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Li X, Tang Y, Deng X, Zhou F, Huang X, Bai Z, Liang X, Wang Y, Lyu J. Modified frailty index effectively predicts adverse outcomes in sepsis patients in the intensive care unit. Intensive Crit Care Nurs 2024; 84:103749. [PMID: 38896964 DOI: 10.1016/j.iccn.2024.103749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 06/04/2024] [Accepted: 06/05/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND Frailty and sepsis have a significant impact on patient prognosis. However, research into the relationship between frailty and sepsis in the general adult population remains inadequate. This paper aims to investigate the association between frailty and adverse outcomes in this population. METHOD This retrospective analysis investigated sepsis patients who were initially admitted to the intensive care unit (ICU). The Modified Frailty Index (MFI) was derived by tracking patients' International Classification of Diseases (ICD) codes during their hospitalization. Patients were classified into two groups based on their MFI scores: a frail group (MFI ≥ 3) and a non-frail group (MFI = 0-2). The key outcomes were mortality rates at 90 and 180 days, with secondary outcomes including the incidence of delirium and pressure injury. RESULT Of the 21,338 patients who were recruited for this study (median age about 68 years, 41.8 % female), 5,507 were classified as frail and 15,831 were classified as non-frail. Frail patients were significantly more likely to have delirium (48.9 % vs. 36.1 %, p < 0.001) and pressure injury (60.5 % vs. 51.4 %, p < 0.001). After controlling for confounding variables, the multifactorial Cox proportional hazard regression analyses revealed a significantly elevated mortality rate at 90 days (adjusted HR: 1.58, 95 % CI: 1.24-2.02, p < 0.001) and 180 days (adjusted HR: 1.47, 95 % CI: 1.18, 1.83, p < 0.001) in the frail group compared to their non-frail counterparts. CONCLUSIONS Frailty independently predisposes adult sepsis patients in the ICU to adverse outcomes. Future investigations should concentrate on evaluating frailty and developing targeted interventions to improve patient prognosis. IMPLICATION FOR CLINICAL PRACTICE The MFI provides a simple clinical assessment tool that can be integrated into electronic medical records for immediate calculation. This simplifies the assessment process and plays a key role in predicting patient outcomes.
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Affiliation(s)
- Xinya Li
- School of Nursing, Jinan University, Guangzhou, China
| | - Yonglan Tang
- School of Nursing, Jinan University, Guangzhou, China
| | - Xingwen Deng
- Department of Medical Information, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Fuling Zhou
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Xiaxuan Huang
- Department of Neurology, the First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Zihong Bai
- Department of Neurology, the First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Xin Liang
- School of Nursing, Jinan University, Guangzhou, China
| | - Yu Wang
- School of Nursing, Jinan University, Guangzhou, China; Community Health Service Center of Jinan University, Guangzhou, China; Department of School Clinic, the First Affiliated Hospital of Jinan University, Guangzhou, China.
| | - Jun Lyu
- Department of Clinical Research, the First Affiliated Hospital of Jinan University, Guangzhou, China.
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Dragoescu AN, Padureanu V, Stanculescu AD, Chiutu L, Padureanu R, Andrei M, Radu MA, Mitroi G, Dragoescu PO. The Role of Neutrophil-to-Lymphocyte Ratio (NLR) in Urosepsis-Associated Delirium. Cureus 2024; 16:e62110. [PMID: 38863776 PMCID: PMC11165295 DOI: 10.7759/cureus.62110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2024] [Indexed: 06/13/2024] Open
Abstract
Introduction Urosepsis is a systemic, dysregulated, inflammatory reaction to a urinary tract infection and can have severe effects on all systems, which can often lead to multi-organ failure and death. Sepsis-associated delirium is a common complication in critically ill patients, contributing to adverse outcomes and prolonged hospital stays. The neutrophil-to-lymphocyte ratio (NLR) has emerged as a potential biomarker for sepsis severity and prognosis. Material and methods Our study investigates the utility of NLR in the diagnostic strategies for urosepsis-associated delirium in a cohort of 76 patients with sepsis and septic shock admitted to the Intensive Care Unit (ICU). We performed a single-centre retrospective observational study in the Craiova Clinical Emergency Hospital between June and October 2023. Results Patients with urological conditions that were diagnosed with urosepsis included 76 patients. These patients were clustered as follows: a group with delirium (37 patients, 48.7%) and another group without delirium (39 patients, 51.3%). Complete blood count parameters were obtained upon admission, and delirium was assessed using standardized diagnostic criteria. We identified a strong significant positive correlation between elevated NLR values on ICU admission and the development of delirium during hospitalization in urosepsis patients. Receiver operating characteristic (ROC) analysis showed similar diagnostic performance for NLR score. Conclusions The findings suggest that NLR may serve as a valuable biomarker for early detection, risk stratification, and guiding therapeutic interventions in urosepsis-associated delirium, thus improving outcomes in critically ill patients.
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Affiliation(s)
- Alice Nicoleta Dragoescu
- Department of Anesthesiology and Intensive Care, University of Medicine and Pharmacy of Craiova, Craiova, ROU
| | - Vlad Padureanu
- Department of Internal Medicine, University of Medicine and Pharmacy of Craiova, Craiova, ROU
| | - Andreea Doriana Stanculescu
- Department of Anesthesiology and Intensive Care, University of Medicine and Pharmacy of Craiova, Craiova, ROU
| | - Luminita Chiutu
- Department of Anesthesiology and Intensive Care, University of Medicine and Pharmacy of Craiova, Craiova, ROU
| | - Rodica Padureanu
- Department of Internal Medicine, University of Medicine and Pharmacy of Craiova, Craiova, ROU
| | - Maria Andrei
- Department of Cardiology, Emergency Clinical County Hospital of Craiova, Craiova, ROU
| | - Mihai Alexandru Radu
- Department of Urology, Emergency Clinical County Hospital of Craiova, Craiova, ROU
| | - George Mitroi
- Department of Urology, University of Medicine and Pharmacy of Craiova, Craiova, ROU
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Dangayach NS, Kreitzer N, Foreman B, Tosto-Mancuso J. Post-Intensive Care Syndrome in Neurocritical Care Patients. Semin Neurol 2024; 44:398-411. [PMID: 38897212 DOI: 10.1055/s-0044-1787011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
Post-intensive care syndrome (PICS) refers to unintended consequences of critical care that manifest as new or worsening impairments in physical functioning, cognitive ability, or mental health. As intensive care unit (ICU) survival continues to improve, PICS is becoming increasingly recognized as a public health problem. Studies that focus on PICS have typically excluded patients with acute brain injuries and chronic neurodegenerative problems. However, patients who require neurocritical care undoubtedly suffer from impairments that overlap substantially with those encompassed by PICS. A major challenge is to distinguish between impairments related to brain injury and those that occur as a consequence of critical care. The general principles for the prevention and management of PICS and multidomain impairments in patients with moderate and severe neurological injuries are similar including the ICU liberation bundle, multidisciplinary team-based care throughout the continuum of care, and increasing awareness regarding the challenges of critical care survivorship among patients, families, and multidisciplinary team members. An extension of this concept, PICS-Family (PICS-F) refers to the mental health consequences of the intensive care experience for families and loved ones of ICU survivors. A dyadic approach to ICU survivorship with an emphasis on recognizing families and caregivers that may be at risk of developing PICS-F after neurocritical care illness can help improve outcomes for ICU survivors. In this review, we will summarize our current understanding of PICS and PICS-F, emerging literature on PICS in severe acute brain injury, strategies for preventing and treating PICS, and share our recommendations for future directions.
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Affiliation(s)
- Neha S Dangayach
- Department of Neurology and Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Natalie Kreitzer
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Jenna Tosto-Mancuso
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY
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Garmoe W, Rao K, Gorter B, Kantor R. Neurocognitive Impairment in Post-COVID-19 Condition in Adults: Narrative Review of the Current Literature. Arch Clin Neuropsychol 2024; 39:276-289. [PMID: 38520374 DOI: 10.1093/arclin/acae017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 02/16/2024] [Indexed: 03/25/2024] Open
Abstract
The severe acute respiratory syndrome coronavirus 2 virus has, up to the time of this article, resulted in >770 million cases of COVID-19 illness worldwide, and approximately 7 million deaths, including >1.1 million in the United States. Although defined as a respiratory virus, early in the pandemic, it became apparent that considerable numbers of people recovering from COVID-19 illness experienced persistence or new onset of multi-system health problems, including neurologic and cognitive and behavioral health concerns. Persistent multi-system health problems are defined as Post-COVID-19 Condition (PCC), Post-Acute Sequelae of COVID-19, or Long COVID. A significant number of those with PCC report cognitive problems. This paper reviews the current state of scientific knowledge on persisting cognitive symptoms in adults following COVID-19 illness. A brief history is provided of the emergence of concerns about persisting cognitive problems following COVID-19 illness and the definition of PCC. Methodologic factors that complicate clear understanding of PCC are reviewed. The review then examines research on patterns of cognitive impairment that have been found, factors that may contribute to increased risk, behavioral health variables, and interventions being used to ameliorate persisting symptoms. Finally, recommendations are made about ways neuropsychologists can improve the quality of existing research.
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Affiliation(s)
- William Garmoe
- Director of Psychology, MedStar National Rehabilitation Network, Washington, DC, USA
| | - Kavitha Rao
- Clinical Neuropsychologist, MedStar Good Samaritan Hospital, Baltimore, MD, USA
| | - Bethany Gorter
- Neuropsychology Post-Doctoral Fellow, MedStar National Rehabilitation Hospital, Washington, DC, USA
| | - Rachel Kantor
- Neuropsychology Post-Doctoral Fellow, MedStar National Rehabilitation Hospital, Washington, DC, USA
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Sonneville R, Couffignal C, Sigaud F, Godard V, Audibert J, Contou D, Celier A, Djibre M, Schmidt J, Jaquet P, Mekontso Dessap A, Bourel C, Bellot R, Roy C, Lamara F, Essardy F, Timsit JF, Cornic R, Bouadma L. Restrictive use of Restraints and Delirium Duration in the Intensive Care Unit (R2D2-ICU): protocol for a French multicentre parallel-group open-label randomised controlled trial. BMJ Open 2024; 14:e083414. [PMID: 38631841 PMCID: PMC11029382 DOI: 10.1136/bmjopen-2023-083414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 03/27/2024] [Indexed: 04/19/2024] Open
Abstract
INTRODUCTION Physical restraint (PR) is prescribed in patients receiving invasive mechanical ventilation in the intensive care unit (ICU) to avoid unplanned removal of medical devices. However, it is associated with an increased risk of delirium. We hypothesise that a restrictive use of PR, as compared with a systematic use, could reduce the duration of delirium in ICU patients receiving invasive mechanical ventilation. METHODS AND ANALYSIS The Restrictive use of Restraints and Delirium Duration in ICU (R2D2-ICU) study is a national multicentric, parallel-group, randomised (1:1) open-label, controlled, superiority trial, which will be conducted in 10 ICUs. A total of 422 adult patients requiring invasive mechanical ventilation for an expected duration of at least 48 hours and eligible for prescription of PR will be randomly allocated within 6 hours from intubation to either the restrictive PR use group or the systematic PR use group, until day 14, ICU discharge or death, whichever comes first. In both groups, PR will consist of the use of wrist straps. The primary endpoint will be delirium or coma-free days, defined as the number of days spent alive in the ICU without coma or delirium within the first 14 days after randomisation. Delirium will be assessed using the Confusion Assessment Method-ICU twice daily. Key secondary endpoints will encompass agitation episodes, opioid, propofol, benzodiazepine and antipsychotic drug exposure during the 14-day intervention period, along with a core outcome set of measures evaluated 90 days postrandomisation. ETHICS AND DISSEMINATION The R2D2-ICU study has been approved by the Comité de Protection des Personnes (CPP) ILE DE FRANCE III-PARIS (CPP19.09.06.37521) on June 10th, 2019). Participant recruitment started on 25 January 2021. Results will be published in international peer-reviewed medical journals and presented at conferences. TRIAL REGISTRATION NUMBER NCT04273360.
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Affiliation(s)
- Romain Sonneville
- Médecine Intensive Réanimation, APHP.Nord, Hôpital Bichat Claude Bernard, Paris, France
- INSERM UMR 1137, IAME, Université Paris Cité, Paris, France
| | - Camille Couffignal
- INSERM UMR 1137, IAME, Université Paris Cité, Paris, France
- Epidemiologie, Biostatistique, Recherche Clinique, APHP.Nord, Hôpital Bichat Claude Bernard, Paris, France
| | - Florian Sigaud
- Médecine Intensive Réanimation, Grenoble University Hospital, La Tronche, France
| | - Virginie Godard
- Epidemiologie, Biostatistique, Recherche Clinique, APHP.Nord, Hôpital Bichat Claude Bernard, Paris, France
| | - Juliette Audibert
- Service de Réanimation Polyvalente et USC, Hopital Louis Pasteur, Chartres, France
| | - Damien Contou
- Service de Réanimation Polyvalente, Centre Hospitalier Victor Dupouy, Argenteuil, France
| | - Adam Celier
- Département R3S, Médecine Intensive Réanimation, Sorbonne Université Pitié-Salpêtrière Hospital, Paris, France
| | - Michel Djibre
- Médecine Intensive Réanimation, APHP, Hôpital Tenon, Paris, France
| | - Julien Schmidt
- Médecine Intensive Réanimation, Assistance Publique-Hôpitaux de Paris, Bobigny, France
| | - Pierre Jaquet
- Médecine Intensive Réanimation, Hopital Delafontaine, Saint Denis, France
| | - Armand Mekontso Dessap
- Médecine Intensive Réanimation, APHP, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Claire Bourel
- Médecine Intensive Réanimation, Centre hospitalo-universitaire, Lille, France
| | - Romane Bellot
- Epidemiologie, Biostatistique, Recherche Clinique, APHP.Nord, Hôpital Bichat Claude Bernard, Paris, France
| | - Carine Roy
- Epidemiologie, Biostatistique, Recherche Clinique, APHP.Nord, Hôpital Bichat Claude Bernard, Paris, France
| | - Fariza Lamara
- Médecine Intensive Réanimation, APHP.Nord, Hôpital Bichat Claude Bernard, Paris, France
| | - Fatiha Essardy
- Médecine Intensive Réanimation, APHP.Nord, Hôpital Bichat Claude Bernard, Paris, France
| | - Jean-François Timsit
- Médecine Intensive Réanimation, APHP.Nord, Hôpital Bichat Claude Bernard, Paris, France
- INSERM UMR 1137, IAME, Université Paris Cité, Paris, France
| | - Renaud Cornic
- Epidemiologie, Biostatistique, Recherche Clinique, APHP.Nord, Hôpital Bichat Claude Bernard, Paris, France
| | - Lila Bouadma
- Médecine Intensive Réanimation, APHP.Nord, Hôpital Bichat Claude Bernard, Paris, France
- INSERM UMR 1137, IAME, Université Paris Cité, Paris, France
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Abstract
Over 2.6 million adults over the age of 65 develop delirium each year in the United States (US). Delirium is associated with a significant increase in mortality and the US health care costs associated with delirium are estimated at over $164 billion annually. Despite the prevalence of the condition, the molecular pathophysiology of delirium remains unexplained, limiting the development of pharmacotherapies. Delirious patients can be identified by prominent impairments in attention and working memory (WM), two cognitive domains that localize to the dorsolateral prefrontal cortex (dlPFC). The dlPFC is also a key site for Alzheimer's disease (AD) pathology, and given the high risk of delirium in AD patients, suggests that efforts at understanding delirium might focus on the dlPFC as a final common endpoint for cognitive changes. Preclinical studies of the dlPFC reproduce many of the pharmacological observations made of delirious patients, including sensitivity to anticholinergics and an 'inverted U' pattern of dependence on monoaminergic input, with diminished performance outside a narrow range of signaling. Medications like guanfacine, which influence the dlPFC in the context of attention-deficit/hyperactivity disorder (ADHD), have emerged as therapies for delirium and motivate a detailed understanding of the influence of α-2 agonists on WM. In this review, I will discuss the neural circuitry and molecular mechanisms underlying WM and the function of the dlPFC. Localizing the cognitive deficits that are commonly seen in delirious patients may help identify new molecular targets for this highly prevalent disease.
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Affiliation(s)
- Kyle A. Lyman
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
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Piel JHA, Bargemann L, Leypoldt F, Wandinger KP, Dargvainiene J. Serum NFL and tau, but not serum UCHL-1 and GFAP or CSF SNAP-25, NPTX2, or sTREM2, correlate with delirium in a 3-year retrospective analysis. Front Neurol 2024; 15:1356575. [PMID: 38566855 PMCID: PMC10985356 DOI: 10.3389/fneur.2024.1356575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 02/26/2024] [Indexed: 04/04/2024] Open
Abstract
Delirium represents a common terminal pathway of heterogeneous neurological conditions characterized by disturbances in consciousness and attention. Contemporary theories highlight the acute impairment of synaptic function and network connectivity, driven by neuroinflammation, oxidative stress, and neurotransmitter imbalances. However, established biomarkers are still missing. Innovative diagnostic techniques, such as single-molecule array analysis, enable the detection of biomarkers in blood at picomolar concentrations. This approach paves the way for deeper insights into delirium and potentially therapeutic targets for tailored medical treatments. In a retrospective 3-year study, we investigated seven biomarkers indicative of neuroaxonal damage [neurofilament light chain (NFL), ubiquitin carboxyl-terminal hydrolase (UCHL-1), and tau protein], microglial activation [glial fibrillary acidic protein (GFAP) and soluble triggering receptor expressed on myeloid cells 2 (sTREM2)], and synaptic dysfunction [synaptosomal-associated protein 25 (SNAP-25) and neuronal pentraxin 2 (NPTX2)]. The analysis of 71 patients with delirium, Alzheimer's disease (AD), and non-AD controls revealed that serum NFL levels are higher in delirium cases compared to both AD and non-AD. This suggests that elevated NFL levels in delirium are not exclusively the result of dementia-related damage. Serum tau levels were also elevated in delirium cases compared to controls. Conversely, cerebrospinal fluid (CSF) SNAP-25 showed higher levels in AD patients compared to controls only. These findings add to the increasing body of evidence suggesting that serum NFL could be a valuable biomarker of neuroaxonal damage in delirium research. Although SNAP-25 and NPTX2 did not exhibit significant differences in delirium, the exploration of synaptic biomarkers remains promising for enhancing our understanding of this condition.
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Affiliation(s)
| | - Leon Bargemann
- Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Frank Leypoldt
- Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
- Institute of Clinical Chemistry, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Klaus-Peter Wandinger
- Institute of Clinical Chemistry, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Justina Dargvainiene
- Institute of Clinical Chemistry, University Medical Center Schleswig-Holstein, Kiel, Germany
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Huet O, Gargadennec T, Oilleau JF, Rozec B, Nesseler N, Bouglé A, Kerforne T, Lasocki S, Eljezi V, Dessertaine G, Amour J, Chapalain X. Prevention of post-operative delirium using an overnight infusion of dexmedetomidine in patients undergoing cardiac surgery: a pragmatic, randomized, double-blind, placebo-controlled trial. Crit Care 2024; 28:64. [PMID: 38419119 PMCID: PMC10902989 DOI: 10.1186/s13054-024-04842-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 02/19/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND After cardiac surgery, post-operative delirium (PoD) is acknowledged to have a significant negative impact on patient outcome. To date, there is no valuable and specific treatment for PoD. Critically ill patients often suffer from poor sleep condition. There is an association between delirium and sleep quality after cardiac surgery. This study aimed to establish whether promoting sleep using an overnight infusion of dexmedetomidine reduces the incidence of delirium after cardiac surgery. METHODS Randomized, pragmatic, multicentre, double-blind, placebo controlled trial from January 2019 to July 2021. All adult patients aged 65 years or older requiring elective cardiac surgery were randomly assigned 1:1 either to the dexmedetomidine group or the placebo group on the day of surgery. Dexmedetomidine or matched placebo infusion was started the night after surgery from 8 pm to 8 am and administered every night while the patient remained in ICU, or for a maximum of 7 days. Primary outcome was the occurrence of postoperative delirium (PoD) within the 7 days after surgery. RESULTS A total of 348 patients provided informed consent, of whom 333 were randomized: 331 patients underwent surgery and were analysed (165 assigned to dexmedetomidine and 166 assigned to placebo). The incidence of PoD was not significantly different between the two groups (12.6% vs. 12.4%, p = 0.97). Patients treated with dexmedetomidine had significantly more hypotensive events (7.3% vs 0.6%; p < 0.01). At 3 months, functional outcomes (Short-form 36, Cognitive failure questionnaire, PCL-5) were comparable between the two groups. CONCLUSION In patients recovering from an elective cardiac surgery, an overnight infusion of dexmedetomidine did not decrease postoperative delirium. Trial registration This trial was registered on ClinicalTrials.gov (number: NCT03477344; date: 26th March 2018).
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Affiliation(s)
- Olivier Huet
- Department of Anaesthesia, Intensive Care Medicine and Peri-Operative Medicine, Hôpital de la cavale Blanche, CHRU de Brest, Brest, France.
| | - Thomas Gargadennec
- Department of Anaesthesia, Intensive Care Medicine and Peri-Operative Medicine, Hôpital de la cavale Blanche, CHRU de Brest, Brest, France
| | - Jean-Ferréol Oilleau
- Department of Anaesthesia, Intensive Care Medicine and Peri-Operative Medicine, Hôpital de la cavale Blanche, CHRU de Brest, Brest, France
| | - Bertrand Rozec
- Department of Anaesthesia, Intensive Care Medicine and Peri-Operative Medicine, Hôpital Laennec, University Hospital Centre Nantes, Nantes, France
| | - Nicolas Nesseler
- Department of Anaesthesia, Intensive Care Medicine and Peri-Operative Medicine, University Hospital of Rennes, Rennes, France
| | - Adrien Bouglé
- Department of Anaesthesia, Intensive Care Medicine and Peri-Operative Medicine, Institut de Cardiologie, Hôpital La Pitié-Salpêtrière, Paris, France
| | - Thomas Kerforne
- Department of Anaesthesia, Intensive Care Medicine and Peri-Operative Medicine CHU de POITIERS, Poitiers, France
| | - Sigismond Lasocki
- Department of Anaesthesia, Intensive Care Medicine and Peri-Operative Medicine, CHU de ANGERS, I, Angers, France
| | - Vedat Eljezi
- Department of Anaesthesia, Intensive Care Medicine and Peri-Operative Medicine, Hôpital Gabriel Montpied, CHU de Clermont Ferrand, Clermont Ferrand, France
| | - Géraldine Dessertaine
- Department of Anaesthesia, Intensive Care Medicine and Peri-Operative Medicine, Grenoble Alpes University Hospital, Grenoble, France
| | - Julien Amour
- Department of Anaesthesia, Intensive Care Medicine and Peri-Operative Medicine, Hôpital Privé Jacques Cartier, Massy, France
| | - Xavier Chapalain
- Department of Anaesthesia, Intensive Care Medicine and Peri-Operative Medicine, Hôpital de la cavale Blanche, CHRU de Brest, Brest, France
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Long C, Lin D, Zhang L, Lin Y, Yao Q, Zhang G, Li L, Liu H, Ying J, Wang X, Hua F. Association between human blood metabolome and the risk of delirium: a Mendelian Randomization study. Front Endocrinol (Lausanne) 2024; 14:1332712. [PMID: 38274231 PMCID: PMC10808797 DOI: 10.3389/fendo.2023.1332712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 12/19/2023] [Indexed: 01/27/2024] Open
Abstract
Background Delirium significantly contributes to both mortality and morbidity among hospitalized older adults. Furthermore, delirium leads to escalated healthcare expenditures, extended hospital stays, and enduring cognitive deterioration, all of which are acknowledged detrimental outcomes. Nonetheless, the current strategies for predicting and managing delirium remain constrained. Our aim was to employ Mendelian randomization (MR) to investigate the potential causal relationship between metabolites and delirium, as well as to identify potential therapeutic targets. Methods We identified 129 distinct blood metabolites from three genome-wide association studies (GWASs) conducted on the metabolome, involving a total of 147,827 participants of European descent. Genetic information pertaining to delirium was sourced from the ninth iteration of the Finngen Biobank, encompassing 359,699 individuals of Finnish ancestry. We conducted MR analyses to evaluate the connections between blood metabolites and delirium. Additionally, we extended our analysis to encompass the entire phenome using MR, aiming to uncover potential on-target consequences resulting from metabolite interventions. Results In our investigation, we discovered three metabolites serving as causal mediators in the context of delirium: clinical low density lipoprotein cholesterol (LDL-C) (odds ratio [OR]: 1.47, 95% confidence interval [CI]: 1.25-1.73, p = 3.92 x 10-6), sphingomyelin (OR: 1.47, 95% CI: 1.25-1.74, p = 5.97 x 10-6), and X-11593-O-methylascorbate (OR: 0.21, 95% CI: 0.10-0.43, p = 1.86 x 10-5). Furthermore, utilizing phenome-wide MR analysis, we discerned that clinical LDL-C, sphingomyelin, and O-methylascorbate not only mediate delirium susceptibility but also impact the risk of diverse ailments. Limitations (1) Limited representation of the complete blood metabolome, (2) reliance on the PheCode system based on hospital diagnoses may underrepresent conditions with infrequent hospital admissions, and (3) limited to European ancestry. Conclusion The genetic prediction of heightened O-methylascorbate levels seems to correspond to a diminished risk of delirium, in contrast to the association of elevated clinical LDL-C and sphingomyelin levels with an amplified risk. A comprehensive analysis of side-effect profiles has been undertaken to facilitate the prioritization of drug targets. Notably, O-methylascorbate emerges as a potentially auspicious target for mitigating and treating delirium, offering the advantage of lacking predicted adverse side effects.
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Affiliation(s)
- Chubing Long
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Key Laboratory of Anesthesiology of Jiangxi Province, Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Dong Lin
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Key Laboratory of Anesthesiology of Jiangxi Province, Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Lieliang Zhang
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Key Laboratory of Anesthesiology of Jiangxi Province, Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Yue Lin
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Key Laboratory of Anesthesiology of Jiangxi Province, Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Qing Yao
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Key Laboratory of Anesthesiology of Jiangxi Province, Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Guangyong Zhang
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Key Laboratory of Anesthesiology of Jiangxi Province, Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Longshan Li
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Key Laboratory of Anesthesiology of Jiangxi Province, Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Hailin Liu
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Key Laboratory of Anesthesiology of Jiangxi Province, Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Jun Ying
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Key Laboratory of Anesthesiology of Jiangxi Province, Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Xifeng Wang
- Key Laboratory of Anesthesiology of Jiangxi Province, Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Department of Anesthesiology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Fuzhou Hua
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Key Laboratory of Anesthesiology of Jiangxi Province, Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
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10
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Kinalski SDS, Beuter M, Benetti ERR, Leite MT, Venturini L, Brandão MAG. Nursing microtheory in the prevention of delirium in older adult in the intensive care unit. Rev Lat Am Enfermagem 2023; 31:e4070. [PMID: 38055590 PMCID: PMC10695289 DOI: 10.1590/1518-8345.6707.4070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 09/04/2023] [Indexed: 12/08/2023] Open
Abstract
OBJECTIVE to describe a microtheory for nursing care in the prevention of delirium in older adult in the intensive care unit. METHOD prescriptive theoretical research, based on substruction. Roy's Adaptation Model constructs were deduced and data from the phenomenon of nursing care in the prevention of delirium in older adult in intensive care were induced, based on an integrative literature review. RESULTS the microtheory has a theoretical and operational system and a model of care. In the theoretical system, Roy's focal and contextual stimulus constructs were used. From them, the concepts of focal and contextual care and the variable adaptive response to prevention were elaborated. From the relational statements, four axioms, two postulates, eight propositions and an epistemic assumption were elaborated. TWO EMPIRICAL INDICATORS WERE ESTABLISHED IN THE OPERATING SYSTEM the Confusion Assessment Method for Intensive Care Units and the demographic/clinical history of the older adult. Subsequently, two transformational statements, four hypotheses and the model of care represented in figure were produced. CONCLUSION the microtheory produced prescribes care in the prevention of delirium in older adult in intensive care, through a construct of interest to nursing, and allows interceptions for the development of instruments that guide nursing activities.
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Affiliation(s)
| | - Margrid Beuter
- Universidade Federal de Santa Maria, Santa Maria, RS, Brasil
| | | | | | - Larissa Venturini
- Universidade Federal de Santa Maria, Hospital Universitário de Santa Maria, Santa Maria, RS, Brasil
| | - Marcos Antônio Gomes Brandão
- Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
- Becario del Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Brasil
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11
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Hanifa ALB, Alrø AB, Holm A, Dreyer P. Nurses' experiences of managing cognitive problems in intensive care unit patients: A qualitative study. Intensive Crit Care Nurs 2023; 79:103508. [PMID: 37541066 DOI: 10.1016/j.iccn.2023.103508] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 07/18/2023] [Accepted: 07/21/2023] [Indexed: 08/06/2023]
Abstract
OBJECTIVES Nurses hold a key position in identifying symptoms and initiating preventive strategies for cognitive impairment in delirious and non-delirious intensive care unit patients. However, it remains unclear whether nurses consider cognitive impairment as a distinct concern from delirium. By understanding nurses' perspectives, we may identify barriers and facilitators in caring for patients with cognitive challenges in the intensive care unit. The objective of this study was to explore nurses' experiences of cognitive problems in patients admitted to an intensive care unit. RESEARCH METHODOLOGY A phenomenological-hermeneutic study of interviews with ten nurses from intensive care units. Data were collected in March-April 2022 and analysed using a Ricœur-inspired method of interpretation. FINDINGS Three themes related to nurses' experiences of cognitive problems emerged through analysis; 1) Cognitive problems and delirium are seen as two sides of the same coin, 2) Searching for the person behind the patient, and 3) Maintaining a sense of normality in a confusing environment. CONCLUSIONS The interconnected concept of cognitive impairment and delirium syndrome meant that nurses assessed and managed cognitive problems in intensive care unit patients by focusing on preventing delirium. Apart from delirium screening, nurses relied on relatives' knowledge to assess patients' cognition. Most significantly, our study revealed a previously unexplored approach by nurses to manage patients' cognition, which involved "shielding" patients from the noisy and disruptive intensive care unit environment. IMPLICATIONS FOR CLINICAL PRACTICE Effective communication methods, coupled with family involvement may aid nurses in identifying patients' cognitive problems. In the acute phase of critical illness, distinguishing between delirium and cognitive problems may not be clinically relevant, as delirium protocols may protect patients' cognition. Further investigating the concept of shielding may reveal previously unexplored nursing approaches to manage cognitive problems.
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Affiliation(s)
- Ann Louise Bødker Hanifa
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; The ICU Cognitive Rehabilitation Nursing Research Programme (ICU-CogHab).
| | - Anette Bjerregaard Alrø
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; The ICU Cognitive Rehabilitation Nursing Research Programme (ICU-CogHab).
| | - Anna Holm
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; The ICU Cognitive Rehabilitation Nursing Research Programme (ICU-CogHab).
| | - Pia Dreyer
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; The ICU Cognitive Rehabilitation Nursing Research Programme (ICU-CogHab); Department of Public Health, Section of Nursing Science, Aarhus University, Bartholins Allé 2, 8000 Aarhus C, Denmark.
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12
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Nielsen AH, Larsen LK, Collet MO, Lehmkuhl L, Bekker C, Jensen JF, Laerkner E, Nielsen TA, Rossen BS, Thorn L, Laursen E, Fischer S, Villumsen M, Shiv LH, Høgh M, Rahr MN, Svenningsen H. Intensive care unit nurses' perception of three different methods for delirium screening: A survey (DELIS-3). Aust Crit Care 2023; 36:1035-1042. [PMID: 36774292 DOI: 10.1016/j.aucc.2022.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 10/06/2022] [Accepted: 12/09/2022] [Indexed: 02/11/2023] Open
Abstract
BACKGROUND Delirium is common in critically ill patients with detrimental effects in terms of increased morbidity, mortality, costs, and human suffering. Delirium detection and management depends on systematic screening for delirium, which can be challenging to implement in clinical practice. OBJECTIVES The aim of this study was to explore how nurses in the intensive care unit perceived the use of Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), the Confusion Assessment Method for the Intensive Care Unit-7 (CAM-ICU-7), and Intensive Care Delirium Screening Checklist (ICDSC) for delirium screening of patients in the intensive care unit. METHODS This was a cross-sectional, electronic-based survey of nurses' perceptions of delirium screening with the three different instruments for delirium screening. Nurses were asked to grade their perception of the usability of the three instruments and how well they were perceived to detect delirium and delirium symptom changes on a 1- to 6-point Likert scale. Open questions about perceived advantages and disadvantages of each instrument were analysed using the framework method. RESULTS One hundred twenty-seven of 167 invited nurses completed the survey and rated the CAM-ICU-7 as faster and easier than the ICDSC, which was more nuanced and reflected changes in the patient's delirium better. Despite being rated as the fastest, easiest, and most used, the CAM-ICU provided less information and was considered inferior to the CAM-ICU-7 and ICDSC. Using familiar instruments made delirium screening easier, but being able to grade and nuance the delirium assessment was experienced as important for clinical practice. CONCLUSIONS Both the ICDSC and the CAM-ICU-7 were perceived well suited for detection of delirium and reflected changes in delirium intensity. The CAM-ICU was rated as fast and easy but inferior in its ability to grade and nuance the assessment of delirium. Emphasis on clinical meaningfulness and continued education in delirium screening are necessary for adherence to delirium management guidelines.
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Affiliation(s)
- Anne Højager Nielsen
- Department of Anaesthesiology and Intensive Care, Gødstrup Hospital, Hospitalsparken 15, 7400 Herning, Denmark; Institute for Clinical Medicine, Aarhus University, Incuba Skejby, Building 2, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark.
| | - Laura Krone Larsen
- Department of Anaesthesia and Intensive Care 6021, The Neuroscience Centre, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen O, Denmark.
| | - Marie Oxenbøll Collet
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen O, Denmark.
| | - Lene Lehmkuhl
- Department of Anesthesiology and Intensive Care Medicine, OUH Svendborg Hospital, Baagøes Alle 15, 5700 Svendborg, Denmark.
| | - Camilla Bekker
- Department of Anaesthesiology and Intensive Care Medicine, Zealand University Hospital, Lykkebækvej 1, 4600 Køge, Denmark.
| | - Janet Froulund Jensen
- Department of Neurology, Zealand University Hospital, Sygehusvej 10, 4000 Roskilde, Denmark; Department of Anesthesiology, Holbæk Hospital, Smedelundsgade 60, 4300 Holbæk, Denmark.
| | - Eva Laerkner
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, J.B. Winsløws Vej 4, 5000 Odense C, Denmark.
| | - Tina Allerslev Nielsen
- Department of Anaesthesiology and Intensive Care, Viborg Regional Hospital, Banevejen 7C, 8800 Viborg, Denmark.
| | - Birgitte Sonne Rossen
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Glostrup Valdemar Hansensvej 13, 2600 Glostrup, Denmark.
| | - Linette Thorn
- Department of Intensive Care, Aarhus University Hospital, AUH, Palle Juul-Jensens Boulevard 165, 8200 Aarhus N, Denmark.
| | - Edel Laursen
- Department of Anaesthesiology and Intensive Care, Horsens Regional Hospital, Sundvej 30, 8700 Horsens, Denmark.
| | - Susanne Fischer
- Department of Anaesthesiology and Intensive Care, Sydvestjysk Sygehus Esbjerg, Finsensgade 35, 6700 Esbjerg, Denmark.
| | - Marianne Villumsen
- Department of Anaesthesiology and Intensive Care, Randers Regional Hospital, Skovlyvej 15, 8930 Randers NØ, Denmark.
| | - Louise Hvid Shiv
- Department of Intensive Care, North Zealand Hospital, Dyrhavevej 29, 3400 Hillerød, Denmark.
| | - Marianne Høgh
- Department of Intensive Care, Vejle Hospital, Beriderbakken 4, 7100 Vejle, Denmark.
| | - Mette Nygaard Rahr
- Department of Anaesthesiology and Intensive Care, Gødstrup Hospital, Hospitalsparken 15, 7400 Herning, Denmark.
| | - Helle Svenningsen
- Research Centre for Health and Welfare Technology, Programme for Rehabilitation, Programme for Physical and Mental Health, VIA University College, Campus Aarhus N, Hedeager 2, 8200 Aarhus N, Denmark.
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Graham ND, Graham ID, Vanderspank-Wright B, Varin MD, Nadalin Penno L, Fergusson DA, Squires JE. A systematic review and critical appraisal of guidelines and their recommendations for sedation interruptions in adult mechanically ventilated patients. Aust Crit Care 2023; 36:889-901. [PMID: 36522246 DOI: 10.1016/j.aucc.2022.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 10/03/2022] [Accepted: 10/09/2022] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE The objectives of the review were to (i) assess the methodological quality of all accessible and published guidelines and care bundles that offer a recommendation related to sedation interruptions, using the AGREE-II instrument, to (ii) determine what is the recommended best practice for sedation interruptions from the available guidelines, and then to have (iii) a closer inspection of the overall credibility and applicability of the recommendations using the AGREE-REX instrument. This review will benefit the outcomes of critically ill patients and the multidisciplinary team responsible for the care of mechanically ventilated adults with continuous medication infusions by providing a synthesis of the recommended action(s), actor(s), contextual information, target(s), and timing related to sedation interruptions from current best practice. REVIEW METHOD USED We conducted a systematic review. DATA SOURCES We applied a peer-reviewed search strategy to four electronic databases from 2010 to November 2021-MEDLINE, CINAHL, Embase, and The Cochrane Database of Systematic Reviews-and included grey literature. REVIEW METHOD Findings are reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses checklist. We assessed overall quality using the validated Appraisal of Guidelines for Research and Evaluation II and AGREE Recommendation Excellence tools. RESULTS We identified 11 clinical practice guidelines and care bundles comprising 15 recommendations related to sedation interruption. There are three key findings: (i) deficiencies exist with the methodological quality of included guidelines, (ii) sedation interruption is recommended practice for the care of adult mechanically ventilated patients, and (iii) the current evidence is of low quality, which impacts overall credibility and applicability of the recommendations. CONCLUSIONS Sedation interruptions are currently best practice for adult mechanically ventilated patients; however, the available guidelines and recommendations have several deficiencies. Future research is needed to further understand the role of the nurse and other actors to enact this practice.
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Affiliation(s)
- Nicole D Graham
- University of Ottawa, Faculty of Health Sciences, School of Nursing, 451 Smyth Road, Ottawa, ON, K1H 8M5, Canada.
| | - Ian D Graham
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, P.O. Box 711, Ottawa ON, K1H 8L6, Canada; Faculty of Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada; University of Ottawa, Faculty of Health Sciences, School of Nursing, 451 Smyth Road, Ottawa, ON, K1H 8M5, Canada.
| | - Brandi Vanderspank-Wright
- University of Ottawa, Faculty of Health Sciences, School of Nursing, 451 Smyth Road, Ottawa, ON, K1H 8M5, Canada.
| | - Melissa Demery Varin
- University of Ottawa, Faculty of Health Sciences, School of Nursing, 451 Smyth Road, Ottawa, ON, K1H 8M5, Canada.
| | - Letitia Nadalin Penno
- University of Ottawa, Faculty of Health Sciences, School of Nursing, 451 Smyth Road, Ottawa, ON, K1H 8M5, Canada.
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, P.O. Box 711, Ottawa ON, K1H 8L6, Canada; Department of Medicine, University of Ottawa, Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, P.O. Box 711, Ottawa ON, K1H 8L6, Canada.
| | - Janet E Squires
- University of Ottawa, Faculty of Health Sciences, School of Nursing, 451 Smyth Road, Ottawa, ON, K1H 8M5, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, P.O. Box 711, Ottawa ON, K1H 8L6, Canada.
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14
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Faisal H, Farhat S, Grewal NK, Masud FN. ICU Delirium in Cardiac Patients. Methodist Debakey Cardiovasc J 2023; 19:74-84. [PMID: 37547895 PMCID: PMC10402849 DOI: 10.14797/mdcvj.1246] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 05/23/2023] [Indexed: 08/08/2023] Open
Abstract
Delirium is a prevalent complication in critically ill medical and surgical cardiac patients. It is associated with increased morbidity and mortality, prolonged hospitalizations, cognitive impairments, functional decline, and hospital costs. The incidence of delirium in cardiac patients varies based on the criteria used for the diagnosis, the population studied, and the type of surgery (cardiac or not cardiac). Delirium experienced when cardiac patients are in the intensive care unit (ICU) is likely preventable in most cases. While there are many protocols for recognizing and managing ICU delirium in medical and surgical cardiac patients, there is no homogeneity, nor are there established clinical guidelines. This review provides a comprehensive overview of delirium in cardiac patients and highlights its presentation, course, risk factors, pathophysiology, and management. We define cardiac ICU patients as both medical and postoperative surgical patients with cardiac disease in the ICU. We also highlight current controversies and future considerations of innovative therapies and nonpharmacological and pharmacological management interventions. Clinicians caring for critically ill patients with cardiac disease must understand the complex syndrome of ICU delirium and recognize the impact of delirium in predicting long-term outcomes for ICU patients.
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Affiliation(s)
- Hina Faisal
- Center for Critical Care, Houston Methodist Hospital, Weill Cornell Graduate School of Medical Sciences, Houston, Texas, US
| | - Souha Farhat
- Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Graduate School of Medical Sciences, Houston, Texas, US
| | - Navneet K. Grewal
- Memorial Hermann Southwest Hospital, UT Health Houston, McGovern Medical School, Houston, Texas, US
| | - Faisal N. Masud
- Center for Critical Care, Houston Methodist Hospital, Weill Cornell Graduate School of Medical Sciences, Houston, Texas, US
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15
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Huang J, Zheng H, Zhu X, Zhang K, Ping X. The efficacy and safety of haloperidol for the treatment of delirium in critically ill patients: a systematic review and meta-analysis of randomized controlled trials. Front Med (Lausanne) 2023; 10:1200314. [PMID: 37575982 PMCID: PMC10414537 DOI: 10.3389/fmed.2023.1200314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 07/18/2023] [Indexed: 08/15/2023] Open
Abstract
Purpose Delirium is common during critical illness and is associated with poor outcomes. Therefore, we conducted this meta-analysis to investigate the efficacy and safety of haloperidol for the treatment of delirium in critically ill patients. Methods Randomized controlled trials enrolling critically ill adult patients to compare haloperidol with placebo were searched from inception through to February 20th, 2023. The primary outcome were delirium-free days and overall mortality, secondary outcomes were length of intensive care unit stay, length of hospital stay, and adverse events. Results Nine trials were included in our meta-analysis, with a total of 3,916 critically ill patients. Overall, the pooled analyses showed no significant difference between critically ill patients treated with haloperidol and placebo for the delirium-free days (MD -0.01, 95%CI -0.36 to 0.34, p = 0.95, I2 = 30%), overall mortality (OR 0.89, 95%CI 0.76 to 1.04, p = 0.14, I2 = 0%), length of intensive care unit stay (MD -0.06, 95%CI -0.16 to 0.03, p = 0.19, I2 = 0%), length of hospital stay (MD -0.06, 95%CI -0.61 to 0.49, p = 0.83, I2 = 0%), and adverse events (OR 0.90, 95%CI 0.60 to 1.37, p = 0.63, I2 = 0%). Conclusion Among critically ill patients, the use of haloperidol as compared to placebo has no significant effect on delirium-free days, overall mortality, length of intensive care unit and/or hospital stay. Moreover, the use of haloperidol did not increase the risk of adverse events.
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Affiliation(s)
- Jian Huang
- Department of Critical Care Medicine, Hangzhou Ninth People’s Hospital, Hangzhou, China
| | - Hui Zheng
- Department of Emergency Medicine, Hangzhou Ninth People’s Hospital, Hangzhou, China
| | - Xianfeng Zhu
- Department of Critical Care Medicine, Hangzhou Ninth People’s Hospital, Hangzhou, China
| | - Kai Zhang
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaofeng Ping
- Department of Critical Care Medicine, Hangzhou Ninth People’s Hospital, Hangzhou, China
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Alhalaiqa F, Masa’Deh R, Al Omari O, Shawashreh A, Khalifeh AH, Gray R. The Impact of an Educational Programme on Jordanian Intensive Care Nurses' Knowledge, Attitudes, and Practice Regarding Delirium and their Levels of Self-Efficacy: A Quasi-Experimental Design. IRANIAN JOURNAL OF NURSING AND MIDWIFERY RESEARCH 2023; 28:312-319. [PMID: 37575493 PMCID: PMC10412801 DOI: 10.4103/ijnmr.ijnmr_437_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 10/06/2021] [Accepted: 09/21/2022] [Indexed: 08/15/2023]
Abstract
Background Delirium is a common problem among patients in Intensive Care Units (ICUs); however, it remains underdiagnosed. We aimed to determine the impact of a nursing education program on Jordanian nurses' knowledge, practice, attitudes, self-efficacy, and ability to detect delirium among ICU patients. Materials and Methods We conducted a nonequivalent, quasi-experimental design from January 2019 to January 2020. A total of 175 nurses who work in an ICU were included at the baseline and divided into two groups: (1) intervention (86 nurses), who received education for 6 hours each day across two different days and (2) a control group (89 nurses), who maintained their usual routine of care. Data were collected by means of a booklet of questionnaires about the nurses' knowledge and practice, attitudes, and self-efficacy. Results Data from 160 nurses were included in the analysis. The education program intervention (n = 81) significantly increased nurses' knowledge and practice, positive attitudes, and self-efficacy compared with the control group (n = 79, p < 0.001). In addition, nurses who received the educational intervention were able to detect more cases of delirium (28%, from a total of 51 patients) than the controls, who detected three (6.50%) out of a total of 31 patients (p = 0.003). Conclusions The ICU nurses who received the delirium-focused educational program increased their knowledge and practice, positive attitudes, and their self-efficacy; in addition, their ability to detect delirium was increased. The implementation of such a program is recommended for the health policymakers and stakeholders.
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Affiliation(s)
- Fadwa Alhalaiqa
- Professor Psychiatric Mental Health Nursing, Faculty of Nursing, Dean of Allied Medical Sciences, Oman
| | - Rami Masa’Deh
- School of Nursing, Applied Science Private University, Jordan, Philadelphia University, Jordan
| | - Omar Al Omari
- Professor, Fundamentals and Administration, Faculty of Nursing, Sultan Qaboos University, Oman
| | - Atef Shawashreh
- Training and Consultation Unit, Institute of Family Health, Noor Al-Hussein Foundation, Amman, Jordan
| | | | - Richard Gray
- Professor of Clinical Nursing Practice and Director, The La Trobe Alfred Clinical School, The Alfred Centre, 99 Commercial Rd, Melbourne VIC 3004, Australia
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Measures for the Core Outcome Set for Research Evaluating Interventions to Prevent and/or Treat Delirium in Critically Ill Adults: An International Consensus Study (Del-COrS). Crit Care Explor 2023; 5:e0884. [PMID: 37025304 PMCID: PMC10072315 DOI: 10.1097/cce.0000000000000884] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023] Open
Abstract
To gain consensus on measurement methods for outcomes (delirium occurrence, severity, time to resolution, mortality, health-related quality of life [HrQoL], emotional distress including anxiety, depression, acute stress, and post-traumatic stress disorder, and cognition) of our Core Outcome Set (COS) for trials of interventions to prevent and/or treat delirium in critically ill adults.
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Fleischmann R, Andrasch T, Warwas S, Kunz R, Gross S, Witt C, Ruhnau J, Vogelgesang A, Ulm L, Mengel A, von Sarnowski B. Predictors of post-stroke delirium incidence and duration: Results of a prospective observational study using high-frequency delirium screening. Int J Stroke 2023; 18:278-284. [PMID: 35722813 PMCID: PMC9940154 DOI: 10.1177/17474930221109353] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Post-stroke delirium (PSD) is a modifiable predictor for worse outcome in stroke. Knowledge of its risk factors would facilitate clinical management of affected patients, but recently updated national guidelines consider available evidence insufficient. AIMS The study aimed to establish risk factors for PSD incidence and duration using high-frequency screening. METHODS We prospectively investigated patients with ischemic stroke admitted within 24 h. Patients were screened twice daily for the presence of PSD throughout the treatment period. Sociodemographic, treatment-related, and neuroimaging characteristics were evaluated as predictors of either PSD incidence (odds ratios (OR)) or duration (PSD days/unit of the predictor, b), using logistic and linear regression models, respectively. RESULTS PSD occurred in 55/141 patients (age = 73.8 ± 10.4 years, 61 female, National Institutes of Health Stroke Scale (NIHSS) = 6.4 ± 6.5). Age (odds ratio (OR) = 1.06 (95% confidence interval (CI): 1.02-1.10), b = 0.08 (95% CI = 0.04-0.13)), and male gender (b = 0.99 (95% CI = 0.05-1.93)) were significant non-modifiable risk factors. In a multivariable model adjusted for age and gender, presence of pain (OR < sub > mvar </sub >= 1.75 (95% CI = 1.12-2.74)), urinary catheter (OR < sub > mvar </sub > = 3.16 (95% CI = 1.10-9.14)) and post-stroke infection (PSI; OR < sub > mvar </sub > = 4.43 (95% CI = 1.09-18.01)) were predictors of PSD incidence. PSD duration was impacted by presence of pain (b < sub > mvar </sub >= 0.49 (95% CI = 0.19-0.81)), urinary catheter (b < sub > mvar </sub > = 1.03 (95% CI = 0.01-2.07)), intravenous line (b < sub > mvar </sub >= 0.36 (95% CI = 0.16-0.57)), and PSI (b < sub > mvar </sub >= 1.60 (95% CI = 0.42-2.78)). PSD (OR = 3.53 (95% CI = 1.48-5.57)) and PSI (OR = 5.29 (95% CI = 2.92-7.66)) independently predicted inferior NIHSS at discharge. Insular and basal ganglia lesions increased the PSD risk about four- to eight-fold. DISCUSSION/CONCLUSION This study identified modifiable risk factors, the management of which might reduce the negative impact PSD has on outcome.
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Affiliation(s)
- Robert Fleischmann
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany,Robert Fleischmann, Department of Neurology, University Medicine Greifswald, Ferdinand-Sauerbruch-Str. 1, Greifswald 17475, Germany.
| | - Tina Andrasch
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Sina Warwas
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Rhina Kunz
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Stefan Gross
- Department of Internal Medicine B, University Medicine Greifswald, German Centre for Cardiovascular Research (DZHK), partner site Greifswald, Germany
| | - Carl Witt
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Johanna Ruhnau
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Antje Vogelgesang
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Lena Ulm
- Friedrich Loeffler Institute of Medical Microbiology, University Medicine Greifswald, Greifswald, Germany
| | - Annerose Mengel
- Department of Neurology and Stroke, Hertie-Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, Tübingen, Germany
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Predicting Intensive Care Delirium with Machine Learning: Model Development and External Validation. Anesthesiology 2023; 138:299-311. [PMID: 36538354 DOI: 10.1097/aln.0000000000004478] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Delirium poses significant risks to patients, but countermeasures can be taken to mitigate negative outcomes. Accurately forecasting delirium in intensive care unit (ICU) patients could guide proactive intervention. Our primary objective was to predict ICU delirium by applying machine learning to clinical and physiologic data routinely collected in electronic health records. METHODS Two prediction models were trained and tested using a multicenter database (years of data collection 2014 to 2015), and externally validated on two single-center databases (2001 to 2012 and 2008 to 2019). The primary outcome variable was delirium defined as a positive Confusion Assessment Method for the ICU screen, or an Intensive Care Delirium Screening Checklist of 4 or greater. The first model, named "24-hour model," used data from the 24 h after ICU admission to predict delirium any time afterward. The second model designated "dynamic model," predicted the onset of delirium up to 12 h in advance. Model performance was compared with a widely cited reference model. RESULTS For the 24-h model, delirium was identified in 2,536 of 18,305 (13.9%), 768 of 5,299 (14.5%), and 5,955 of 36,194 (11.9%) of patient stays, respectively, in the development sample and two validation samples. For the 12-h lead time dynamic model, delirium was identified in 3,791 of 22,234 (17.0%), 994 of 6,166 (16.1%), and 5,955 of 28,440 (20.9%) patient stays, respectively. Mean area under the receiver operating characteristics curve (AUC) (95% CI) for the first 24-h model was 0.785 (0.769 to 0.801), significantly higher than the modified reference model with AUC of 0.730 (0.704 to 0.757). The dynamic model had a mean AUC of 0.845 (0.831 to 0.859) when predicting delirium 12 h in advance. Calibration was similar in both models (mean Brier Score [95% CI] 0.102 [0.097 to 0.108] and 0.111 [0.106 to 0.116]). Model discrimination and calibration were maintained when tested on the validation datasets. CONCLUSIONS Machine learning models trained with routinely collected electronic health record data accurately predict ICU delirium, supporting dynamic time-sensitive forecasting. EDITOR’S PERSPECTIVE
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Sepsis-Associated Delirium: A Narrative Review. J Clin Med 2023; 12:jcm12041273. [PMID: 36835809 PMCID: PMC9962483 DOI: 10.3390/jcm12041273] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 01/21/2023] [Accepted: 01/30/2023] [Indexed: 02/09/2023] Open
Abstract
Delirium is characterized by an acutely altered mental status accompanied by reductions in cognitive function and attention. Delirium in septic patients, termed sepsis-associated delirium (SAD), differs in several specific aspects from the other types of delirium that are typically encountered in intensive care units. Since sepsis and delirium are both closely associated with increased morbidity and mortality, it is important to not only prevent but also promptly diagnose and treat SAD. We herein reviewed the etiology, pathogenesis, risk factors, prevention, diagnosis, treatment, and prognosis of SAD, including coronavirus disease 2019 (COVID-19)-related delirium. Delirium by itself not only worsens long-term prognosis, but it is also regarded as an important factor affecting the outcome of post-intensive care syndrome. In COVID-19 patients, the difficulties associated with adequately implementing the ABCDEF bundle (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) and the need for social isolation are issues that require the development of conventional care for SAD.
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Davis KA, Dietrich MS, Gilmer MJ, Fuchs DC, Akard TF. Postoperative opioid administration and post-traumatic stress symptoms in preschool children after cardiac surgery. J Pediatr Nurs 2023; 68:44-51. [PMID: 36333168 DOI: 10.1016/j.pedn.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 10/05/2022] [Accepted: 10/11/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE The purpose of this study was to explore relationships between postoperative opioid administration and posttraumatic stress symptoms (PTSS) in preschool-aged children surviving cardiac surgery. DESIGN AND METHODS This was a cross-sectional, descriptive study using survey administration and medical chart review. Primary caregivers of children aged three to six years who underwent cardiac surgery at our institution between 2018 and 2020 were invited to participate. Opioid administration was calculated according to morphine milligram equivalents and indexed to the child's body weight. Caregivers completed the Young Child Posttraumatic Stress Disorder Checklist to explore child PTSS. We used correlational methods to assess the strength and direction of relationships between postoperative opioid administration and child PTSS. RESULTS We did not find a statistically significant relationship between total postoperative opioid administration and child PTSS. When analyzing individual opioid agents, morphine did show a significant inverse relationship to YCPC scores (rs = -.57, p = .017) in children with single ventricle physiology. CONCLUSIONS Total postoperative opioid administration was not statistically significantly related to child PTSS in our sample. Differing patterns of association were noted among children with single- versus bi-ventricular physiology. Postoperative morphine administration was favorably associated with PTSS in children with single-ventricle physiology. PRACTICE IMPLICATIONS Nurses caring for preschool children who undergo cardiac surgery should anticipate the potential development of PTSS in their patients. Studies using larger sample sizes and longitudinal design are needed to replicate the significant relationship between morphine administration and PTSS in preschoolers with single-ventricle physiology.
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Affiliation(s)
- Kelly A Davis
- Vanderbilt University School of Nursing, Vanderbilt University, 461 21st Avenue South, Nashville, TN 37240, USA; Division of Pediatric Critical Care, Vanderbilt University Medical Center, 2200 Children's Way, Nashville, TN 37232, USA.
| | - Mary S Dietrich
- Vanderbilt University School of Nursing, Vanderbilt University, 461 21st Avenue South, Nashville, TN 37240, USA; Department of Biostatistics, Vanderbilt University Medical Center, 1211 Medical Center Drive Nashville, TN 37232, USA
| | - Mary Jo Gilmer
- Vanderbilt University School of Nursing, Vanderbilt University, 461 21st Avenue South, Nashville, TN 37240, USA
| | - D Catherine Fuchs
- Department of Child and Adolescent Psychiatry, Vanderbilt University Medical Center, 2200 Children's Way, Nashville, TN 37232, USA
| | - Terrah Foster Akard
- Vanderbilt University School of Nursing, Vanderbilt University, 461 21st Avenue South, Nashville, TN 37240, USA
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Dang V, Mansukhani MP, Wang Z, Kinzelman Vesely E, Kolla BP. Prophylactic Use of Ramelteon for Delirium in Hospitalized Patients: A Systematic Review and Meta-Analyses. J Acad Consult Liaison Psychiatry 2023; 64:65-72. [PMID: 35718086 DOI: 10.1016/j.jaclp.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 05/19/2022] [Accepted: 06/09/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Small prospective studies, case reports, as well as some randomized placebo-controlled trials and previous meta-analyses have shown that ramelteon, a melatonin agonist, may reduce the risk of developing delirium. OBJECTIVE The goal of this systemic review and meta-analyses was to assess the current evidence supporting the use of ramelteon in delirium prevention by including data from larger (>100 subjects) and more recent trials since the most recent meta-analyses were published in 2019. There were no exclusions for trial size, age, ramelteon dose, length of treatment, or hospital setting. METHODS Medline, Embase, PsycINFO, EBM Reviews, Scopus, and Web of Science databases were queried using the search terms delirium (with subterms including prevention and control), ramelteon, Rozerem, or melatonin receptor agonists, for English-language publications until March 16, 2021. Randomized placebo-controlled trials of hospitalized subjects receiving ramelteon for delirium prevention were included. The primary outcome of interest was delirium incidence. Odds ratios of the risk of developing incident delirium and 95% confidence intervals were calculated using a random effects model. RESULTS A total of 177 articles were identified by the literature search. Five studies (n = 443, 53.7% male) met criteria for inclusion in the final meta-analyses. The meta-analyses of the randomized placebo-controlled trials revealed that ramelteon did not result in a reduction in the risk of incident delirium (n = 443; odds ratio = 0.49; 95% confidence interval = 0.13-1.85). A moderate degree of heterogeneity was noted among the studies (I2 = 53%). CONCLUSIONS Current evidence suggests that ramelteon is ineffective as a prophylactic drug in reducing the incidence of delirium in hospitalized patients.
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Affiliation(s)
- Vanessa Dang
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN
| | | | - Zhen Wang
- Health Services Research, Rochester, MN
| | | | - Bhanu Prakash Kolla
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN; Center for Sleep Medicine, Mayo Clinic, Rochester, MN.
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Development and Evaluation of an Intensive Care Unit Video Series to Educate Staff on Delirium Detection. ATS Sch 2022; 3:535-547. [PMID: 36726713 PMCID: PMC9885989 DOI: 10.34197/ats-scholar.2022-0011oc] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 08/08/2022] [Indexed: 02/04/2023] Open
Abstract
Background Delirium affects up to 80% of patients who are mechanically ventilated in the intensive care unit (ICU) but often goes undetected because of incomplete and/or inaccurate clinician evaluation and documentation. A lack of effective, feasible, and sustainable educational methods represents a key barrier to efforts to optimize, scale, and sustain delirium detection competencies. Progress with such barriers may be addressed with asynchronous video-based education. Objective To evaluate a novel ICU Delirium Video Series for bedside providers via a knowledge assessment quiz and a feedback questionnaire. Methods An interdisciplinary team scripted and filmed an educational ICU Delirium Video Series, providing detailed instruction on delirium detection using the validated CAM-ICU (Confusion Assessment Method for the ICU). A cohort of bedside nurses subsequently viewed and evaluated the ICU Delirium Video Series using a feedback questionnaire and a previously developed knowledge assessment quiz pre- and post-video viewing. Results Twenty nurses from four ICUs viewed the ICU Delirium Video Series and completed the pre-post quiz and questionnaire. Ten (50%) respondents had 10 or more years of ICU experience, and seven (35%) reported receiving no CAM-ICU education locally. After video viewing, overall pre-post scores improved significantly (66% vs. 79%; P < 0.0001). In addition, after video viewing, more nurses reported comfort in their ability to evaluate and manage patients with delirium. Conclusion Viewing the ICU Delirium Video Series resulted in significant improvements in knowledge and yielded valuable feedback. Asynchronous video-based delirium education can improve knowledge surrounding a key bedside competency.
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Ditzel FL, Hut SC, Dijkstra-Kersten SM, Numan T, Leijten FS, van den Boogaard M, Slooter AJ. An automated electroencephalography algorithm to detect polymorphic delta activity in acute encephalopathy presenting as postoperative delirium. Psychiatry Clin Neurosci 2022; 76:676-678. [PMID: 36098948 DOI: 10.1111/pcn.13478] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/02/2022] [Accepted: 09/07/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Fienke L Ditzel
- Department of Intensive Care Medicine and University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Suzanne Ca Hut
- Department of Intensive Care Medicine and University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Sandra Ma Dijkstra-Kersten
- Department of Intensive Care Medicine and University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Tianne Numan
- Department of Intensive Care Medicine and University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Frans Ss Leijten
- Department of Clinical Neurophysiology, and University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Mark van den Boogaard
- Department of Intensive Care Medicine, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Arjen Jc Slooter
- Department of Intensive Care Medicine and University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Department of Neurology, UZ Brussel and Vrije Universiteit Brussel, Brussels, Belgium
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Denk A, Müller K, Schlosser S, Heissner K, Gülow K, Müller M, Schmid S. Liver diseases as a novel risk factor for delirium in the ICU-Delirium and hepatic encephalopathy are two distinct entities. PLoS One 2022; 17:e0276914. [PMID: 36413529 PMCID: PMC9681112 DOI: 10.1371/journal.pone.0276914] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 10/15/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Delirium prevalence is high in critical care settings. We examined the incidence, risk factors, and outcome of delirium in a medical intensive care unit (MICU) with a particular focus on liver diseases. We analyzed this patient population in terms of delirium risk prediction and differentiation between delirium and hepatic encephalopathy. METHODS We conducted an observational study and included 164 consecutive patients admitted to an MICU of a university hospital. Patients were assessed for delirium using the Confusion Assessment Method for ICUs and the Richmond Agitation-Sedation Scale (RASS). On admission and at the onset of delirium Sequential Organ Failure Assessment (SOFA) score was determined. A population of patients with liver disease was compared to a population with gastrointestinal diseases. In the population with liver diseases, hepatic encephalopathy was graded according to the West Haven classification. We analyzed the incidence, subtype, predisposing, precipitating, and health-care setting-related factors, treatment, outcome of delirium and the association between delirium and hepatic encephalopathy in patients with liver diseases. RESULTS The incidence of delirium was 32.5% (n = 53). Univariable binary regression analyses adjusted by the Holm-Bonferroni method showed that the development of delirium was significantly determined by 10 risk factors: Alcohol abuse (p = 0.016), severity of disease (Simplified Acute Physiology Score (SAPS) II, p = 0.016), liver diseases (p = 0.030) and sepsis (p = 0.016) compared to the control group (gastrointestinal (GI) diseases and others), increased sodium (p = 0.016), creatinine (p = 0.030), urea (p = 0.032) or bilirubin (p = 0.042), decreased hemoglobin (p = 0.016), and mechanical ventilation (p = 0.016). Of note, we identified liver diseases as a novel and relevant risk factor for delirium. Hepatic encephalopathy was not a risk factor for delirium. Delirium and hepatic encephalopathy are both life-threatening but clearly distinct conditions. The median SOFA score for patients with delirium at delirium onset was significantly higher than the SOFA score of all patients at admission (p = 0.008). Patients with delirium had five times longer ICU stays (p = 0.004) and three times higher in-hospital mortality (p = 0.036). Patients with delirium were five times more likely to be transferred to an intensive medical rehabilitation unit for post-intensive care (p = 0.020). Treatment costs per case were more than five times higher in patients with delirium than in patients without delirium (p = 0.004). CONCLUSIONS The 10 risk factors identified in this study should be assessed upon admission to ICU for effective detection, prevention, and treatment of delirium. Liver diseases are a novel risk factor for delirium with a level of significance comparable to sepsis as an established risk factor. Of note, in patients with liver diseases delirium and hepatic encephalopathy should be recognized as distinct entities to initiate appropriate treatment. Therefore, we propose a new algorithm for efficient diagnosis, characterization, and treatment of altered mental status in the ICU. This algorithm integrates the 10 risk factor prediction-model for delirium and prompts grading of the severity of hepatic encephalopathy using the West Haven classification if liver disease is present or newly diagnosed.
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Affiliation(s)
- Alexander Denk
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious diseases, University Hospital Regensburg, Regensburg, Germany
| | - Karolina Müller
- Center for Clinical Studies, University Hospital Regensburg, Regensburg, Germany
| | - Sophie Schlosser
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious diseases, University Hospital Regensburg, Regensburg, Germany
| | - Klaus Heissner
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious diseases, University Hospital Regensburg, Regensburg, Germany
| | - Karsten Gülow
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious diseases, University Hospital Regensburg, Regensburg, Germany
| | - Martina Müller
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious diseases, University Hospital Regensburg, Regensburg, Germany
| | - Stephan Schmid
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious diseases, University Hospital Regensburg, Regensburg, Germany
- * E-mail:
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Decreasing Delirium Through Family Presence: It Is a Complex Equation. Crit Care Med 2022; 50:1683-1685. [PMID: 36227042 DOI: 10.1097/ccm.0000000000005663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kalvas LB, Harrison TM, Solove S, Happ MB. Sleep disruption and delirium in critically ill children: Study protocol feasibility. Res Nurs Health 2022; 45:604-615. [PMID: 35986659 PMCID: PMC9529999 DOI: 10.1002/nur.22259] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 07/12/2022] [Accepted: 07/31/2022] [Indexed: 08/19/2023]
Abstract
Delirium is a serious complication of pediatric critical illness. Sleep disruption is frequently observed in children with delirium, and circadian rhythm dysregulation is one proposed cause of delirium. Children admitted to the pediatric intensive care unit (PICU) experience multiple environmental exposures with the potential to disrupt sleep. Although researchers have measured PICU light and sound exposure, sleep, and delirium, these variables have not yet been fully explored in a single study. Furthermore, caregiving patterns have not often been included as a component of the PICU environment. Measuring the light and sound exposure, caregiving patterns, and sleep of critically ill children requires continuous PICU bedside data collection. This presents multiple methodological challenges. In this paper, we describe the protocol for an observational pilot study of the PICU environment, sleep, and delirium experienced by a sample of 10 critically ill children 1-4 years of age. We also evaluate and discuss the feasibility (i.e., acceptability, implementation, practicality) of the study protocol. Light and sound exposure were measured with bedside sensors. Caregiving was quantified through video recording. Sleep was measured via actigraphy and confirmed by video recording. Delirium screening with the Cornell Assessment of Pediatric Delirium was conducted twice daily, either in person or via video review. This study provides a refined measurement framework to inform future, large-scale studies and the development of nurse-driven sleep promotion interventions.
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Affiliation(s)
- Laura Beth Kalvas
- Post-Docotral Fellow
- The Ohio State University College of Nursing, Columbus, OH
| | - Tondi M. Harrison
- The Ohio State University College of Nursing, Columbus, OH
- Associate Professor
| | - Sandra Solove
- The Ohio State University College of Nursing, Columbus, OH
- Research Regulatory Coordinator
| | - Mary Beth Happ
- The Ohio State University College of Nursing, Columbus, OH
- Senior Associate Dean for Research and Innovation
- Distinguished Professor of Critical Care Research
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Wojnar-Gruszka K, Sega A, Płaszewska-Żywko L, Wojtan S, Potocka M, Kózka M. Pain Assessment with the BPS and CCPOT Behavioral Pain Scales in Mechanically Ventilated Patients Requiring Analgesia and Sedation. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:10894. [PMID: 36078609 PMCID: PMC9517797 DOI: 10.3390/ijerph191710894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/19/2022] [Accepted: 08/30/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Intensive Care Unit (ICU) patients often experience pain, especially during diagnostic, nursing, and therapeutic interventions. Pain assessment using the Behavioral Pain Scale (BPS) and Critical Care Pain Observation Tool (CCPOT) are recommended, but they are difficult to do in patients undergoing deep sedation. This study analyzed the usefulness of the BPS and CCPOT scales in assessing pain among patients with varying degrees of sedation. METHODS In 81 mechanically ventilated and sedated ICU patients, 1005 measurements were performed using the BPS and CCPOT scales. The study was conducted by 3 trained observers 3 times a day (each measurement at rest, during painful nursing interventions, and after the intervention). The Richmond Agitation-Sedation Scale (RASS), the Simplified Acute Physiology Score (SAPS II), and the Acute Physiology and Chronic Health Evaluation (APACHE II) were also analyzed from medical records as well as information on the length of hospitalization and treatment. RESULTS It was shown that signs of pain increased significantly (p < 0.001) during interventions in patients on both scales (BPS and CCPOT), and then returned to values close to the resting period. RASS results correlated significantly (p < 0.05) and positively with the results of the BPS and CCPOT. A strong correlation was found between the results of both scales at each stage of the study (R = 0.622-0.907). CONCLUSIONS Nursing procedures are a source of pain in analgosedated patients. The BPS and CCPOT scales are useful tools for assessing the occurrence of pain in mechanically ventilated patients, including those in deep sedation.
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Affiliation(s)
- Katarzyna Wojnar-Gruszka
- Department of Clinical Nursing, Faculty of Health Sciences, Collegium Medicum, Jagiellonian University, 31-501 Kraków, Poland
| | - Aurelia Sega
- Department of Clinical Nursing, Faculty of Health Sciences, Collegium Medicum, Jagiellonian University, 31-501 Kraków, Poland
| | - Lucyna Płaszewska-Żywko
- Department of Clinical Nursing, Faculty of Health Sciences, Collegium Medicum, Jagiellonian University, 31-501 Kraków, Poland
| | - Stanisław Wojtan
- Department of Clinical Nursing, Faculty of Health Sciences, Collegium Medicum, Jagiellonian University, 31-501 Kraków, Poland
- Department of Anaesthesiology and Intensive Therapy, University Hospital in Kraków, 30-688 Kraków, Poland
| | - Marcelina Potocka
- Department of Clinical Nursing, Faculty of Health Sciences, Collegium Medicum, Jagiellonian University, 31-501 Kraków, Poland
| | - Maria Kózka
- Department of Clinical Nursing, Faculty of Health Sciences, Collegium Medicum, Jagiellonian University, 31-501 Kraków, Poland
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Lin L, Zhang X, Xu S, Peng Y, Li S, Huang X, Chen L, Lin Y. Outcomes of postoperative delirium in patients undergoing cardiac surgery: A systematic review and meta-analysis. Front Cardiovasc Med 2022; 9:884144. [PMID: 36017087 PMCID: PMC9395738 DOI: 10.3389/fcvm.2022.884144] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 07/21/2022] [Indexed: 11/13/2022] Open
Abstract
Background Postoperative delirium (POD) is an acute brain dysfunction that is frequently observed in patients undergoing cardiac surgery. Increasing evidence indicates POD is related to higher mortality among cardiac surgical patients, but the results remain controversial. Moreover, a quantitative evaluation of the influence of POD on hospital days, intensive care unit (ICU) time, and mechanical ventilation (MV) time has not been performed. Objective This study aimed to evaluate the correlation between POD and outcomes in patients undergoing cardiac surgery by a systematic review and meta-analysis. Materials and methods A total of 7 electronic databases (Cochrane Library, PubMed, EMBASE, CINAHL Complete, MEDLINE, Wan-fang database, and China National Knowledge Infrastructure) were searched from January 1980 to July 20, 2021, with language restrictions to English and Chinese, to estimate the impact of the POD on outcome in patients who underwent cardiac surgery. The meta-analysis was registered with PROSPERO (Registration: CRD42021228767). Results Forty-two eligible studies with 19785 patients were identified. 3368 (17.0%) patients were in the delirium group and 16417 (83%) were in the non-delirium group. The meta-analysis showed that compared to patients without POD, patients with POD had 2.77-fold higher mortality (OR = 2.77, 95% CI 1.86-4.11, P < 0.001), 5.70-fold higher MV (>24h) rate (OR = 5.70, 95% CI 2.93-11.09, P < 0.001); and longer MV time (SMD = 0.83, 95% CI 0.57-1.09, P < 0.001), ICU time (SMD = 0.91, 95% CI 0.60-1.22, P < 0.001), hospital days (SMD = 0.62, 95% CI 0.48-0.76, P < 0.001). Conclusion The synthesized evidence suggests that POD is causally related to the increased risk of mortality, prolonged length of ICU and hospital stay, and a longer duration of MV time. Future research should focus on the interventions for POD, to reduce the incidence. Systematic review registration [www.crd.york.ac.uk/PROSPERO], identifier [CRD42021228767].
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Affiliation(s)
- Lingyu Lin
- Department of Nursing, Fujian Medical University, Fuzhou, China
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Xuecui Zhang
- Department of Nursing, Fujian Medical University, Fuzhou, China
| | - Shurong Xu
- Department of Nursing, Fujian Medical University, Fuzhou, China
| | - Yanchun Peng
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Sailan Li
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Xizhen Huang
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Liangwan Chen
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yanjuan Lin
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Department of Nursing, Fujian Medical University Union Hospital, Fuzhou, China
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Austin CA, Yi J, Lin FC, Pandharipande P, Ely EW, Busby-Whitehead J, Carson SS. The Association of Selective Serotonin Reuptake Inhibitors With Delirium in Critically Ill Adults: A Secondary Analysis of the Bringing to Light the Risk Factors and Incidence of Neuropsychologic Dysfunction in ICU Survivors ICU Study. Crit Care Explor 2022; 4:e0740. [PMID: 35923593 PMCID: PMC9329078 DOI: 10.1097/cce.0000000000000740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES: To assess the association between selective serotonin reuptake inhibitors (SSRI) and delirium in the subsequent 24 hours after drug administration in critically ill adults. DESIGN: Retrospective cohort study utilizing the Bringing to Light the Risk Factors and Incidence of Neuropsychologic Dysfunction in ICU Survivors dataset. SETTING: Two large U.S. ICUs. PATIENTS: Critically ill adults admitted to a medical or surgery ICU between March 2007 and May 2010 with respiratory failure or shock. INTERVENTIONS: Our primary outcome was the occurrence rate of delirium or coma during each day in the ICU. Our exposure variable was SSRI administration on the prior day in the ICU. As a secondary question, we assessed the association of SSRI administration and delirium the same day of SSRI administration in the ICU. MEASUREMENTS AND MAIN RESULTS: We analyzed 821 patients. The median age was 61.2 years old (interquartile range, 50.9–70.7), and 401 (48.8%) were female. A total of 233 patients (28.4%) received prescribed SSRIs at least once during their ICU admission. Delirium was present in 606 (74%) of the patients at some point during hospitalization in the ICU. Coma was present in 532 (64.8%) of the patients at some point during hospitalization in the ICU. After adjusting for multiple potential confounding factors, we found that SSRI administration in the ICU was associated with lower odds of delirium/coma (odds ratio [OR], 0.75; 95% CI, 0.57–1.00) the next day. An SSRI administered on the same day reduced the odds of delirium/coma as well (OR, 0.66; 95% CI, 0.50–0.87). CONCLUSIONS: SSRI administration is associated with decreased risk of delirium/coma in 24 hours and on the same day of administration in critically ill patients in a medical or surgical ICU.
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Lin L, Peng Y, Zhang H, Huang X, Chen L, Lin Y. Family‐centred care interventions to reduce the delirium prevalence in critically ill patients: A systematic review and meta‐analysis. Nurs Open 2022; 9:1933-1942. [PMID: 35434971 PMCID: PMC9190678 DOI: 10.1002/nop2.1214] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 12/30/2021] [Accepted: 04/03/2022] [Indexed: 11/10/2022] Open
Abstract
Aim This study aimed to determine whether family‐centred care (FCC) intervention reduces the ICU delirium prevalence. Design A systematic review and meta‐analysis. Methods The databases, including PubMed, Cochrane Central Register of Controlled Trials, Web of Science, CINAHL Complete, China National Knowledge Infrastructure (CNKI), China Biology Medicine disc (CBMdisc), WANFANG Data and VIP Information, were systematically searched up to 30 November 2021. The search term includes keywords related to intensive care units, delirium and family‐centred care. Meta‐analyses were performed and presented by risk ratio (RR), mean difference (MD) and corresponding 95% confidence intervals (CIs). Results The meta‐analysis results showed that compared with the usual care, FCC intervention has positive effects on reducing ICU delirium prevalence [RR = 0.54, 95% CIs (0.36, 0.81), p < .05]. However, no effect was observed on ICU stays, mechanical ventilation duration and ICU‐acquired infection between the two groups. Conclusions Family‐centred care is an effective intervention to reduce the ICU delirium prevalence. But the result should be treated cautiously as the high levels of heterogeneity, further high‐quality studies are required to determine the effectiveness of FCC intervention in the ICU setting.
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Affiliation(s)
- Lingyu Lin
- School of Nursing Fujian medical University Fuzhou China
| | - Yanchun Peng
- Department of Cardiovascular Surgery Union Hospital Fujian Medical University Fuzhou China
| | - Haoruo Zhang
- Union Hospital Fujian Medical University Fuzhou China
| | - Xizhen Huang
- Department of Cardiovascular Surgery Union Hospital Fujian Medical University Fuzhou China
| | - Liangwan Chen
- Department of Cardiovascular Surgery Union Hospital Fujian Medical University Fuzhou China
| | - Yanjuan Lin
- Department of Cardiovascular Surgery Union Hospital Fujian Medical University Fuzhou China
- Department of Nursing Union Hospital Fujian Medical University Fuzhou China
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Austin CA, Szeto A, Gupta A, Wiltshire T, Crona DJ, Kistler C. The Pharmacogenetics of Opiates and Its Impact on Delirium in Mechanically Ventilated Adults: A Pilot Study. J Pharm Technol 2022; 38:195-201. [PMID: 35832565 PMCID: PMC9272493 DOI: 10.1177/87551225221085116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Pharmacogenetics may explain a substantial proportion of the variation seen in the efficacy and risk profile of analgesosedative drugs and the incidence of delirium in critically ill adults. Objectives: Conduct a feasibility study to demonstrate the reliability of collecting and analyzing pharmacogenetic information from critically ill patients and to assess the impact of pharmacogenetics on intensive care unit (ICU) outcomes. Methods: We prospectively enrolled subjects from the Medical ICU at the University of North Carolina (UNC). DNA was obtained via a buccal swab and evaluated using the DNA2Rx assay. We collected data on demographics, daily cumulative psychoactive medication exposure, and severity of illness. We performed daily delirium assessments via the CAM-ICU. We analyzed associations between select single nucleotide polymorphisms (SNPs) and delirium. Results: From June, 2018 through January, 2019, we screened 244 patients and enrolled 50. The median age was 62.0 years old (range: 28-82 years old), and 27 (54%) of the subjects were female. In all, 49 (98%) samples were both high quality and sufficient quantity. In secondary analyses, we found that 80% (12/15) of patients with two 2 copies of a G allele at rs4680 on COMT experienced delirium, whereas 44% (4/9) of patients with 2 copies of an A allele at this location had delirium. In all, 44% (4/9) of patients with 2 T allele copies at rs7439366 on UGT2B7 experienced delirium compared to 73% (11/15) of patients with 2 C allele copies at this location. Conclusions: We can feasibly collect genetic information from critically ill adults. We were able to efficiently collect high quality DNA of sufficient quantity to conduct pharmacogenetic analysis in this critically ill population. Although the sample size of our current study is too small to conduct robust inferential analyses, it suggests potential SNP targets for a future larger study.
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Affiliation(s)
- C. Adrian Austin
- Division of Pulmonary and Critical Care Medicine, Division of Geriatric Medicine, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Division of Geriatric Medicine, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Andy Szeto
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Apoorva Gupta
- School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Timothy Wiltshire
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | - Daniel J. Crona
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
- Department of Pharmacy, UNC Hospitals and Clinics, Chapel Hill, NC, USA
| | - Christine Kistler
- Division of Geriatric Medicine, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Family Medicine, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Tian Y, Qin Z, Han Y. Suvorexant with or without ramelteon to prevent delirium: a systematic review and meta-analysis. Psychogeriatrics 2022; 22:259-268. [PMID: 34881812 DOI: 10.1111/psyg.12792] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 11/01/2021] [Accepted: 11/23/2021] [Indexed: 12/12/2022]
Abstract
Delirium is a common and serious neurobehavioral syndrome, associated with prolonged hospital stays, and increased morbidity and mortality. As it remains unclear whether suvorexant with or without ramelteon prevents delirium in elderly hospitalized patients, we conducted a systematic review and meta-analysis to evaluate, searching the PubMed, Cochrane Library, Web of Science, EMBASE, and EBSCOhost databases for all randomized controlled trials (RCTs), case-control studies, and cohort studies that investigated the effects of suvorexant with or without ramelteon on delirium in adult hospitalized patients. The primary outcome was the incidence of delirium. Two randomized controlled trials, 7 cohort studies and 2 case-control studies involving 2594 patients were included in this meta-analysis. The results showed that both suvorexant alone (odds ratio (OR) = 0.30, 95% confidence interval (CI): 0.14-0.65, P = 0.002) and suvorexant with ramelteon (OR = 0.39, 95% CI 0.23-0.65, P = 0.0003) reduced the incidence of delirium in adult hospitalized patients. Six studies involved the use of benzodiazepines; subgroup analysis performed separately in the suvorexant alone and suvorexant with ramelteon groups indicated that when benzodiazepine was administered, suvorexant with ramelteon was effective at reducing the incidence of delirium (OR = 0.53, 95% CI 0.37-0.74, P = 0.0002), but no significant difference was observed for suvorexant alone (OR = 0.40, 95% CI 0.11-1.53, P = 0.18). The current literature thus supports the effectiveness of suvorexant with or without ramelteon for delirium prevention, although suvorexant alone failed to significantly reduce the incidence of delirium when benzodiazepine was administered. The present study was limited by the significant heterogeneity among the included studies, and caution should be exercised when interpreting the results. This study was registered in the PROSPERO database (CRD4202017964).
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Affiliation(s)
- Yu Tian
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zaisheng Qin
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yunyang Han
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
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Taylor AD, Chen A, Reddy AJ, Lewandowski A, Torbic H. Retrospective evaluation of a delirium order set utilizing nonpharmacologic and pharmacologic interventions for the treatment of delirium in medical intensive care unit patients. Am J Health Syst Pharm 2022; 79:S33-S42. [PMID: 35136926 DOI: 10.1093/ajhp/zxac042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE To describe the use of a medical intensive care unit (MICU) delirium order set pilot and its associated impact on utilization of nonpharmacologic and pharmacologic interventions, pharmacologic continuation at transitions of care, and resolution of ICU delirium. METHODS This was a retrospective cohort analysis of MICU patients who received delirium management using an order set pilot compared to standard care. Patients 18 years of age or older admitted to the MICU between May 2019 and January 2020 who received an antipsychotic or valproic acid for the treatment of delirium were included. RESULTS Pharmacologic treatment continuation past ICU discharge occurred in 30% of patients in the pilot cohort (n = 50) compared to 54% of patients receiving standard care (n = 50; P = 0.027). On treatment days 1 through 7, utilization of deliriogenic medications was significantly lower in the pilot cohort (78% vs 96%, P = 0.007). No differences were observed between the groups in delirium resolution, delirium recurrence, hospital and ICU length of stay, or mortality. CONCLUSION A MICU order set prioritizing nonpharmacologic management and limiting the duration of pharmacologic agents for delirium may aid providers in the management of ICU delirium and reduce exposure to pharmacologic interventions.
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Affiliation(s)
- Alex D Taylor
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | - Alyssa Chen
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | - Anita J Reddy
- Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Heather Torbic
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
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35
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Alvarez E, Gutierrez P. Discourse and micropower in the intervention with hospitalized elderly people with delirium: reflection on absent narratives. CADERNOS BRASILEIROS DE TERAPIA OCUPACIONAL 2022. [DOI: 10.1590/2526-8910.ctoarf240431372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Abstract In this essay, we analyze the interactions between elderly people (EP) hospitalized with delirium and the health team. To reflect on the construction of these interactions we rely on the philosopher Michel Foucault, in his presentation and book “Order of Discourse”, where we consider how micro-power social relations can be presented in various contexts, landing the interaction described from the strategies and discourse exclusion tactics. It is emphasized mainly i) reason and insanity, identified in EP hospitalized with delirium, which may have a narrative from the neurocognitive disorder, presenting an experience of isolation; on the other hand ii) the health team is based on determining what is true from what is false, using its knowledge and tactics from the process of diagnosis and intervention, which cannot collect the experiences of EP with delirium. Finally, we propose a new construction of the phenomenon from agency realism that integrates the knowledge of the health team and the experience of the EP with delirium.
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Affiliation(s)
- Evelyn Alvarez
- Universidad Diego Portales, Chile; Universidad de Chile, Chile
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36
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Lam MTY, Malhotra A, LaBuzetta JN, Kamdar BB. Sleep in Critical Illness. Respir Med 2022. [DOI: 10.1007/978-3-030-93739-3_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Alvarez E, Gutierrez P. Discurso y micropoder en la intervención con personas mayores con delirium hospitalizadas: reflexión en torno a las narrativas ausentes. CADERNOS BRASILEIROS DE TERAPIA OCUPACIONAL 2022. [DOI: 10.1590/2526-8910.ctoarf240431373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Resumen Este ensayo analiza ¿cómo son las interacciones entre las personas mayores (PM) hospitalizadas con delirium y el personal de salud? Para reflexionar en la construcción de estas interacciones, nos basamos en el filósofo Michel Foucault, en su presentación y libro del “Orden del Discurso”, donde consideramos como las relaciones sociales de micropoder pueden presentarse en diversos contextos, dialogando la interacción descrita desde las estrategias y tácticas de exclusión del discurso. Enfocamos sobre i) la razón y la locura, al identificar en las PM hospitalizadas con delirium, una narrativa desde el trastorno neurocognitivo, presentando una experiencia de aislamiento y por otro lado ii) el personal de salud, que se basa en determinar lo verdadero de lo falso, utilizando su conocimientos y tácticas desde el proceso de diagnóstico e intervención, el cual no logra recoger las experiencias de las PM con delirium. Por último, proponemos desde el realismo agencial una nueva construcción del fenómeno, que integre el conocimiento del personal de salud y la experiencia de las PM con delirium.
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Affiliation(s)
- Evelyn Alvarez
- Universidad Diego Portales, Chile; Universidad de Chile, Chile
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38
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Williamson CA, Faiver L, Nguyen AM, Ottenhoff L, Rajajee V. Incidence, Predictors and Outcomes of Delirium in Critically Ill Patients With COVID-19. Neurohospitalist 2021; 12:31-37. [PMID: 34950384 PMCID: PMC8385278 DOI: 10.1177/19418744211034815] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background and Purpose: A variety of neurological manifestations have been attributed to COVID-19, but there is currently limited evidence regarding risk factors and outcomes for delirium in critically ill patients with COVID-19. The purpose of this study was to identify delirium in a large cohort of ICU patients with COVID-19, and to identify associated features and clinical outcomes at the time of hospital discharge. Methods: This is an observational cohort study of 213 consecutive patients admitted to an ICU for COVID-19 respiratory illness. Delirium was diagnosed by trained abstractors using the CHART-DEL instrument. The associations between key clinical features, sedation and delirium were examined, as were the impacts of delirium on clinical outcomes. Results: Delirium was identified in 57.3% of subjects. Delirious patients were more likely to receive mechanical ventilation, had lower P: F ratios, higher rates of renal replacement therapy and ECMO, and were more likely to receive enteral benzodiazepines. Only mechanical ventilation remained a significant predictor of delirium in a logistic regression model. Mortality was not significantly different, but delirious patients experienced greater mechanical ventilation duration, ICU/hospital lengths of stay, worse functional outcomes at discharge, and were less likely to be discharged home. Conclusions: Delirium is common in critically ill patients with COVID-19 and appears to be associated with greater disease severity. When present, delirium is associated with worse functional status at discharge, but not increased mortality. Additional studies are necessary to determine the generalizability of these results and the impact of delirium on longer-term cognitive and functional outcomes.
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Affiliation(s)
- Craig A Williamson
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA.,Department of Neurology, University of Michigan, Ann Arbor, MI, USA.,Center for Integrative Research in Critical Care, University of Michigan, Ann Arbor, MI, USA
| | - Laura Faiver
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Andrew M Nguyen
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Lauren Ottenhoff
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA.,Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Venkatakrishna Rajajee
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA.,Department of Neurology, University of Michigan, Ann Arbor, MI, USA.,Center for Integrative Research in Critical Care, University of Michigan, Ann Arbor, MI, USA
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Geen O, Rochwerg B, Wang XM. Optimisation des soins chez les personnes âgées gravement malades. CMAJ 2021; 193:E1850-1859. [PMID: 34872961 PMCID: PMC8648358 DOI: 10.1503/cmaj.210652-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Olivia Geen
- Division de médecine gériatrique (Geen, Wang) et de médecine de soins intensifs (Rochwerg), Départements de médecine et des méthodes, impacts et données probantes de la recherche en santé (Rochwerg), Université McMaster, Hamilton, Ont.
| | - Bram Rochwerg
- Division de médecine gériatrique (Geen, Wang) et de médecine de soins intensifs (Rochwerg), Départements de médecine et des méthodes, impacts et données probantes de la recherche en santé (Rochwerg), Université McMaster, Hamilton, Ont
| | - Xuyi Mimi Wang
- Division de médecine gériatrique (Geen, Wang) et de médecine de soins intensifs (Rochwerg), Départements de médecine et des méthodes, impacts et données probantes de la recherche en santé (Rochwerg), Université McMaster, Hamilton, Ont
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Effect of Patient and Family Centred Care interventions for adult intensive care unit patients and their families: A systematic review and meta-analysis. Intensive Crit Care Nurs 2021; 69:103156. [PMID: 34753631 DOI: 10.1016/j.iccn.2021.103156] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 09/05/2021] [Accepted: 09/08/2021] [Indexed: 11/05/2022]
Abstract
OBJECTIVES To assess the evidence for the feasibility and effect of patient and familycentred care interventions provided in the intensive care unit, single or multicomponent, versus usual care, for reducing delirium, anxiety, depression and post-traumatic stress disorder in patients and family-members. DESIGN A systematic review and meta-analysis following the PRISMA guidelines and GRADE approach. A systematic literature search of relevant databases, screening and inclusion of studies, data extraction and assessment of risk of bias according to Cochrane methodology. The study is preregistered on PROSPERO (CRD42020160768). SETTING Adult intensive care units. RESULTS Nine randomised controlled trials enrolling a total of 1170 patients and 1226 family-members were included. We found moderate to low certainty evidence indicating no effect of patient and family centred care on delirium, anxiety, depression, post-traumatic stress disorder, in-hospital mortality, intensive care length of stay or family-members' anxiety, depression and post-traumatic stress disorder. No studies looked at the effect of patient and family centred care on pain or cognitive function in patients. Evaluation of feasibility outcomes was scarce. The certainty of the evidence was low to moderate, mainly due to substantial risk of bias in individual studies and imprecision due to few events and small sample size. CONCLUSION It remains uncertain whether patient and family centred care compared to usual care may reduce delirium in patients and psychological sequelae of intensive care admission in patients and families due to limited evidence of moderate to low certainty. Lack of systematic process evaluation of intervention feasibility as recommended by the Medical Research Council to identify barriers and facilitators of patient and family centred care in the adult intensive care unit context, further limits the conclusions that can be drawn.
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van Delft L, Valkenet K, Slooter A, Veenhof C. Perceptions and ideas of critically ill patients, their family and staff members regarding family participation in the physiotherapy-related care of critically ill patients: a qualitative study. Physiother Theory Pract 2021; 38:2856-2873. [PMID: 34696667 DOI: 10.1080/09593985.2021.1990451] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Involvement of families in physiotherapy-related tasks of critically ill patients could be beneficial for both patients and their family. Before designing an intervention regarding family participation in the physiotherapy-related care of critically ill patients, there is a need to investigate the opinions of critically ill patients, their family and staff members in detail. OBJECTIVE Exploring the perceptions of critically ill patients, their family and staff members regarding family participation in physiotherapy-related tasks of critically ill patients and the future intervention. METHODS A multicenter study with a qualitative design is presented. Semistructured interviews were conducted with critically ill patients, family and intensive care staff members, until theoretical saturation was reached. The conventional content method was used for data analyses. RESULTS Altogether 18 interviews were conducted between May 2019 and February 2020. In total, 22 participants were interviewed: four patients, five family members, and 13 ICU staff members. Six themes emerged: 1) prerequisites for family participation (e.g., permission and capability); 2) timing and interactive aspects of engaging family (e.g., communication); 3) eligibility of patients and family (e.g., first-degree relatives and spouses, and long stay patients); 4) suitability of physiotherapy-related tasks for family (e.g., passive, active and breathing exercises); 5) expected effects (e.g., physical recovery and psychological wellbeing); and 6) barriers and facilitators, which may affect the feasibility (e.g., safety, privacy, and responsibility). CONCLUSION Patients, family members and staff members supported the idea of increased family participation in physiotherapy-related tasks and suggested components of an intervention. These findings are necessary to further design and investigate family participation in physiotherapy-related tasks.
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Affiliation(s)
- Lotte van Delft
- Department of Rehabilitation, Physiotherapy Science and Sport, University Medical Center Utrecht Brain Center, Utrecht University, Utrecht, Netherlands
| | - Karin Valkenet
- Department of Rehabilitation, Physiotherapy Science and Sport, University Medical Center Utrecht Brain Center, Utrecht University, Utrecht, Netherlands
| | - Arjen Slooter
- Department of Intensive Care Medicine, University Medical Center Utrecht Brain Center, Utrecht University, Utrecht, Netherlands
| | - Cindy Veenhof
- Department of Rehabilitation, Physiotherapy Science and Sport, University Medical Center Utrecht Brain Center, Utrecht University, Utrecht, Netherlands.,Research Group Innovation of Human Movement Care, Hu University of Applied Science, Utrecht, Netherlands
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Lee HJ, Bae E, Lee HY, Lee SM, Lee J. Association of natural light exposure and delirium according to the presence or absence of windows in the intensive care unit. Acute Crit Care 2021; 36:332-341. [PMID: 34696555 PMCID: PMC8907453 DOI: 10.4266/acc.2021.00556] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 08/07/2021] [Indexed: 11/30/2022] Open
Abstract
Background Patients in the intensive care unit (ICU) have increased risks of delirium, which is associated with worse outcomes. As pharmacologic treatments for delirium are ineffective, prevention is important. Nonpharmacologic preventive strategies include exposure to natural light and restoring circadian rhythm. We investigated the effect of exposure to natural light through windows on delirium in the ICU. Methods This retrospective cohort study assessed all patients admitted to the medical ICU of a university-affiliated hospital between January and June 2020 for eligibility. The ICU included 12 isolation rooms, six with and six without windows. Patients with ICU stays of >48 hours were included and were divided into groups based on their admission to a single room with (window group) or without windows (windowless group). The primary outcome was the cumulative incidence of delirium. The secondary outcomes were the numbers of delirium- and mechanical ventilation-free days, ICU and hospital length of stay, and in-ICU and 28-day mortalities. Results Of the 150 included patients (window group: 83 [55.3%]; windowless group: 67 [44.7%]), the cumulative incidence of delirium was significantly lower in the window group than in the windowless group (21.7% vs. 43.3%; relative risk, 1.996; 95% confidence interval [CI], 1.220–3.265). Other secondary outcomes did not differ between groups. Admission to a room with a window was independently associated with a decreased risk of delirium (adjusted odds ratio, 0.318; 95% CI, 0.125–0.805). Conclusions Exposure to natural light through windows was associated with a lower incidence of delirium in the ICU.
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Affiliation(s)
- Hyo Jin Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Eunhye Bae
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hong Yeul Lee
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea
| | - Sang-Min Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jinwoo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
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Affiliation(s)
- Olivia Geen
- Divisions of Geriatric Medicine (Geen, Wang) and Critical Care Medicine (Rochwerg), Department of Medicine, and Department of Health Research Methods, Impact and Evidence (Rochwerg), McMaster University, Hamilton, Ont.
| | - Bram Rochwerg
- Divisions of Geriatric Medicine (Geen, Wang) and Critical Care Medicine (Rochwerg), Department of Medicine, and Department of Health Research Methods, Impact and Evidence (Rochwerg), McMaster University, Hamilton, Ont
| | - Xuyi Mimi Wang
- Divisions of Geriatric Medicine (Geen, Wang) and Critical Care Medicine (Rochwerg), Department of Medicine, and Department of Health Research Methods, Impact and Evidence (Rochwerg), McMaster University, Hamilton, Ont
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Reducing Delirium in Hospitalized Adults Through a Structured Sleep Promotion Program. J Nurs Care Qual 2021; 36:149-154. [PMID: 32568963 DOI: 10.1097/ncq.0000000000000499] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Delirium affects approximately 1 in 4 patients during their hospitalization and is associated with numerous complications. Sleep deprivation is a significant risk factor for developing delirium and is a patient dissatisfier. PROBLEM An internal assessment revealed that up to 25% of all patients on medical-surgical units had a diagnosis of delirium while in the hospital. APPROACH An evidence-based practice project was implemented to reduce the development of delirium through sleep promotion on 2 inpatient units. A dedicated time was selected, and key strategies were identified to promote sleep with minimal interruptions. OUTCOMES Delirium decreased by 33% and 45% on the 2 units over 1 year. Overall, patient satisfaction for quietness at night survey responses also increased (P = .0005; CI, 0.05 to 0.67) with ongoing sustainment. CONCLUSIONS Implementation of a dedicated period to sleep was associated with a reduction in delirium and increased patient satisfaction for quietness at night.
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45
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Stollings JL, Kotfis K, Chanques G, Pun BT, Pandharipande PP, Ely EW. Delirium in critical illness: clinical manifestations, outcomes, and management. Intensive Care Med 2021; 47:1089-1103. [PMID: 34401939 PMCID: PMC8366492 DOI: 10.1007/s00134-021-06503-1] [Citation(s) in RCA: 106] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 07/29/2021] [Indexed: 12/22/2022]
Abstract
Delirium is the most common manifestation of brain dysfunction in critically ill patients. In the intensive care unit (ICU), duration of delirium is independently predictive of excess death, length of stay, cost of care, and acquired dementia. There are numerous neurotransmitter/functional and/or injury-causing hypotheses rather than a unifying mechanism for delirium. Without using a validated delirium instrument, delirium can be misdiagnosed (under, but also overdiagnosed and trivialized), supporting the recommendation to use a monitoring instrument routinely. The best-validated ICU bedside instruments are CAM-ICU and ICDSC, both of which also detect subsyndromal delirium. Both tools have some inherent limitations in the neurologically injured patients, yet still provide valuable information about delirium once the sequelae of the primary injury settle into a new post-injury baseline. Now it is known that antipsychotics and other psychoactive medications do not reliably improve brain function in critically ill delirious patients. ICU teams should systematically screen for predisposing and precipitating factors. These include exacerbations of cardiac/respiratory failure or sepsis, metabolic disturbances (hypoglycemia, dysnatremia, uremia and ammonemia) receipt of psychoactive medications, and sensory deprivation through prolonged immobilization, uncorrected vision and hearing deficits, poor sleep hygiene, and isolation from loved ones so common during COVID-19 pandemic. The ABCDEF (A2F) bundle is a means to facilitate implementation of the 2018 Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (PADIS) Guidelines. In over 25,000 patients across nearly 100 institutions, the A2F bundle has been shown in a dose-response fashion (i.e., greater bundle compliance) to yield improved survival, length of stay, coma and delirium duration, cost, and less ICU bounce-backs and discharge to nursing homes.
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Affiliation(s)
- Joanna L Stollings
- Critical Illness Brain Dysfunction Survivorship Center, Nashville, Vanderbilt University Medical Center, 1211 Medical Center Drive, B-131 VUH, Nashville, TN, 37232-7610, USA.
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Katarzyna Kotfis
- Department Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, Szczecin, Poland
| | - Gerald Chanques
- Department of Anaesthesia and Critical Care Medicine, Saint Eloi Hospital, Montpellier University Hospital Center, and PhyMedExp, University of Montpellier, INSERM, CNRS, Montpellier, France
| | - Brenda T Pun
- Critical Illness Brain Dysfunction Survivorship Center, Nashville, Vanderbilt University Medical Center, 1211 Medical Center Drive, B-131 VUH, Nashville, TN, 37232-7610, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Pratik P Pandharipande
- Critical Illness Brain Dysfunction Survivorship Center, Nashville, Vanderbilt University Medical Center, 1211 Medical Center Drive, B-131 VUH, Nashville, TN, 37232-7610, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - E Wesley Ely
- Critical Illness Brain Dysfunction Survivorship Center, Nashville, Vanderbilt University Medical Center, 1211 Medical Center Drive, B-131 VUH, Nashville, TN, 37232-7610, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA
- Geriatric Research, Education and Clinical Center Service, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care System, Nashville, TN, USA
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Association of Histamine-2 Blockers and Proton-Pump Inhibitors With Delirium Development in Critically Ill Adults: A Retrospective Cohort Study. Crit Care Explor 2021; 3:e0507. [PMID: 34396144 PMCID: PMC8357254 DOI: 10.1097/cce.0000000000000507] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Supplemental Digital Content is available in the text. OBJECTIVES: Histamine-2 receptor antagonists are commonly administered for stress ulcer prophylaxis in critically ill adults and may be associated with delirium development. We aimed to determine differential associations of histamine-2 receptor antagonist or proton-pump inhibitor administration with delirium development in patients admitted to a medical ICU. DESIGN: Retrospective observational study using a deidentified database sourced from the University of North Carolina Health Care system. Participants were identified as having delirium utilizing an International Classification of Diseases-based algorithm. Associations among histamine-2 receptor antagonist, proton-pump inhibitor, or no medication administration and delirium were identified using relative risk. Multiple logistic regression was used to control for potential confounders including mechanical ventilation and age. SETTING: Academic tertiary care medical ICU in the United States. PATIENTS: Adults admitted to the University of North Carolina medical ICU from January 2015 to December 2019, excluding those on concurrent histamine-2 receptor antagonists and proton-pump inhibitors in the same encounter. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We identified 6,645 critically ill patients, of whom 29% (n = 1,899) received mechanical ventilation, 45% (n = 3,022) were 65 or older, and 22% (n = 1,487) died during their medical ICU encounter. Of the 6,645 patients, 31% (n = 2,057) received an histamine-2 receptor antagonist and no proton-pump inhibitors, 40% (n = 2,648) received a proton-pump inhibitor and no histamine-2 receptor antagonists, and 46% (n = 3,076) had delirium. The histamine-2 receptor antagonist group had a greater association with delirium than the proton-pump inhibitor group compared with controls receiving neither medication, after controlling for mechanical ventilation and age (risk ratio, 1.36; 1.25–1.47; p < 0.001) and (risk ratio, 1.15; 1.07–1.24; p < 0.001, respectively). CONCLUSIONS: Histamine-2 receptor antagonists are more strongly associated with increased delirium than proton-pump inhibitors. Prospective studies are necessary to further elucidate this association and to determine if replacement of histamine-2 receptor antagonists with proton-pump inhibitors in ICUs decreases the burden of delirium in critically ill patients.
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The stability of quetiapine oral suspension compounded from commercially available tablets. PLoS One 2021; 16:e0255963. [PMID: 34375349 PMCID: PMC8354457 DOI: 10.1371/journal.pone.0255963] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 07/27/2021] [Indexed: 11/19/2022] Open
Abstract
Quetiapine fumarate (QF) is an atypical antipsychotic used off-label for the treatment of delirium in critically-ill infants and children. For the treatment of pediatric populations or patient populations with trouble swallowing tablets, an oral suspension would be an ideal dosage formulation. However, there are no liquid formulations of QF commercially available. Therefore, a compounded oral suspension prepared from the commercial QF tablets is widely used in clinical settings. The extemporaneous preparation of QF compounded oral suspension changes the formulation from a solid form to a liquid form. Thus, the stability of QF compounded oral suspension should be critically evaluated to guide pharmacists for administration and storage of QF compounded oral suspensions. However, the stability of the nonaqueous oral QF suspension was not measured. The objective of this study was to develop QF compounded oral suspensions at 10 mg/mL by using commercial QF tablets in two readily available aqueous vehicles (Ora-Sweet and Ora-Blend) and measure their stability at both room temperature and under refrigeration. Physical stability of the QF compounded suspensions were evaluated by appearance and odor. Chemical stability of the QF compounded suspensions were evaluated based on pH, degradation, drug content and the amount of the drug dissolved in the vehicles. An HPLC method was validated and used to evaluate QF compounded suspensions over 60 days. In addition to the total drug in the suspensions, the dissolved drug in the vehicles was also measured during the stability testing and evaluated as a stability parameter. Overall, QF suspension prepared in Ora-Blend was preferable, demonstrating a superior 60-day stability at both room temperature and refrigerated storage.
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Affiliation(s)
- Sarah Jane Palmer
- Registered nurse and freelance writer, based at the Department of Work and Pensions as a disability analyst
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Li X, Wang Y, Liu J, Xiong Y, Chen S, Han J, Xie W, Wu Q. Effects of perioperative interventions for preventing postoperative delirium: A protocol for systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore) 2021; 100:e26662. [PMID: 34398027 PMCID: PMC8294881 DOI: 10.1097/md.0000000000026662] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 06/24/2021] [Accepted: 06/28/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Postoperative delirium (POD) not only increases the medical burden but also adversely affects patient prognosis. Although some cases of delirium can be avoided by early intervention, there is no clear evidence indicating whether any of these measures can effectively prevent POD in specific patient groups. OBJECTIVE The aim of this meta-analysis was to compare the efficacy and safety of the existing preventive measures for managing POD. METHODS The PubMed, OVID (Embase and MEDLINE), Web of Science, and the Cochrane Library databases were searched for articles published before January 2020. The relevant randomized controlled trials (RCTs) were selected based on the inclusion and exclusion criteria. Data extraction and methodological quality assessment were performed according to a predesigned data extraction form and scoring system, respectively. The interventions were compared on the basis of the primary outcome like incidence of POD, and secondary outcomes like duration of delirium and the length of intensive care unit and hospital stay. RESULTS Sixty-three RCTs were included in the study, covering interventions like surgery, anesthesia, analgesics, intraoperative blood glucose control, cholinesterase inhibitors, anticonvulsant drugs, antipsychotic drugs, sleep rhythmic regulation, and multi-modal nursing. The occurrence of POD was low in 4 trials that monitored the depth of anesthesia with bispectral index during the operation (P < .0001). Two studies showed that supplementary analgesia was useful for delirium prevention (P = .002). Seventeen studies showed that perioperative sedation with α2-adrenergic receptor agonists prevented POD (P = .0006). Six studies showed that both typical and atypical antipsychotic drugs can reduce the incidence of POD (P = .002). Multimodal nursing during the perioperative period effectively reduced POD in 6 studies (P < .00001). Furthermore, these preventive measures can reduce the duration of delirium, as well as the total and postoperative length of hospitalized stay for non-cardiac surgery patients. For patients undergoing cardiac surgery, effective prevention can only reduce the length of intensive care unit stay. CONCLUSION Measures including intraoperative monitoring of bispectral index, supplemental analgesia, α2-adrenergic receptor agonists, antipsychotic drugs, and multimodal care are helpful to prevent POD effectively. However, larger, high-quality RCTs are needed to verify these findings and develop more interventions and drugs for preventing postoperative delirium.
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Huang S, Xu J, Du Y, Wang Y, Wei H, Wei G, Hu M. The effect of evidence-based cluster nursing intervention on the incidences of delirium and the prognoses of ICU patients. Am J Transl Res 2021; 13:8309-8315. [PMID: 34377321 PMCID: PMC8340266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 03/29/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE This study explored the effect of evidence-based cluster nursing intervention on the incidences of delirium and the prognoses of ICU patients. METHODS 108 ICU patients admitted to our hospital from January 2020 to June 2020 were recruited as the study cohort and randomly divided into a control group and an observation group, with 54 cases in each group. The patients in the control group underwent routine nursing intervention, and the patients in the observation group underwent evidence-based cluster nursing intervention. The incidences of delirium, the durations of the mechanical ventilation, the ICU hospitalization durations, as well as the satisfaction levels in the two groups of patients were compared. RESULT The incidences of delirium in the observation group were conspicuously lower than they were in the control group (14.81%, 40.74%, X 2 = 9.0462, P = 0.0026). The duration of the delirium in the observation group was conspicuously lower than it was in the control group (2.87 ± 1.28), (5.21 ± 1.33), t = 9.3155, P = 0.0000. The durations of the mechanical ventilation and the ICU hospitalizations in the observation group were conspicuously shorter than they were in the control group. The differences were statistically significant (P < 0.05). The nursing satisfaction levels in the observation group were conspicuously higher than they were in the control group (94.44%, 72.22%, X 2 = 9.6000, P = 0.0019). There was no significant difference in the in-hospital mortality between the two groups (X2 = 2.1862, 0.1393). CONCLUSION Evidence-based cluster nursing intervention can conspicuously reduce the incidences of delirium, shorten the durations of the mechanical ventilation and the ICU stays, and improve patient prognosis, so it is worthy of clinical application.
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Affiliation(s)
- Suping Huang
- Department of Nursing, Shenzhen Longhua District Central HospitalShenzhen 518110, China
| | - Jiaqing Xu
- Department of Nursing, Piking University Shenzhen HospitalShenzhen 518110, China
| | - Yunbo Du
- Department of Critical Care Medicine, Shenzhen Longhua District Central HospitalShenzhen 518110, China
| | - Yanmei Wang
- Department of Nursing, Shenzhen Longhua District Central HospitalShenzhen 518110, China
| | - Hong Wei
- Department of Nursing, Shenzhen Longhua District Central HospitalShenzhen 518110, China
| | - Guiju Wei
- Department of Nursing, Shenzhen Longhua District Central HospitalShenzhen 518110, China
| | - Min Hu
- Department of Nursing, Shenzhen Longhua District Central HospitalShenzhen 518110, China
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