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Temporal biomarker profiles and their association with ICU acquired delirium: a cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:137. [PMID: 29801516 PMCID: PMC5970442 DOI: 10.1186/s13054-018-2054-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 04/29/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND Neuroinflammation is thought to play an important role in the pathogenesis of ICU-acquired delirium, but the association between inflammatory and brain-specific proteins and ICU delirium is poor. We investigated whether or not serial determinations of markers may improve this association. METHODS Critically ill patients with a high risk of ICU delirium and with an ICU length of stay of at least 6 days were included in the study. Blood was drawn on days 1, 2, 4 and 6 after ICU admission and analyzed for different markers of inflammation and several brain proteins. Differences in courses over time prior to and following the onset of delirium and absolute differences over time were analyzed in patients with and without delirium using repeated measurement analysis of variance. In addition, a cross-sectional analysis of levels of these markers before the first onset of delirium was performed. RESULTS Fifty patients were included in this study. In the longitudinal analysis, there were no differences in the levels of any of the markers immediately prior to and following the onset of delirium, but overall, median levels of adiponectin (9019 (IQR 5776-15,442) vs. 6148 (IQR 4447-8742) ng/ml, p = 0.05) were significantly higher in patients with delirium compared to patients without delirium. In the cross-sectional analysis, median levels of the brain protein Tau (90 (IQR 46-224) vs. 31 (IQR 31-52) pg/ml, p = 0.009) and the ratio Tau/amyloid β1-42 (1.42 ((IQR 0.9-2.57) vs. 0.68 (IQR 0.54-0.96), p = 0.003) were significantly higher in patients with hypoactive delirium compared to patients without. Levels of neopterin (111 (IQR 37-111) vs. 29 (IQR 16-64) mmol/l, p = 0.004) and IL-10 (28 (IQR 12-39) vs. 9 (IQR 4-12) pg/ml, p = 0.001) were significantly higher in patients with hypoactive delirium compared to patients with mixed-type delirium. CONCLUSIONS While there are differences in markers (adiponectin and several brain proteins) between patients with and without delirium, the development of delirium is not preceded by a change in the biomarker profile of inflammatory markers or brain proteins. Patients with hypoactive delirium account for the observed differences in biomarkers. TRIAL REGISTRATION ClinicalTrials.gov, NCT 01274819 . Registered on 12 January 2011.
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Reduced ex vivo release of pro-inflammatory cytokines and elevated plasma interleukin-6 are inflammatory signatures of post-stroke delirium. J Neuroinflammation 2018; 15:111. [PMID: 29669581 PMCID: PMC5907192 DOI: 10.1186/s12974-018-1156-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 04/09/2018] [Indexed: 11/10/2022] Open
Abstract
Background Experimental studies suggest that systemic inflammation contributes to the pathophysiology of delirium. The aim of our study was to determine blood-derived inflammatory signatures of post-stroke delirium. Methods We included 144 ischemic stroke patients. We assessed delirium on a daily basis during the first 7 days of hospitalization. Venous blood was collected at day 3 after the onset of stroke and stimulated ex vivo with lipopolysaccharide (LPS). We measured LPS-induced cytokine concentration (TNFα, IP-10, IL-1β, IL-6, IL-8, IL-10, and IL-12p70) as well as plasma levels of IL-6 and TNFα. Results Delirium was diagnosed in 21.5% of patients. After correction for monocyte count, patients with delirium had reduced LPS-induced TNFα, IP-10, IL-1β, IL-6, and IL-12 release. The plasma IL-6 level was higher in delirious patients compared to patients without delirium. After adjusting for stroke severity and infections, higher ex vivo TNFα (OR 0.29, 95%CI 0.11–0.72, P = 0.01), IP-10 (OR 0.25, 95%CI 0.08–0.73, P = 0.01), IL-1β (OR 0.42, 95%CI 0.20–0.89, P = 0.02), and IL-12 (OR 0.07, 95%CI 0.01–0.70, P = 0.02) release was associated with the reduced risk of delirium. In multivariate analysis, the higher plasma IL-6 was associated with the increased risk of delirium (OR 1.61, 95%CI 1.00–2.58, P = 0.04). Conclusions Reduced ex vivo release of pro-inflammatory cytokines after LPS stimulation and the elevated plasma IL-6 are signatures of post-stroke delirium.
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Abstract
PURPOSE OF REVIEW The purpose of this review is to provide a practical clinical approach to confusion in the patient with cancer. Confusion in the cancer population has a broader differential diagnosis than in the general medical population. The clinician must consider the usual differential diagnoses as well as causes unique to the cancer patient including direct complications from the cancer and indirect complications related to cancer treatment. RECENT FINDINGS In the recent age of precision medicine, the oncologist now utilizes the genomic profile of both the patient and the tumor to provide advanced biologic therapies including targeted anticancer drugs, antiangiogenic agents, and immunotherapy. Such advances carry with them an emerging pattern of neurotoxicity which, although less well described in the literature, is now an important consideration to the clinical approach to confusion in cancer patients. SUMMARY Confusion is the most common neurologic complication in cancer and is associated with significant morbidity, mortality, and prolonged hospital stays resulting in increased healthcare costs. Early recognition and treatment of delirium is essential to improve clinical outcomes.
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Xin X, Xin F, Chen X, Zhang Q, Li Y, Huo S, Chang C, Wang Q. Hypertonic saline for prevention of delirium in geriatric patients who underwent hip surgery. J Neuroinflammation 2017; 14:221. [PMID: 29137628 PMCID: PMC5686947 DOI: 10.1186/s12974-017-0999-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 11/08/2017] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Postoperative delirium (POD) is a common disorder in the elderly patients, and neuroinflammation is the possible underlying mechanism. This study is designed to determine whether or not hypertonic saline (HS) pre-injection can alleviate POD in aged patients. METHODS This prospective study recruited 120 geriatric patients who underwent hip surgery. The patients were randomly divided into two groups: control group (NS group) and HS group. Patients in the NS group were pre-injected with 4 mL/kg isotonic saline, and those in the HS group were pre-injected with 4 mL/kg 7.5% HS. All 120 patients were then subjected to general anesthesia. Blood samples were extracted to detect the concentration of inflammatory factors, namely, IL-1β, IL-6, IL-10, and TNF-α, and the nerve injury factor S100β. Flow cytometry was used to detect the number of monocytes in peripheral venous blood and evaluate the relationship of inflammation to delirium. The nursing delirium screening scale (Nu-DESC) was used to determine cognitive function 1 to 3 days postoperatively. RESULTS Analysis using random-effect multivariable logistic regression indicated that HS administration before anesthesia was associated with a low risk of POD (odds ratio [OR], 0.13; 95% CI, 0.04 to 0.41; P = 0.001) and few CD14 + CD16+ monocytes (β = - 0.61; 95% CI, - 0.74 to - 0.48; P = 0.000) the following day. When the association between HS and delirium was controlled for CD14 + CD16+ monocytes, the effect size became nonsignificant (odds ratio [OR], 0.86; 95% CI, 0.14 to 5.33; P = 0.874). TNF-α was significantly associated with POD (odds ratio [OR], 1.10; 95% CI, 1.05 to 1.16; P = 0.000). However, IL-1β, IL-6, IL-10, and S100β were not significantly related to POD. CONCLUSION HS can alleviate POD in geriatric patients and may inhibit the secretion of inflammatory factors by monocytes.
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Affiliation(s)
- Xi Xin
- Department of Anesthesiology, The Third Hospital of Hebei Medical University, No 139, Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Fei Xin
- Department of Respiration, Tianjin Institute of Respiratory Diseases, Tianjin Haihe Hospital, Tianjin Medical University, Tianjin, 300350, People's Republic of China
| | - Xuguang Chen
- Department of Anesthesiology, The Third Hospital of Hebei Medical University, No 139, Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Qi Zhang
- Department of Anesthesiology, The Third Hospital of Hebei Medical University, No 139, Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Yanan Li
- Department of Anesthesiology, The Third Hospital of Hebei Medical University, No 139, Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Shuping Huo
- Department of Anesthesiology, The Third Hospital of Hebei Medical University, No 139, Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Chongfu Chang
- Department of Anesthesiology, The Third Hospital of Hebei Medical University, No 139, Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Qiujun Wang
- Department of Anesthesiology, The Third Hospital of Hebei Medical University, No 139, Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China.
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Skrobik Y, Devlin J. Trials of statins in delirium-stymied by complex methods? THE LANCET. RESPIRATORY MEDICINE 2017; 5:673-674. [PMID: 28734825 DOI: 10.1016/s2213-2600(17)30289-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 06/26/2017] [Accepted: 06/26/2017] [Indexed: 06/07/2023]
Affiliation(s)
- Yoanna Skrobik
- Faculty of Medicine, McGill University, Montreal, QC H3G 2M1, Canada; Regroupement de soins critiques, Réseau de Santé Respiratoire, Montreal, QC, Canada.
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Page VJ, Casarin A, Ely EW, Zhao XB, McDowell C, Murphy L, McAuley DF. Evaluation of early administration of simvastatin in the prevention and treatment of delirium in critically ill patients undergoing mechanical ventilation (MoDUS): a randomised, double-blind, placebo-controlled trial. THE LANCET RESPIRATORY MEDICINE 2017; 5:727-737. [PMID: 28734823 DOI: 10.1016/s2213-2600(17)30234-5] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 05/30/2017] [Accepted: 05/30/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Delirium in critically ill patients is associated with poor clinical outcomes. Neuroinflammation might be an important mechanism in the pathogenesis of delirium, and since simvastatin has anti-inflammatory properties it might reduce delirium. We aimed to establish whether early treatment with simvastatin would decrease the time that survivors of critical illness spent in delirium or coma. METHODS We undertook this randomised, double-blind, placebo-controlled trial in a general adult intensive care unit (ICU) in Watford General Hospital (Watford, UK). We enrolled critically ill patients (≥18 years) needing mechanical ventilation within 72 h of admission. We randomly assigned patients (1:1 ratio) to receive either simvastatin 80 mg or placebo daily for up to a maximum of 28 days, irrespective of coma or delirium status. We assessed delirium using the Confusion Assessment Method for the ICU (CAM-ICU). The primary outcome was number of days alive and was assessed as delirium-free and coma-free in the first 14 days after being randomly allocated to receive treatment or placebo. ICU clinical and research staff and patients were masked to treatment. We did intention-to-treat analyses with no extrapolation. This trial is registered with the International Standard Randomised Controlled Trial Registry, number ISRCTN89079989. FINDINGS Between Feb 1, 2013, and July 29, 2016, 142 patients were randomly assigned to receive simvastatin (n=71) or placebo (n=71), and were included in the final analysis. The mean number of days alive without delirium and without coma at day 14 did not differ significantly between the two groups (5·7 days [SD 5·1] with simvastatin and 6·1 days [5·2] with placebo; mean difference 0·4 days, 95% CI -1·3 to 2·1; p=0·66). The most common adverse event was an elevated creatine kinase concentration to more than ten times the upper limit of normal (eight [11%] in the simvastatin group vs three [4%] in the placebo group p=0·208). No patient had a serious adverse event related to the study drug. INTERPRETATION These results do not support the hypothesis that simvastatin modifies duration of delirium and coma in critically ill patients. FUNDING National Institute for Health Research.
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Affiliation(s)
- Valerie J Page
- Intensive Care Unit, Watford General Hospital, Watford, UK; Faculty of Medicine, Imperial College London, South Kensington Campus, London, UK.
| | - Annalisa Casarin
- Health Research Building, University of Hertfordshire, Hatfield, UK
| | - E Wesley Ely
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA; VA Tennessee Valley Geriatric Research Education Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Xiao Bei Zhao
- Intensive Care Unit, Watford General Hospital, Watford, UK
| | - Cliona McDowell
- Northern Ireland Clinical Trials Unit, Royal Victoria Hospital, Belfast Health and Social Care Trust, Grosvenor Road, Belfast, Northern Ireland
| | - Lynn Murphy
- Northern Ireland Clinical Trials Unit, Royal Victoria Hospital, Belfast Health and Social Care Trust, Grosvenor Road, Belfast, Northern Ireland
| | - Daniel F McAuley
- Centre for Experimental Medicine, The Queen's University of Belfast, Health Sciences Building, Belfast, Northern Ireland; Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, Northern Ireland
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Kallenbach TF, Amado LA. Assessment of delirium in the intensive care unit. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2017. [DOI: 10.1080/22201181.2017.1332809] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- TF Kallenbach
- Department of Anaesthesia, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - LA Amado
- Department of Anaesthesia, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
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Dillon ST, Vasunilashorn SM, Ngo L, Otu HH, Inouye SK, Jones RN, Alsop DC, Kuchel GA, Metzger ED, Arnold SE, Marcantonio ER, Libermann TA. Higher C-Reactive Protein Levels Predict Postoperative Delirium in Older Patients Undergoing Major Elective Surgery: A Longitudinal Nested Case-Control Study. Biol Psychiatry 2017; 81:145-153. [PMID: 27160518 PMCID: PMC5035711 DOI: 10.1016/j.biopsych.2016.03.2098] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 03/03/2016] [Accepted: 03/03/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Delirium is a common, morbid, and costly postoperative complication. We aimed to identify blood-based postoperative delirium markers in a nested case-control study of older surgical patients using a proteomics approach followed by enzyme-linked immunosorbent assay (ELISA) validation. METHODS The Successful Aging after Elective Surgery study enrolled dementia-free adults ≥70 years old undergoing major scheduled noncardiac surgery (N = 566; 24% delirium). Plasma was collected at four time points: preoperative, postanesthesia care unit, postoperative day 2, and 1 month postoperative. Matched pairs were selected for the independent discovery (39 pairs) and replication cohorts (36 pairs), which were subsequently combined into the pooled cohort (75 pairs). Isobaric tags for relative and absolute quantitation-based relative quantitation mass spectrometry proteomics were performed to identify the strongest delirium-related protein, which was selected for ELISA validation. Using the ELISA results, statistical analyses using nonparametric signed rank tests were performed in all cohorts examining the association between the identified protein and delirium. RESULTS C-reactive protein emerged from the proteomics analysis as the strongest delirium-related protein. Validation by ELISA confirmed that compared with controls, cases had significantly higher C-reactive protein levels in the discovery, replication, and pooled cohorts at the preoperative (median paired difference [MPD] 1.97 mg/L [p < .05], 0.29 mg/L, 1.56 mg/L [p < .01]), postanesthesia care unit (MPD 2.83 mg/L, 2.22 mg/L [p < .05], 2.53 mg/L [p < .01]) and postoperative day 2 (MPD 71.97 mg/L [p < .01], 35.18 mg/L [p < .05], 63.76 mg/L [p < .01]) time points, but not 1 month postoperative (MPD 2.72 mg/L, -0.66 mg/L, 1.10 mg/L). CONCLUSIONS Elevated preoperative and postoperative plasma levels of C-reactive protein were associated with delirium, suggesting that a preinflammatory state and heightened inflammatory response to surgery are potential pathophysiologic mechanisms of delirium.
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Affiliation(s)
- Simon T Dillon
- Beth Israel Deaconess Medical Center Genomics, Proteomics, Bioinformatics and Systems Biology Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Sarinnapha M Vasunilashorn
- Division of Interdisciplinary Medicine and Biotechnology, Division of General Medicine and Primary Care, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.
| | - Long Ngo
- Division of Interdisciplinary Medicine and Biotechnology, Division of General Medicine and Primary Care, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Hasan H Otu
- Department of Electrical and Computer Engineering, University of Nebraska-Lincoln, Lincoln, Nebraska
| | - Sharon K Inouye
- Division of Gerontology, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Richard N Jones
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts; Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - David C Alsop
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - George A Kuchel
- University of Connecticut Center on Aging, University of Connecticut Health Center, Farmington, Connecticut
| | - Eran D Metzger
- Division of Interdisciplinary Medicine and Biotechnology, Division of General Medicine and Primary Care, Boston, Massachusetts; Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Steven E Arnold
- Harvard Medical School, Boston, Massachusetts; Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Edward R Marcantonio
- Division of Interdisciplinary Medicine and Biotechnology, Division of General Medicine and Primary Care, Boston, Massachusetts; Division of Gerontology, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Towia A Libermann
- Beth Israel Deaconess Medical Center Genomics, Proteomics, Bioinformatics and Systems Biology Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
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Hennessy E, Gormley S, Lopez-Rodriguez AB, Murray C, Murray C, Cunningham C. Systemic TNF-α produces acute cognitive dysfunction and exaggerated sickness behavior when superimposed upon progressive neurodegeneration. Brain Behav Immun 2017; 59:233-244. [PMID: 27633985 PMCID: PMC5176008 DOI: 10.1016/j.bbi.2016.09.011] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 09/01/2016] [Accepted: 09/12/2016] [Indexed: 12/13/2022] Open
Abstract
Inflammation influences chronic neurodegeneration but its precise roles are not yet clear. Systemic inflammation caused by infection, trauma or co-morbidity can alter the brain's inflammatory status, produce acute cognitive impairments, such as delirium, and drive new pathology and accelerated decline. Consistent with this, elevated systemic TNF-α is associated with more rapid cognitive decline over 6months in Alzheimer's disease patients. In the current study we challenged normal animals and those with existing progressive neurodegeneration (ME7 prion disease) with TNF-α (i.p.) to test the hypothesis that this cytokine has differential effects on cognitive function, sickness behavior and features of underlying pathology contingent on the animals' baseline condition. TNF-α (50μg/kg) had no impact on performance of normal animals (normal brain homogenate; NBH) on working memory (T-maze) but produced acute impairments in ME7 animals similarly challenged. Plasma TNF-α and CCL2 levels were equivalent in NBH and ME7 TNF-challenged animals but hippocampal and hypothalamic transcription of IL-1β, TNF-α and CCL2 and translation of IL-1β were higher in ME7+TNF-α than NBH+TNF-α animals. TNF-α produced an exaggerated sickness behavior response (hypothermia, weight loss, inactivity) in ME7 animals compared to that in NBH animals. However a single challenge with this dose was not sufficient to produce de novo neuronal death, synaptic loss or tau hyperphosphorylation that was distinguishable from that arising from ME7 alone. The data indicate that acutely elevated TNF-α has robust acute effects on brain function, selectively in the degenerating brain, but more sustained levels may be required to significantly impact on underlying neurodegeneration.
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Affiliation(s)
- Edel Hennessy
- School of Biochemistry & Immunology, Trinity College Institute of Neuroscience, Trinity College Dublin, Dublin 2, Ireland
| | - Shane Gormley
- School of Biochemistry & Immunology, Trinity College Institute of Neuroscience, Trinity College Dublin, Dublin 2, Ireland
| | - Ana Belen Lopez-Rodriguez
- School of Biochemistry & Immunology, Trinity College Institute of Neuroscience, Trinity College Dublin, Dublin 2, Ireland
| | - Caoimhe Murray
- School of Biochemistry & Immunology, Trinity College Institute of Neuroscience, Trinity College Dublin, Dublin 2, Ireland
| | - Carol Murray
- School of Biochemistry & Immunology, Trinity College Institute of Neuroscience, Trinity College Dublin, Dublin 2, Ireland
| | - Colm Cunningham
- School of Biochemistry & Immunology, Trinity College Institute of Neuroscience, Trinity College Dublin, Dublin 2, Ireland.
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Postoperative delirium is associated with increased intensive care unit and hospital length of stays after liver transplantation. J Surg Res 2017; 207:223-228. [DOI: 10.1016/j.jss.2016.08.084] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 07/16/2016] [Accepted: 08/24/2016] [Indexed: 11/22/2022]
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Tauber SC, Eiffert H, Brück W, Nau R. Septic encephalopathy and septic encephalitis. Expert Rev Anti Infect Ther 2016; 15:121-132. [DOI: 10.1080/14787210.2017.1265448] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Simone C. Tauber
- Department of Neurology, RWTH University Hospital, Aachen, Germany
| | - Helmut Eiffert
- Department of Medical Microbiology, Georg-August-University, Göttingen, Germany
| | - Wolfgang Brück
- Department of Neuropathology, Georg-August-University, Göttingen, Germany
| | - Roland Nau
- Department of Neuropathology, Georg-August-University, Göttingen, Germany
- Department of Geriatrics, Evangelisches Krankenhaus Göttingen-Weende, Göttingen, Germany
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Jorge-Ripper C, Alemán MR, Ros R, Aguilera S, González-Reimers E, Espelosín E, Santolaria F. Prognostic value of acute delirium recovery in older adults. Geriatr Gerontol Int 2016; 17:1161-1167. [DOI: 10.1111/ggi.12842] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 04/22/2016] [Accepted: 05/11/2016] [Indexed: 01/13/2023]
Affiliation(s)
| | | | - Rosa Ros
- Internal Medicine Unit; Tenerife Spain
| | | | | | - Elisa Espelosín
- Laboratory; Canary Islands University Hospital; Tenerife Spain
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Neerland BE, Hall RJ, Seljeflot I, Frihagen F, MacLullich AMJ, Raeder J, Wyller TB, Watne LO. Associations Between Delirium and Preoperative Cerebrospinal Fluid C-Reactive Protein, Interleukin-6, and Interleukin-6 Receptor in Individuals with Acute Hip Fracture. J Am Geriatr Soc 2016; 64:1456-63. [DOI: 10.1111/jgs.14238] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Bjørn Erik Neerland
- Oslo Delirium Research Group; Department of Geriatric Medicine; Oslo University Hospital; Oslo Norway
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
| | - Roanna J. Hall
- Edinburgh Delirium Research Group; University of Edinburgh; Edinburgh UK
- Centre for Cognitive Ageing and Cognitive Epidemiology; University of Edinburgh; Edinburgh UK
| | - Ingebjørg Seljeflot
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
- Center for Clinical Heart Research; Department of Cardiology; Oslo University Hospital; Oslo Norway
| | - Frede Frihagen
- Department of Orthopedic Surgery; Oslo University Hospital; Oslo Norway
| | - Alasdair M. J. MacLullich
- Edinburgh Delirium Research Group; University of Edinburgh; Edinburgh UK
- Centre for Cognitive Ageing and Cognitive Epidemiology; University of Edinburgh; Edinburgh UK
| | - Johan Raeder
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
- Department of Anesthesiology; Oslo University Hospital; Oslo Norway
| | - Torgeir Bruun Wyller
- Oslo Delirium Research Group; Department of Geriatric Medicine; Oslo University Hospital; Oslo Norway
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
| | - Leiv Otto Watne
- Oslo Delirium Research Group; Department of Geriatric Medicine; Oslo University Hospital; Oslo Norway
- Institute of Basic Medical Sciences; University of Oslo; Oslo Norway
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Characterization of Brain-Heart Interactions in a Rodent Model of Sepsis. Mol Neurobiol 2016; 54:3745-3752. [PMID: 27229490 PMCID: PMC5443875 DOI: 10.1007/s12035-016-9941-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 05/03/2016] [Indexed: 11/23/2022]
Abstract
Loss of heart rate variability (HRV) and autonomic dysfunction are associated with poor outcomes in critically ill patients. Neuronal networks comprising brainstem and hypothalamus are involved in the “flight-or-fight” response via control over the autonomic nervous system and circulation. We hypothesized that sepsis-induced inflammation in brain regions responsible for autonomic control is associated with sympathovagal imbalance and depressed contractility. Sepsis was induced by fecal slurry injection in fluid-resuscitated rats. Sham-operated animals served as controls. Echocardiography-derived peak velocity (PV) was used to separate septic animals into good (PV ≥0.93 m/s, low 72-h mortality) and bad (PV <0.93, high 72-h mortality) prognosis. Cytokine protein levels were assessed by ELISA. All experiments were performed at 24 h post-insult. Increased levels of inflammation and oxidative injury were observed in the hypothalamus (TNF-α, IL-10, nitrite and nitrate and carbonyl groups) and brainstem (IL-1, IL-6, IL-10, nitrite and nitrate and carbonyl groups) of the septic animals (p < 0.05 vs. sham), but not in the pre-frontal cortex, an area not directly implicated in control of the autonomic nervous system. Good prognosis septic animals had increased sympathetic output and increased left ventricular contractility (p < 0.05 vs. sham). There was a significant inverse correlation between high frequency power (a marker of parasympathetic outflow) and contractility (r = −0.73, p < 0.05). We found no correlation between the degree of inflammation or injury to autonomic centers and cardiovascular function. In conclusion, control of autonomic centers and cardiac function in our long-term rodent model of sepsis was related to clinical severity but not directly to the degree of inflammation.
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Tsuruta R, Oda Y. A clinical perspective of sepsis-associated delirium. J Intensive Care 2016; 4:18. [PMID: 27011789 PMCID: PMC4804610 DOI: 10.1186/s40560-016-0145-4] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 03/04/2016] [Indexed: 12/29/2022] Open
Abstract
The term sepsis-associated encephalopathy (SAE) has been applied to animal models, postmortem studies in patients, and severe cases of sepsis. SAE is considered to include all types of brain dysfunction, including delirium, coma, seizure, and focal neurological signs. Clinical data for sepsis-associated delirium (SAD) have been accumulating since the establishment of definitions of coma or delirium and the introduction of validated screening tools. Some preliminary studies have examined the etiology of SAD. Neuroinflammation, abnormal cerebral perfusion, and neurotransmitter imbalances are the main mechanisms underlying the development of SAD. However, there are still no specific diagnostic blood, electrophysiological, or imaging tests or treatments specific for SAD. The duration of delirium in intensive care patients is associated with long-term functional disability and cognitive impairment, although this syndrome usually reverses after the successful treatment of sepsis. Once the respiratory and hemodynamic states are stabilized, patients with severe sepsis or septic shock should receive rehabilitation as soon as possible because early initiation of rehabilitation can reduce the duration of delirium. We expect to see further pathophysiological data and the development of novel treatments for SAD now that reliable and consistent definitions of SAD have been established.
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Affiliation(s)
- Ryosuke Tsuruta
- Acute and General Medicine, Yamaguchi Graduate School of Medicine, 1-1-1 Minamikogushi, Ube, Yamaguchi 755-8505 Japan
| | - Yasutaka Oda
- Acute and General Medicine, Yamaguchi Graduate School of Medicine, 1-1-1 Minamikogushi, Ube, Yamaguchi 755-8505 Japan
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Yamamoto S, Ohta N, Matsumoto A, Horiguchi Y, Koide M, Fujino Y. Haloperidol Suppresses NF-kappaB to Inhibit Lipopolysaccharide-Induced Pro-Inflammatory Response in RAW 264 Cells. Med Sci Monit 2016; 22:367-72. [PMID: 26842661 PMCID: PMC4747317 DOI: 10.12659/msm.895739] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background Haloperidol, a tranquilizing agent, is administered both to treat symptoms of psychotic disorders and to sedate agitated and delirious patients. Notably, haloperidol has been suggested to inhibit the immune response through unknown mechanisms. We hypothesized that the sedative modulates the immune response via NF-κB. Material/Methods Using flow cytometry, we analyzed the effects of haloperidol on expression CD80 and CD86 in RAW 264 cells and in primary macrophages derived from bone marrow. Secretion of interleukin (IL)-1β, IL-6, and IL-12 p40 was measured by enzyme-linked immunosorbent assay. In addition, NF-κB activation was evaluated using a reporter assay based on secretory embryonic alkaline phosphatase. Finally, synthetic antagonists were used to identify the dopamine receptor that mediates the effects of haloperidol. Results Haloperidol inhibited NF-κB activation, and thereby suppressed expression of CD80, as well as secretion of IL-1β, IL-6, and IL-12 p40. CD80 and IL-6 levels were similarly attenuated by a D2-like receptor antagonist, but not by a D1-like receptor antagonist. Conclusions The data strongly suggest that haloperidol inhibits the immune response by suppressing NF-κB signaling via the dopamine D2 receptor.
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Affiliation(s)
- Shunsuke Yamamoto
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Noriyuki Ohta
- Department of Anesthesiology and Intensive Care, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Atsuhiro Matsumoto
- Department of Anesthesiology and Intensive Care, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yu Horiguchi
- Department of Anesthesiology and Intensive Care, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Moe Koide
- Department of Anesthesiology and Intensive Care, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yuji Fujino
- Department of Anesthesiology and Intensive Care, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
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Morais BS, Teixeira AL, Maciel JF, Lima AA, Barbosa IG, Sanches MD. Soluble tumor necrosis factor receptors as predictors of 1-year mortality and renal dysfunction after liver transplantation. Transpl Immunol 2016; 35:29-33. [PMID: 26845019 DOI: 10.1016/j.trim.2016.01.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Revised: 01/29/2016] [Accepted: 01/30/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND Several risk factors influence survival after liver transplantation (LT). Some research has demonstrated a relationship between soluble tumor necrosis factor receptors (sTNFRs) and worse clinical liver disease outcomes, but there are no data showing an association between sTNFRs and outcomes after LT. The primary aim of this study was to determine whether an association exists between perioperative sTNFRs and renal dysfunction or mortality after LT. METHODS Data were collected prospectively from 122 patients submitted to deceased-donor orthotopic LT. Blood samples were collected at seven different perioperative times and analyzed by ELISA. The statistical analysis included univariate analysis followed by logistic regression. The predictive value of significant variables was assessed using ROC curves. RESULTS One-month and 1-year LT survivals were 91% and 81%, respectively. Increased levels of soluble tumor necrosis factor receptor 1 (sTNF-R1) after 24h of graft perfusion were associated with postoperative Renal Replacement Therapy (RRT) (OR 1.25) and 1-year mortality (OR 1.1). RRT was associated with 30-day and 1-year LT mortality, with OR 19.78 and 45.45, respectively. CONCLUSION A higher sTNF-R1 level measured 24h after graft perfusion is an independent predictor of RRT and 1-year mortality after LT.
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Affiliation(s)
- Bruno Salome Morais
- Federal University of Minas Gerais, Postgraduate Program of Surgery, Av. Professor Alfredo Balena, 110, Belo Horizonte, MG 30130-100, Brazil.
| | - Antonio Lucio Teixeira
- Federal University of Minas Gerais, Postgraduate Program of Infectious Diseases and Tropical Medicine, Av. Professor Alfredo Balena, 110, Belo Horizonte, MG 30130-100, Brazil
| | - Jader Freitas Maciel
- Federal University of Minas Gerais, Postgraduate Program of Surgery, Av. Professor Alfredo Balena, 110, Belo Horizonte, MG 30130-100, Brazil
| | - Angela Aparecida Lima
- Federal University of Minas Gerais, IAG, Av. Professor Alfredo Balena, 110, Belo Horizonte, MG 30130-100, Brazil
| | - Izabela Guimaraes Barbosa
- Federal University of Minas Gerais, Postgraduate Program of Neuroscience, Av. Professor Alfredo Balena, 110, Belo Horizonte, MG 30130-100, Brazil
| | - Marcelo Dias Sanches
- Federal University of Minas Gerais, Professor of Surgery Department, Av. Professor Alfredo Balena, 110, Belo Horizonte, MG 30130-100, Brazil
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Biomarkers of Delirium in a Low-Risk Community-Acquired Pneumonia-Induced Sepsis. Mol Neurobiol 2016; 54:722-726. [DOI: 10.1007/s12035-016-9708-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 01/07/2016] [Indexed: 11/26/2022]
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Pipanmekaporn T, Chittawatanarat K, Chaiwat O, Thawitsri T, Wacharasint P, Kongsayreepong S. Incidence and risk factors of delirium in multi-center Thai surgical intensive care units: a prospective cohort study. J Intensive Care 2015; 3:53. [PMID: 26634124 PMCID: PMC4667416 DOI: 10.1186/s40560-015-0118-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Accepted: 11/17/2015] [Indexed: 01/12/2023] Open
Abstract
Background Delirium in intensive care units increases morbidity and mortality risk. The incidence and risk factors of delirium vary among studies. This study therefore aimed to determine the incidence and risk factors of delirium in Thai university-based surgical intensive care units. Methods A multi-center, prospective cohort study was conducted. All patients who had been admitted to surgical intensive care units (SICU) between April 2011 and January 2012 were enrolled. Delirium was diagnosed using the Intensive Care Delirium Screening Checklists (ICDSC). The univariable and multivariable risk regression analyses were analyzed and presented as risk ratio (RR) and 95 % confidence interval (CI). Results The overall incidence of delirium was 3.6 % (162 of 4450, 95 % CI 3.09–4.19 %) whilst the incidences of delirium for patients being admitted ≤48 and >48 h were 0.7 % (21 of 2967, 95 % CI 0.41–1.01 %) and 8.3 % (141 of 1685, 95 % CI 7.04–9.68 %), respectively. The incidence of delirium on each study site was significantly different (range between 0 and 13.9 %, P < 0.001). Delirious patients had a significantly higher age (65.3 ± 15.6 versus 61.8 ± 17.3 years, P = 0.013), higher Acute Physiology and Chronic Health Evaluation II score (APACHE II score) (16 (12–23) versus 10 (7–15), P < 0.001), and higher sequential organ failure assessment score (5 (2–8) versus 2 (1–5), P < 0.001). The median duration of delirium was 3 (1–5) days. Delirious patients had significantly longer duration of ICU stay (8 (5–19) versus 2 (1–4), P < 0.001) and higher ICU mortality rate (23.5 versus 8.1 %, P < 0.001). Sepsis (RR = 3.70, 95 % CI 2.33–5.90, P < 0.001), exposure to sedative medications (RR = 3.54, 95 % CI 2.13–5.87, P < 0.001), higher APACHE II score (RR = 2.79, 95 % CI 1.98–3.95, P < 0.001), thoracic surgery (RR = 1.74, 95 % CI 1.09–2.78, P = 0.021), and emergency surgery (RR = 1.70, 95 % CI 1.09–2.65, P = 0.019) were independent risk factors of delirium in SICU. Conclusions Sepsis, exposure to sedative medications, higher APACHE II score, thoracic surgery, and emergency surgery were independent risk factors of delirium in Thai university-based surgical intensive care units.
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Affiliation(s)
- Tanyong Pipanmekaporn
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, 110, Intavarorote Rd, Muang District, Chiang Mai, 50200 Thailand
| | | | - Onuma Chaiwat
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, 10700 Thailand
| | - Thammasak Thawitsri
- Department of Anesthesiology, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Bangkok, 10330 Thailand
| | - Petch Wacharasint
- Department of Anesthesiology, Phramongkutklao Hospital, Bangkok, 10400 Thailand
| | - Suneerat Kongsayreepong
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, 10700 Thailand
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Schmidt JJ, Jahn J, Golla P, Hafer C, Kielstein JT, Kielstein H. Effect of therapeutic plasma exchange on plasma levels and total removal of adipokines and inflammatory markers. BMC OBESITY 2015; 2:37. [PMID: 26425347 PMCID: PMC4588244 DOI: 10.1186/s40608-015-0067-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 09/12/2015] [Indexed: 12/21/2022]
Abstract
Background Aside from well-established inflammatory mediators adipokines have recently been found to play an important role in a variety of immunologic diseases. Therapeutic plasma exchange (TPE) is an established treatment modality for the acute removal of pathophysiological relevant disease mediators. The aim of this study was to determine adipokine removal during TPE therapy. Methods 21 Caucasian patients (10 females, 11 males) with an indication for TPE using albumin as exchange fluid received two consecutive TPE sessions. Blood samples for measurement of resistin, leptin, sICAM-1, sCD40L, MCP-1, and sTNF-R were drawn before and at the end of each TPE session. Samples from the total removed plasma were collected at the end of every treatment. Results We found a significant reduction in pre- vs. post-TPE plasma concentrations for sICAM-1 (517 ± 246 vs. 260 ± 159 ng/ml, p < 0.0001), sTNF-R (8.1 ± 6.4 vs. 5.7 ± 3.9 ng/ml, p < 0.05), and resistin plasma levels (14.3 ± 6.9 vs. 9.5 ± 4.7 ng/ml, p < 0.001). Solely sICAM-1 reduction persisted for 25 ± 5 h between the first and second TPE treatment, while the other investigated mediators increased to baseline levels. Substantial amounts of all measured mediators could be recovered from the removed plasma. Conclusions TPE provides a persistent reduction in sICAM-1 levels and temporarily affects several adipokine and cytokine plasma levels. Our findings are of importance not only for the interpretation of blood levels of cytokines in patients undergoing TPE but provide solid evidence that TPE markedly decreases sICAM-1.
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Affiliation(s)
- Julius J Schmidt
- Department of Internal Medicine, Division of Nephrology and Hypertension, Medical School Hannover, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany
| | - Janine Jahn
- Department of Anatomy and Cell Biology, Faculty of Medicine, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Paulina Golla
- Department of Internal Medicine, Division of Nephrology and Hypertension, Medical School Hannover, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany
| | - Carsten Hafer
- Department of Internal Medicine, Division of Nephrology and Hypertension, Medical School Hannover, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany
| | - Jan T Kielstein
- Department of Internal Medicine, Division of Nephrology and Hypertension, Medical School Hannover, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany
| | - Heike Kielstein
- Department of Anatomy and Cell Biology, Faculty of Medicine, Martin Luther University Halle-Wittenberg, Halle, Germany
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Chittawatanarat K, Pichaiya T, Chandacham K, Jirapongchareonlap T, Chotirosniramit N. Fluid accumulation threshold measured by acute body weight change after admission in general surgical intensive care units: how much should be concerning? Ther Clin Risk Manag 2015; 11:1097-106. [PMID: 26251605 PMCID: PMC4524471 DOI: 10.2147/tcrm.s86409] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background The objective of this study (ClinicalTrials.gov: NCT01351506) was to identify the threshold level of fluid accumulation measured by acute body weight (BW) change during the first week in a general surgical intensive care unit (ICU), which is associated with ICU mortality and other adverse outcomes. Methods Four hundred sixty-five patients were prospectively followed for a 28-day period. The maximum BW change threshold during the first week was evaluated by the maximum percentage change in BW from the ICU admission weight (Max%ΔBW). Daily screening of adverse events in the ICU were recorded. The cutoff point of Max%ΔBW on ICU mortality was defined by considering the area under the receiver operating characteristic (ROC) curve, intersection of the sensitivity and specificity, and the Youden Index. Univariable and multivariable regression analyses were used to demonstrate the associations. Statistical significance was defined as P<0.05. Results The appropriate cutoff value of Max%ΔBW threshold was 5%. Regarding the multivariable regression model, in overall patients, the occurrence of the following adverse events (expressed as adjusted odds ratio [95% confidence interval]) were significantly associated with a Max%ΔBW of >5%: ICU mortality (2.38 [1.25–4.54]) (P=0.008), ICU mortality in patients without renal replacement therapy (RRT) (2.47 [1.21–5.06]) (P=0.013), reintubation within 72 hours (2.51 [1.04–6.00]) (P=0.039), RRT requirement (2.67 [1.13–6.33]) (P=0.026), and delirium (1.97 [1.08–3.57]) (P=0.025). Regarding the postoperative subgroup, a Max%ΔBW value of more than 5% was significantly associated with: ICU mortality (3.87 [1.38–10.85]) (P=0.010), ICU mortality in patients without RRT (6.32 [1.85–21.64]) (P=0.003), reintubation within 72 hours (4.44 [1.30–15.16]) (P=0.017), and vasopressor requirement (2.04 [1.04–4.01]) (P=0.037). Conclusion Fluid accumulation, measured as acute BW change of more than the threshold of 5% during the first week of ICU admission, is associated with adverse outcomes of higher ICU mortality, especially in the patients without RRT, with reintubation within 72 hours, with RRT requirement, with vasopressor requirement, and with delirium. Some of these effects were higher in postoperative patients. This threshold value might be an indicator for caution during fluid management in surgical ICU.
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Affiliation(s)
- Kaweesak Chittawatanarat
- Division of Surgical Critical Care and Trauma, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Todsaporn Pichaiya
- Department of Physical Therapy, Faculty of Associated Medical Science, Chiang Mai University, Chiang Mai, Thailand
| | - Kamtone Chandacham
- Division of Surgical Critical Care and Trauma, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Tidarat Jirapongchareonlap
- Division of Surgical Critical Care and Trauma, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Narain Chotirosniramit
- Division of Surgical Critical Care and Trauma, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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What’s new in post-ICU cognitive impairment? Intensive Care Med 2015; 41:708-11. [DOI: 10.1007/s00134-014-3632-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 12/23/2014] [Indexed: 10/24/2022]
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Hsieh SJ, Soto GJ, Hope AA, Ponea A, Gong MN. The association between acute respiratory distress syndrome, delirium, and in-hospital mortality in intensive care unit patients. Am J Respir Crit Care Med 2015; 191:71-8. [PMID: 25393331 PMCID: PMC4299633 DOI: 10.1164/rccm.201409-1690oc] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Both acute respiratory distress syndrome (ARDS) and intensive care unit (ICU) delirium are associated with significant morbidity and mortality. However, the risk of delirium and its impact on mortality in ARDS patients is unknown. OBJECTIVES To determine if ARDS is associated with a higher risk for delirium compared with respiratory failure without ARDS, and to determine the association between ARDS and in-hospital mortality after adjusting for delirium. METHODS Prospective observational cohort study of adult ICU patients admitted to two urban academic hospitals. MEASUREMENTS AND MAIN RESULTS Delirium was assessed daily using the Confusion Assessment Method for the ICU and Richmond Agitation and Sedation Scale. Of the 564 patients in our cohort, 48 had ARDS (9%). Intubated patients with ARDS had the highest prevalence of delirium compared with intubated patients without ARDS and nonintubated patients (73% vs. 52% vs. 21%, respectively; P < 0.001). After adjusting for common risk factors for delirium, ARDS was associated with a higher risk for delirium compared with mechanical ventilation without ARDS (odds ratio [OR], 6.55 [1.56-27.54]; P = 0.01 vs. OR, 1.98 [1.16-3.40]; P < 0.013); reference was nonintubated patients. Although ARDS was significantly associated with hospital mortality (OR, 10.44 [3.16-34.50]), the effect was largely reduced after adjusting for delirium and persistent coma (OR, 5.63 [1.55-20.45]). CONCLUSIONS Our findings suggest that ARDS is associated with a greater risk for ICU delirium than mechanical ventilation alone, and that the association between ARDS and in-hospital mortality is weakened after adjusting for delirium and coma. Future studies are needed to determine if prevention and reduction of delirium in ARDS patients can improve outcomes.
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Affiliation(s)
- S. Jean Hsieh
- Albert Einstein College of Medicine and,Department of Medicine, Montefiore Medical
Center, Bronx, New York
| | - Graciela J. Soto
- Albert Einstein College of Medicine and,Department of Medicine, Montefiore Medical
Center, Bronx, New York
| | - Aluko A. Hope
- Albert Einstein College of Medicine and,Department of Medicine, Montefiore Medical
Center, Bronx, New York
| | - Ana Ponea
- Department of Medicine, Montefiore Medical
Center, Bronx, New York
| | - Michelle N. Gong
- Albert Einstein College of Medicine and,Department of Medicine, Montefiore Medical
Center, Bronx, New York
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Sobbi SC, van den Boogaard M. Inflammation biomarkers and delirium in critically ill patients: new insights? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:153. [PMID: 25042374 PMCID: PMC4075413 DOI: 10.1186/cc13930] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
The pathophysiological mechanism of the serious and frequently occurring disorder delirium is poorly understood. Inflammation and sepsis are known risk factors for ICU delirium and therefore these patients are highly susceptible to delirium. Several studies have been performed to determine which cytokines are most associated with delirium but the results are inconclusive. Also, new biomarkers associated with brain dysfunction and cognitive impairment are still recognized and need to be studied to determine their relation with delirium. In this commentary we address some limitations concerning an interesting new study that warrants directions for future studies.
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