Delirium in the intensive care unit

Antipsychotics for the prevention and treatment of delirium in the intensive care unit: what is their role?

Delirium affects up to 80% of critically ill patients, worsens outcomes, and is frequently treated with antipsychotics despite uncertainty regarding their efficacy and safety. We identified published, English-language, randomized, controlled studies evaluating antipsychotics in ICU patients either with delirium or at risk for developing delirium. In 105 mechanically ventilated patients, the number of days spent alive without delirium or coma was similar between haloperidol (median, 14.0 days; interquartile range [IQR], 6.0-18.0 days) or ziprasidone (median, 15.0 days; IQR, 9.1-18.0 days) prophylaxis, and placebo (median, 12.5 days; IQR, 1.2-17.2 days) groups (p=0.66). Treating delirium with quetiapine, compared to placebo, in 36 ICU patients was associated with a quicker resolution of delirium (median for quetiapine, 1.0 days; IQR, 0.5-3.0 days/median for placebo, 4.5 days; IQR, 2.0-7.0 days [p=0.001]). In a third study, a similar decrease over time in delirium severity was noted between fixed-dose oral olanzapine and oral haloperidol in patients with delirium. None of the studies identified serious safety concerns with administering the antipsychotics that were studied. Published prospective, randomized clinical trials evaluating antipsychotic therapy for preventing or treating delirium in the ICU are few in number. The conclusions that can be drawn from them are limited by their heterogeneity, inconsistency in incorporating non-antipsychotic strategies known to reduce delirium or in maintaining patients in an arousable state, their size, the lack of ICU and non-ICU clinical outcomes evaluated, and the lack of placebo arms. A research framework for future evaluation of the use of antipsychotic therapy in the critically ill is proposed.

High serum cortisol level is associated with increased risk of delirium after coronary artery bypass graft surgery: a prospective cohort study

Introduction

The pathophysiology of postoperative delirium remains poorly understood. The purpose of this study was to examine the relationship between serum cortisol level and occurrence of early postoperative delirium in patients undergoing coronary artery bypass graft (CABG) surgery.

Methods

A total of 243 patients undergoing elective CABG surgery were enrolled. Patients were examined twice daily during the first five postoperative days and postoperative delirium was diagnosed by using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Blood samples were obtained between 7 a.m. and 8 a.m. on the first postoperative day and serum cortisol concentrations were then measured. Multivariate logistic regression analyses were performed to identify risk factors of postoperative delirium.

Results

Postoperative delirium occurred in 50.6% (123 of 243) of patients. High serum cortisol level was significantly associated with increased risk of postoperative delirium (OR 3.091, 95% CI 1.763-5.418, P < 0.001). Other independent risk factors of postoperative delirium included increasing age (OR 1.111, 95% CI 1.065-1.159, P < 0.001), history of diabetes mellitus (OR 1.905, 95% CI 1.001-3.622, P = 0.049), prolonged duration of surgery (OR 1.360, 95% CI 1.010-1.831, P = 0.043), and occurrence of complications within the first day after surgery (OR 2.485, 95% CI 1.184-5.214, P = 0.016). Patients who developed postoperative delirium had a higher incidence of postoperative complications and a prolonged duration of postoperative ICU and hospital stay.

Conclusions

Delirium was a common complication after CABG surgery. High serum cortisol level was associated with increased risk of postoperative delirium. Patients who developed delirium had outcomes worse than those who did not.

Delirium as a predictor of sepsis in post-coronary artery bypass grafting patients: a retrospective cohort study

Introduction

Delirium is the most common neurological complication following cardiac surgery. Much research has focused on potential causes of delirium; however, the sequelae of delirium have not been well investigated. The objective of this study was to investigate the relationship between delirium and sepsis post coronary artery bypass grafting (CABG) and to determine if delirium is a predictor of sepsis.

Methods

Peri-operative data were collected prospectively on all patients. Subjects were identified as having agitated delirium if they experienced a short-term mental disturbance marked by confusion, illusions and cerebral excitement. Patient characteristics were compared between those who became delirious and those who did not. The primary outcome of interest was post-operative sepsis. The association of delirium with sepsis was assessed by logistic regression, adjusting for differences in age, acuity, and co-morbidities.

Results

Among 14,301 patients, 981 became delirious and 227 developed sepsis post-operatively. Rates of delirium increased over the years of the study from 4.8 to 8.0% (P = 0.0003). A total of 70 patients of the 227 with sepsis, were delirious. In 30.8% of patients delirium preceded the development of overt sepsis by at least 48 hours. Multivariate analysis identified several factors associated with sepsis, (receiver operating characteristic (ROC) 79.3%): delirium (odds ratio (OR) 2.3, 95% confidence interval (CI) 1.6 to 3.4), emergent surgery (OR 3.3, CI 2.2 to 5.1), age (OR 1.2, CI 1.0 to 1.3), pre-operative length of stay (LOS) more than seven days (OR 1.6, CI 1.1 to 2.3), pre-operative renal insufficiency (OR 1.9, CI 1.2 to 2.9) and complex coronary disease (OR 3.1, CI 1.8 to 5.3).

Conclusions

These data demonstrate an association between delirium and post-operative sepsis in the CABG population. Delirium emerged as an independent predictor of sepsis, along with traditional risk factors including age, pre-operative renal failure and peripheral vascular disease. Given the advancing age and increasing rates of delirium in the CABG population, the prevention and management of delirium need to be addressed.

The user experience of critical care discharge: a meta-synthesis of qualitative research

OBJECTIVES

This review identifies the most significant factors, which impact upon the user experience of progress and recovery from critical illness during the first month after discharge from critical care, and discusses these in relation to the development of effective critical care discharge support strategies.

DESIGN

Meta-synthesis of qualitative primary research.

DATA SOURCES

Qualitative research published in English between 1990 and 2009 was identified using online databases: CINAHL, MEDLINE, EMBASE, British Nursing Index, CDSR, ACP Journal Club, Cochrane library, Social Policy and Practice and PsycInfo. Studies of adult patients, relatives/carers/significant others, which focused on experiences after discharge from an intensive care or high dependency unit to a general ward were retrieved.

REVIEW METHODS

Following screening against inclusion/exclusion criteria, methodological appraisal of studies was conducted using a published framework. Ten studies met the criteria for inclusion.

RESULTS

Five key themes emerged from the meta-synthesis: physical and psychological symptoms; making progress; the need to know; and safety and security.

CONCLUSIONS

Findings from this meta-synthesis and other related literature supports the existence of physical and psychological problems in the immediate period following discharge from critical care to the ward, and suggests that patients and their families have a desire for more control over their recovery. However, this desire is countered by a need to feel safe and protected, culminating in an expression of dependence on healthcare staff. Any effective support strategy needs to take account of these findings.

Bed rest in health and critical illness: a body systems approach

Bed rest is a common intervention for critically ill adults. Associated with both benefits and adverse effects, bed rest is undergoing increasing scrutiny as a therapeutic option in the intensive care unit. Bed rest has molecular and systemic effects, ultimately affecting functional outcomes in healthy individuals as well as in those with acute and critical illnesses. Using empirical sources, the purpose of this article was to describe the consequences of bed rest and immobility, especially consequences with implications for critically ill adults in the intensive care unit. This review uses body systems to cluster classic and current results of bed rest studies, beginning with cardiovascular and including pulmonary, renal, skin, nervous, immune, gastrointestinal/ metabolic, and skeletal systems. It concludes with effects on muscles, a system profoundly affected by immobility and bed rest.