.

RESULTS

Of the 821 patients enrolled, 6% had cognitive impairment at baseline, and delirium developed in 74% during the hospital stay. At 3 months, 40% of the patients had global cognition scores that were 1.5 SD below the population means (similar to scores for patients with moderate traumatic brain injury), and 26% had scores 2 SD below the population means (similar to scores for patients with mild Alzheimer's disease). Deficits occurred in both older and younger patients and persisted, with 34% and 24% of all patients with assessments at 12 months that were similar to scores for patients with moderate traumatic brain injury and scores for patients with mild Alzheimer's disease, respectively. A longer duration of delirium was independently associated with worse global cognition at 3 and 12 months (P=0.001 and P=0.04, respectively) and worse executive function at 3 and 12 months (P=0.004 and P=0.007, respectively). Use of sedative or analgesic medications was not consistently associated with cognitive impairment at 3 and 12 months.

CONCLUSIONS

Patients in medical and surgical ICUs are at high risk for long-term cognitive impairment. A longer duration of delirium in the hospital was associated with worse global cognition and executive function scores at 3 and 12 months. (Funded by the National Institutes of Health and others; BRAIN-ICU ClinicalTrials.gov number, NCT00392795.).

Pediatric delirium: monitoring and management in the pediatric intensive care unit

This review article updates the pediatric medical community on the current literature regarding diagnosis and treatment of delirium in critically ill children. This information will be of value to pediatricians, intensivists, and anesthesiologists in developing delirium monitoring and management protocols in their pediatric critical care units.

Understanding terminology of delirium and long-term cognitive impairment in critically ill patients

Delirium, an acute brain dysfunction, frequently affects intensive care unit (ICU) patients during the course of a critical illness. Besides the acute morbidities, ICU survivors often experience long-term sequelae in the form of cognitive impairment (LTCI-CI). Though delirium and LTCI-CI are associated with adverse outcomes, little is known on the terminology used to define these acute and chronic co-morbidities. The use of a correct terminology is a key factor to spread the knowledge on clinical conditions. Therefore, we first review the epidemiology, definition of delirium and its related terminology. Second, we report on the epidemiology of LTCI-CI and compare its definition to other forms of cognitive impairments. In particular, we define mild cognitive impairment, dementia and finally postoperative cognitive dysfunction. Future research is needed to interpret the trajectories of LTCI-CI, to differentiate it from neurodegenerative diseases and to provide a formal disease classification.

Abstract P17: Delirium in the Cardiovascular Intensive Care Unit: Implementation of a Screening Tool, Prevalence and Lessons Learned

Background: Delirium is common among critically ill patients (pts) and can lead to significant morbidity and mortality; yet the impact of delirium in a medical/surgical cardiovascular intensive care unit (CVICU) is unknown.

Objectives: We sought to (1) determine the prevalence and risk factors for delirium in a CVICU using the Confusion Assessment method for the ICU (CAM-ICU); and (2) measure the effect of educating and implementing CAM-ICU in routine assessment on attitudes and knowledge gaps regarding delirium among CVICU staff.

Methods: CVICU nurses were educated on delirium and trained in bedside CAM-ICU assessment. The CAM-ICU was performed at least once per shift, and reported during rounds. A survey assessed CVICU nurse attitudes and knowledge of delirium pre-and post-CAM-ICU implementation. Detailed clinical data were then prospectively obtained on 200 consecutive CVICU pts. Dementia or expected lengths of stay (LOS) < 1 day were exclusions.

Results: Median CVICU LOS was 3 days (IQR 2, 5), the median APACHE II score was 23 (IQR 11, 28), and CVICU mortality was 4%. The prevalence of delirium was 26%; similar among medical (n=96) and surgical (n=104) pts. Compared with pre-implementation, post-implementation surveys demonstrated improvements in CAM-ICU use (53% vs 98%), knowledge of delirium and outcomes, and importance of CAM-ICU data for patient care. Using a negative binomial model, the prior use of statins (p = 0.01), dexmedetomidine (p = 0.05), and benzodiazepines (p = 0.05) were associated with the development of delirium, with a trend toward increasing age (p = 0.17). No association with cardiac output, on-pump surgery, or APACHE II score was observed. In addition, restraint use (chi-square 5.2; p = 0.02) or statins (chi-square 4.4; p = 0.04) during the previous 24 hours were associated with the daily prevalence of delirium.

Conclusions: A detailed education intervention implementing routine CAM-ICU assessment increased knowledge of delirium and its clinical importance. Delirium is common in the CVICU, and is associated with the restraint use, dexmedetomidine, and benzodiazepines, likely representing a need for sedation. The association of delirium with prior statin use may reflect a higher burden of cardiovascular disease in these pts.

Organisational culture: variation across hospitals and connection to patient safety climate

CONTEXT

Bureaucratic organisational culture is less favourable to quality improvement, whereas organisations with group (teamwork) culture are better aligned for quality improvement.

OBJECTIVE

To determine if an organisational group culture shows better alignment with patient safety climate.

DESIGN

Cross-sectional administration of questionnaires. Setting 40 Hospital Corporation of America hospitals.

PARTICIPANTS

1406 nurses, ancillary staff, allied staff and physicians.

MAIN OUTCOME MEASURES

Competing Values Measure of Organisational Culture, Safety Attitudes Questionnaire (SAQ), Safety Climate Survey (SCSc) and Information and Analysis (IA).

RESULTS

The Cronbach alpha was 0.81 for the group culture scale and 0.72 for the hierarchical culture scale. Group culture was positively correlated with SAQ and its subscales (from correlation coefficient r = 0.44 to 0.55, except situational recognition), ScSc (r = 0.47) and IA (r = 0.33). Hierarchical culture was negatively correlated with the SAQ scales, SCSc and IA. Among the 40 hospitals, 37.5% had a hierarchical dominant culture, 37.5% a dominant group culture and 25% a balanced culture. Group culture hospitals had significantly higher safety climate scores than hierarchical culture hospitals. The magnitude of these relationships was not affected after adjusting for provider job type and hospital characteristics.

CONCLUSIONS

Hospitals vary in organisational culture, and the type of culture relates to the safety climate within the hospital. In combination with prior studies, these results suggest that a healthcare organisation's culture is a critical factor in the development of its patient safety climate and in the successful implementation of quality improvement initiatives.

A national survey of the management of delirium in UK intensive care units

BACKGROUND

Delirium is an acute organ dysfunction common amongst patients treated in intensive care units. The associated morbidity and mortality are known to be substantial. Previous surveys have described which screening tools are used to diagnose delirium and which medications are used to treat delirium, but these data are not available for the United Kingdom.

AIM

This survey aimed to describe the UK management of delirium by consultant intensivists. Additionally, knowledge and attitudes towards management of delirium were sought. The results will inform future research in this area.

METHODS

A national postal survey of members of the UK Intensive Care Society was performed. A concise two page questionnaire survey was sent, with a second round of surveys sent to non-respondents after 6 weeks. The questionnaire was in tick-box format.

RESULTS

Six hundred and eighty-one replies were received from 1308 questionnaires sent, giving a response rate of 52%. Twenty-five percent of respondents routinely screen for delirium, but of these only 55% use a screening tool validated for use in intensive care. The majority (80%) of those using a validated instrument used the Confusion Assessment Method for the Intensive Care Unit. Hyperactive delirium is treated pharmacologically by 95%; hypoactive delirium is treated pharmacologically by 25%, with haloperidol the most common agent used in both. Over 80% of respondents agreed that delirium prolongs mechanical ventilation and hospital stay and requires active treatment.

CONCLUSION

This UK survey demonstrates screening for delirium is sporadic. Pharmacological treatment is usually with haloperidol in spite of the limited evidence to support this practice. Hypoactive delirium is infrequently treated pharmacologically.

Liberation and animation: strategies to minimize brain dysfunction in critically ill patients

Acute brain dysfunction, usually manifested as delirium, occurs in up to 80% of critically ill patients. Delirium increases costs of hospitalizations and affects short-term outcomes such as duration of mechanical ventilation, intensive care unit (ICU) length of stay, and the hospital length of stay. Long-term consequences-cognitive impairment and increased risk of death-can be devastating. For adequate recognition and management it is imperative to implement a successful delirium monitoring and assessment strategy. A liberation and animation strategy can reduce both the incidence and the duration of delirium. Liberation aims to reduce the harmful effects of sedative exposure through use of target-based sedation protocols, spontaneous awakening trials, and proper choice of sedative as well as liberation from the ventilator and the ICU. Animation refers to early mobilization, which reduces delirium and improves neurocognitive outcomes. Delirium is a serious problem with important consequences and can be prevented or improved using the information that we have learned in the last decade.

Using real time process measurements to reduce catheter related bloodstream infections in the intensive care unit

PROBLEM

Measuring a process of care in real time is essential for continuous quality improvement (CQI). Our inability to measure the process of central venous catheter (CVC) care in real time prevented CQI efforts aimed at reducing catheter related bloodstream infections (CR-BSIs) from these devices.

DESIGN

A system was developed for measuring the process of CVC care in real time. We used these new process measurements to continuously monitor the system, guide CQI activities, and deliver performance feedback to providers.

SETTING

Adult medical intensive care unit (MICU).

KEY MEASURES FOR IMPROVEMENT

Measured process of CVC care in real time; CR-BSI rate and time between CR-BSI events; and performance feedback to staff.

STRATEGIES FOR CHANGE

An interdisciplinary team developed a standardized, user friendly nursing checklist for CVC insertion. Infection control practitioners scanned the completed checklists into a computerized database, thereby generating real time measurements for the process of CVC insertion. Armed with these new process measurements, the team optimized the impact of a multifaceted intervention aimed at reducing CR-BSIs.

EFFECTS OF CHANGE

The new checklist immediately provided real time measurements for the process of CVC insertion. These process measures allowed the team to directly monitor adherence to evidence-based guidelines. Through continuous process measurement, the team successfully overcame barriers to change, reduced the CR-BSI rate, and improved patient safety. Two years after the introduction of the checklist the CR-BSI rate remained at a historic low.

LESSONS LEARNT

Measuring the process of CVC care in real time is feasible in the ICU. When trying to improve care, real time process measurements are an excellent tool for overcoming barriers to change and enhancing the sustainability of efforts. To continually improve patient safety, healthcare organizations should continually measure their key clinical processes in real time.

Alpha-2 Agonists: Can they Modify the Outcomes in the Postanesthesia Care Unit?

While most patients recover uneventfully from the effects of anesthesia and surgery, for a small percentage of patients the immediate postoperative period can be a period of significant physiological stress. Hence the goal for a Post Anesthesia Care Unit (PACU) is to provide a safe environment for a patient to recover, while avoiding the undesirable side effects of pain, nausea, vomiting and shivering, and to monitor for potentially life threatening hemodynamic and respiratory complications that may require admission into the intensive care unit (ICU). Anesthetic techniques in the operating room are extremely important as these may have significant bearing on the post-operative course. The type of surgery, the patients' co morbid conditions, anticipated extubation and recovery of the patient, as well as the sophistication of the PACU and the expertise of its staff, all influence the choice of anesthetic technique. These agents, however, may themselves contribute to some of the complications and unpleasant events encountered in the PACU. Therefore, evaluation of newer and safer agents, which promote a smoother PACU transition, are warranted. Alpha 2 agonists are increasingly being used as adjuvant therapeutic agents in the perioperative period because of their ability to block the sympathetic stress response, complete with their anesthetic and analgesic sparing properties, lack of respiratory depression and low and predictable side effect profile.

Delirium in the intensive care unit: an under-recognized syndrome of organ dysfunction

The intensivist should think of delirium, or acute central nervous system dysfunction, as the brain's form of "organ dysfunction.'' Delirium is extremely common in intensive care unit (ICU) patients due to factors such as comorbidity, critical illness, and iatrogenesis. This complication of hospital stay is extremely hazardous in older persons and is associated with prolonged hospital stays, institutionalization, and death. Neurologic dysfunction compromises patients' ability to be removed from mechanical ventilation or achieve full recovery and independence. Yet ICU nurses and physicians are usually unaware of the presence of hypoactive delirium and only recognize this disturbance in agitated patients (hyperactive delirium). More importantly, there are few studies that have included ICU patients in the assessment or prevention of delirium. This article reviews the definition and salient features of delirium, its primary risk factors, a newly validated instrument for delirium assessment that is being developed for ICU nurses and physicians, and pharmacological agents associated with the development of delirium and used in its management.

Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU)

CONTEXT

Delirium is a common problem in the intensive care unit (ICU). Accurate diagnosis is limited by the difficulty of communicating with mechanically ventilated patients and by lack of a validated delirium instrument for use in the ICU.

OBJECTIVES

To validate a delirium assessment instrument that uses standardized nonverbal assessments for mechanically ventilated patients and to determine the occurrence rate of delirium in such patients.

DESIGN AND SETTING

Prospective cohort study testing the Confusion Assessment Method for ICU Patients (CAM-ICU) in the adult medical and coronary ICUs of a US university-based medical center.

PARTICIPANTS

A total of 111 consecutive patients who were mechanically ventilated were enrolled from February 1, 2000, to July 15, 2000, of whom 96 (86.5%) were evaluable for the development of delirium and 15 (13.5%) were excluded because they remained comatose throughout the investigation.

MAIN OUTCOME MEASURES

Occurrence rate of delirium and sensitivity, specificity, and interrater reliability of delirium assessments using the CAM-ICU, made daily by 2 critical care study nurses, compared with assessments by delirium experts using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria.

RESULTS

A total of 471 daily paired evaluations were completed. Compared with the reference standard for diagnosing delirium, 2 study nurses using the CAM-ICU had sensitivities of 100% and 93%, specificities of 98% and 100%, and high interrater reliability (kappa = 0.96; 95% confidence interval, 0.92-0.99). Interrater reliability measures across subgroup comparisons showed kappa values of 0.92 for those aged 65 years or older, 0.99 for those with suspected dementia, or 0.94 for those with Acute Physiology and Chronic Health Evaluation II scores at or above the median value of 23 (all P<.001). Comparing sensitivity and specificity between patient subgroups according to age, suspected dementia, or severity of illness showed no significant differences. The mean (SD) CAM-ICU administration time was 2 (1) minutes. Reference standard diagnoses of delirium, stupor, and coma occurred in 25.2%, 21.3%, and 28.5% of all observations, respectively. Delirium occurred in 80 (83.3%) patients during their ICU stay for a mean (SD) of 2.4 (1.6) days. Delirium was even present in 39.5% of alert or easily aroused patient observations by the reference standard and persisted in 10.4% of patients at hospital discharge.

CONCLUSIONS

Delirium, a complication not currently monitored in the ICU setting, is extremely common in mechanically ventilated patients. The CAM-ICU appears to be rapid, valid, and reliable for diagnosing delirium in the ICU setting and may be a useful instrument for both clinical and research purposes.