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Saavedra-Mitjans M, Van der Maren S, Gosselin N, Duclos C, Frenette AJ, Arbour C, Burry L, Williams V, Bernard F, Williamson DR. Use of actigraphy for monitoring agitation and rest-activity cycles in patients with acute traumatic brain injury in the ICU. Brain Inj 2024; 38:692-698. [PMID: 38635547 DOI: 10.1080/02699052.2024.2341323] [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: 11/10/2023] [Accepted: 04/05/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND In traumatic brain injury patients (TBI) admitted to the intensive care unit (ICU), agitation can lead to accidental removal of catheters, devices as well as self-extubation and falls. Actigraphy could be a potential tool to continuously monitor agitation. The objectives of this study were to assess the feasibility of monitoring agitation with actigraphs and to compare activity levels in agitated and non-agitated critically ill TBI patients. METHODS Actigraphs were placed on patients' wrists; 24-hour monitoring was continued until ICU discharge or limitation of therapeutic efforts. Feasibility was assessed by actigraphy recording duration and missing activity count per day. RESULTS Data from 25 patients were analyzed. The mean number of completed day of actigraphy per patient was 6.5 ± 5.1. The mean missing activity count was 20.3 minutes (±81.7) per day. The mean level of activity measured by raw actigraphy counts per minute over 24 hours was higher in participants with agitation than without agitation. CONCLUSIONS This study supports the feasibility of actigraphy use in TBI patients in the ICU. In the acute phase of TBI, agitated patients have higher levels of activity, confirming the potential of actigraphy to monitor agitation.
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Affiliation(s)
- Mar Saavedra-Mitjans
- Faculté de Pharmacie, Université de Montréal, Montréal (Québec), Canada
- Research Centre, Centre intégré universitaire de Santé et de Services sociaux du Nord-de-l'île-de-Montréal, Montreal, Canada
| | - Solenne Van der Maren
- Center for Advanced Research in Sleep Medicine, Centre intégré universitaire de santé et de Services sociaux du Nord-de-l'île-de-Montréal, Montreal, Canada
- Département de Psychologie, Université de Montréal, Montréal (Québec), Canada
| | - Nadia Gosselin
- Center for Advanced Research in Sleep Medicine, Centre intégré universitaire de santé et de Services sociaux du Nord-de-l'île-de-Montréal, Montreal, Canada
- Département de Psychologie, Université de Montréal, Montréal (Québec), Canada
| | - Catherine Duclos
- Center for Advanced Research in Sleep Medicine, Centre intégré universitaire de santé et de Services sociaux du Nord-de-l'île-de-Montréal, Montreal, Canada
- Department of Anesthesiology and Pain Medicine, Department of Neuroscience, Faculté de médecine, Université de Montréal, Montréal (Québec), Canada
- CIFAR Azrieli Global Scholars Program, Toronto, Canada
| | - Anne Julie Frenette
- Research Centre, Centre intégré universitaire de Santé et de Services sociaux du Nord-de-l'île-de-Montréal, Montreal, Canada
- Pharmacy Department, Centre intégré universitaire de santé et de Services sociaux du Nord-de-l'île-de-Montréal, Montreal, Canada
| | - Caroline Arbour
- Faculté de Pharmacie, Université de Montréal, Montréal (Québec), Canada
- Faculté de Sciences Infirmières, Université de Montréal, Montréal (Québec), Canada
| | - Lisa Burry
- Department of Pharmacy and Medicine, Sinai Health System, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Virginie Williams
- Faculté de Pharmacie, Université de Montréal, Montréal (Québec), Canada
| | - Francis Bernard
- Faculté de Pharmacie, Université de Montréal, Montréal (Québec), Canada
- Faculté de Médecine, Université de Montréal, Montréal (Québec), Canada
| | - David R Williamson
- Faculté de Pharmacie, Université de Montréal, Montréal (Québec), Canada
- Research Centre, Centre intégré universitaire de Santé et de Services sociaux du Nord-de-l'île-de-Montréal, Montreal, Canada
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Snow R, Shamshad A, Helliwell A, Wendell LC, Thompson BB, Furie KL, Reznik ME, Mahta A. Predictors of hospital length of stay and long-term care facility placement in aneurysmal subarachnoid hemorrhage. World Neurosurg X 2024; 22:100320. [PMID: 38440380 PMCID: PMC10911846 DOI: 10.1016/j.wnsx.2024.100320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 02/21/2024] [Indexed: 03/06/2024] Open
Abstract
Background Aneurysmal subarachnoid hemorrhage (aSAH) is frequently associated with complications, extended hospital length of stay (LOS) and high health care related costs. We sought to determine predictors for hospital LOS and discharge disposition to a long-term care facility (LTCF) in aSAH patients. Methods We performed a retrospective study of a prospectively collected cohort of consecutive patients with aSAH admitted to an academic referral center from 2016 to 2021. Multiple linear regression was performed to identify predictors for hospital LOS. We then created a 10-point scoring system to predict discharge disposition to a LTCF. Results In a cohort of 318 patients with confirmed aSAH, mean age was 57 years (SD 13.7), 61% were female and 70% were white. Hospital LOS was longer for survivors (median 19 days, IQR 14-25) than for non-survivors (median 5 days, IQR 2-8; p < 0.001). Main predictors for longer LOS for this cohort were ventriculoperitoneal shunt (VPS) requirement (p < 0.001), delayed cerebral ischemia (p = 0.026), and pneumonia (p = 0.014). The strongest predictor for LTCF disposition was age older than 60 years (OR 1.14, 95% CI 1.07-1.21; p < 0.001). LTCF score had high accuracy in predicting discharge disposition to a LTCF (area under the curve [AUC] 0.83; 95% CI 0.75-0.91). Forty-one percent of patients who were discharged to a LTCF had significant functional recovery at 3 months post-discharge. Conclusions VPS requirement and aSAH related complications were associated with longer hospital LOS compared to other factors. LTCF score has high accuracy in predicting discharge disposition to a LTCF.
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Affiliation(s)
- Ryan Snow
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Alizeh Shamshad
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Alexandra Helliwell
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Linda C. Wendell
- Division of Neurology, Mount Auburn Hospital, Cambridge, MA, USA
| | | | - Karen L. Furie
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Michael E. Reznik
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
- Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Ali Mahta
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
- Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
- Section of Medical Education, Warren Alpert Medical School of Brown University, Providence, RI, USA
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Raquer AP, Fong CT, Walters AM, Souter MJ, Lele AV. Delirium and Its Associations with Critical Care Utilizations and Outcomes at the Time of Hospital Discharge in Patients with Acute Brain Injury. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:304. [PMID: 38399591 PMCID: PMC10890045 DOI: 10.3390/medicina60020304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 01/30/2024] [Accepted: 02/08/2024] [Indexed: 02/25/2024]
Abstract
Background and Objectives: We analyzed delirium testing, delirium prevalence, critical care associations outcomes at the time of hospital discharge in patients with acute brain injury (ABI) due to acute ischemic stroke (AIS), non-traumatic subarachnoid hemorrhage (SAH), non-traumatic intraparenchymal hemorrhage (IPH), and traumatic brain injury (TBI) admitted to an intensive care unit. Materials and Methods: We examined the frequency of assessment for delirium using the Confusion Assessment Method for the intensive care unit. We assessed delirium testing frequency, associated factors, positive test outcomes, and their correlations with clinical care, including nonpharmacological interventions and pain, agitation, and distress management. Results: Amongst 11,322 patients with ABI, delirium was tested in 8220 (726%). Compared to patients 18-44 years of age, patients 65-79 years (aOR 0.79 [0.69, 0.90]), and those 80 years and older (aOR 0.58 [0.50, 0.68]) were less likely to undergo delirium testing. Compared to English-speaking patients, non-English-speaking patients (aOR 0.73 [0.64, 0.84]) were less likely to undergo delirium testing. Amongst 8220, 2217 (27.2%) tested positive for delirium. For every day in the ICU, the odds of testing positive for delirium increased by 1.11 [0.10, 0.12]. Delirium was highest in those 80 years and older (aOR 3.18 [2.59, 3.90]). Delirium was associated with critical care resource utilization and with significant odds of mortality (aOR 7.26 [6.07, 8.70] at the time of hospital discharge. Conclusions: In conclusion, we find that seven out of ten patients in the neurocritical care unit are tested for delirium, and approximately two out of every five patients test positive for delirium. We demonstrate disparities in delirium testing by age and preferred language, identified high-risk subgroups, and the association between delirium, critical care resource use, complications, discharge GCS, and disposition. Prioritizing equitable testing and diagnosis, especially for elderly and non-English-speaking patients, is crucial for delivering quality care to this vulnerable group.
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Affiliation(s)
- Alex P. Raquer
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA 99202, USA;
| | - Christine T. Fong
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA 98104, USA; (C.T.F.); (A.M.W.); (M.J.S.)
| | - Andrew M. Walters
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA 98104, USA; (C.T.F.); (A.M.W.); (M.J.S.)
| | - Michael J. Souter
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA 98104, USA; (C.T.F.); (A.M.W.); (M.J.S.)
- Neurocritical Care Service, Harborview Medical Center, Seattle, WA 98104, USA
| | - Abhijit V. Lele
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA 98104, USA; (C.T.F.); (A.M.W.); (M.J.S.)
- Neurocritical Care Service, Harborview Medical Center, Seattle, WA 98104, USA
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Chotai S, Chen JW, Turer R, Smith C, Kelly PD, Bhamidipati A, Davis P, McCarthy JT, Bendfeldt GA, Peyton MB, Dennis BM, Terry DP, Guillamondegui O, Yengo-Kahn AM. Neurological Examination Frequency and Time-to-Delirium After Traumatic Brain Injury. Neurosurgery 2023; 93:1425-1431. [PMID: 37326424 DOI: 10.1227/neu.0000000000002562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 04/17/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND Frequent neurological examinations in patients with traumatic brain injury (TBI) disrupt sleep-wake cycles and potentially contribute to the development of delirium. OBJECTIVE To evaluate the risk of delirium among patients with TBI with respect to their neuro-check frequencies. METHODS A retrospective study of patients presenting with TBI at a single level I trauma center between January 2018 and December 2019. The primary exposure was the frequency of neurological examinations (neuro-checks) assigned at the time of admission. Patients admitted with hourly (Q1) neuro-check frequencies were compared with those who received examinations every 2 (Q2) or 4 (Q4) hours. The primary outcomes were delirium and time-to-delirium. The onset of delirium was defined as the first documented positive Confusion Assessment Method for the Intensive Care Unit score. RESULTS Of 1552 patients with TBI, 458 (29.5%) patients experienced delirium during their hospital stay. The median time-to-delirium was 1.8 days (IQR: 1.1, 2.9). Kaplan-Meier analysis demonstrated that patients assigned Q1 neuro-checks had the greatest rate of delirium compared with the patients with Q2 and Q4 neuro-checks ( P < .001). Multivariable Cox regression modeling demonstrated that Q2 neuro-checks (hazard ratio: 0.439, 95% CI: 0.33-0.58) and Q4 neuro-checks (hazard ratio: 0.48, 95% CI: 0.34-0.68) were protective against the development of delirium compared with Q1. Other risk factors for developing delirium included pre-existing dementia, tobacco use, lower Glasgow Coma Scale score, higher injury severity score, and certain hemorrhage patterns. CONCLUSION Patients with more frequent neuro-checks had a higher risk of developing delirium compared with those with less frequent neuro-checks.
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Affiliation(s)
- Silky Chotai
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville , Tennessee , USA
| | - Jeffrey W Chen
- Vanderbilt University School of Medicine, Nashville , Tennessee , USA
| | - Robert Turer
- Department of Emergency Medicine, University of Texas Southwestern, Dallas , Texas , USA
| | - Candice Smith
- Division of Trauma and Surgicaxzl Critical Care, Vanderbilt University Medical Center, Nashville , Tennessee , USA
| | - Patrick D Kelly
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville , Tennessee , USA
| | | | - Philip Davis
- Vanderbilt University School of Medicine, Nashville , Tennessee , USA
| | - Jack T McCarthy
- Vanderbilt University School of Medicine, Nashville , Tennessee , USA
| | | | - Mary B Peyton
- Vanderbilt University School of Medicine, Nashville , Tennessee , USA
| | - Bradley M Dennis
- Division of Trauma and Surgicaxzl Critical Care, Vanderbilt University Medical Center, Nashville , Tennessee , USA
| | - Douglas P Terry
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville , Tennessee , USA
| | - Oscar Guillamondegui
- Division of Trauma and Surgicaxzl Critical Care, Vanderbilt University Medical Center, Nashville , Tennessee , USA
| | - Aaron M Yengo-Kahn
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville , Tennessee , USA
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Miao Q, Yan Y, Zhou M, Sun X. The Role of Nursing Care in the Management of Patients with Traumatic Subarachnoid Hemorrhage. Galen Med J 2023; 12:1-11. [PMID: 38774855 PMCID: PMC11108670 DOI: 10.31661/gmj.v12i0.3013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Indexed: 05/24/2024] Open
Abstract
Traumatic subarachnoid hemorrhage (tSAH) is a critical condition that requires comprehensive management to optimize patient outcomes. Nursing care plays a key role in the overall management of patients with tSAH via various aspects of care, including neurological assessment, monitoring, intervention, and education. In this review, we aim to evaluate the significant contributions of nursing care in managing patients with tSAH. Nurses perform initial neurological assessments, including the glasgow coma scale, pupil reactivity, vital signs, and sensory-motor evaluations. These assessments provide valuable information for early identification of deteriorating neurological status and prompt intervention. Additionally, nurses closely monitor intracranial pressure (ICP), cerebral perfusion pressure, and other hemodynamic parameters, assisting in the prevention and timely detection of secondary brain injury. For example, some strategies to manage ICP include elevating the head of the bed, maintaining adequate oxygenation and ventilation, administering proper medications, and ensuring fluid and electrolyte balance. Also, through careful monitoring, early recognition, and appropriate preventive measures, nursing care could prevent complications, including infections, deep vein thrombosis, and pressure ulcers. Furthermore, nursing care extends beyond physical management and encompasses psychosocial support for patients and their families. Nurses establish therapeutic relationships, providing emotional support, education, and counseling to alleviate anxiety, address concerns, and facilitate coping mechanisms. Education regarding medication management, lifestyle modifications, and the importance of regular follow-up enhances patient compliance and promotes long-term recovery.
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Affiliation(s)
- Qun Miao
- Department of Neurosurgery, Funan County People’s Hospital, Fuyang, Anhui 236300,
China
| | - Yan Yan
- Department of Neurosurgery, Funan County People’s Hospital, Fuyang, Anhui 236300,
China
| | - Mengjie Zhou
- Department of Neurosurgery, Funan County People’s Hospital, Fuyang, Anhui 236300,
China
| | - Xueqi Sun
- Department of Neurosurgery, Funan County People’s Hospital, Fuyang, Anhui 236300,
China
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Bauernfreund Y, Launders N, Favarato G, Hayes JF, Osborn D, Sampson EL. Incidence and associations of hospital delirium diagnoses in 85,979 people with severe mental illness: A data linkage study. Acta Psychiatr Scand 2023; 147:516-526. [PMID: 35869544 PMCID: PMC10952251 DOI: 10.1111/acps.13480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 07/12/2022] [Accepted: 07/18/2022] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Delirium is an acute neuro-psychiatric disturbance precipitated by a range of physical stressors, with high morbidity and mortality. Little is known about its relationship with severe mental illness (SMI). METHODS We conducted a retrospective cohort study using linked data analyses of the UK Clinical Practice Research Datalink (CPRD) and Hospital Episodes Statistics (HES) databases. We ascertained yearly hospital delirium incidence from 2000 to 2017 and used logistic regression to identify associations with delirium diagnosis in a population with SMI. RESULTS The cohort included 249,047 people with SMI with median follow-up time in CPRD of 6.4 years. A total of 85,979 patients were eligible for linkage to HES. Delirium incidence increased from 0.04 (95% CI 0.02-0.07) delirium associated admissions per 100 person-years in 2000 to 1.05 (95% CI 0.93-1.17) per 100 person-years in 2017, increasing most notably from 2010 onwards. Delirium was associated with older age at study entry (OR 1.05 per year, 95% CI 1.05-1.06), SMI diagnosis of bipolar affective disorder (OR 1.66, 95% CI 1.44-1.93) or other psychosis (OR 1.56, 95% CI 1.35-1.80) relative to schizophrenia, and more physical comorbidities (OR 1.08 per additional comorbidity of the Charlson Comorbidity Index, 95% CI 1.02-1.14). Patients with delirium received more antipsychotic medication during follow-up (1-2 antipsychotics OR 1.65, 95% CI 1.44-1.90; >2 antipsychotics OR 2.49, 95% CI 2.12-2.92). CONCLUSIONS The incidence of recorded delirium diagnoses in people with SMI has increased in recent years. Older people prescribed more antipsychotics and with more comorbidities have a higher incidence. Linked electronic health records are feasible for exploring hospital diagnoses such as delirium in SMI.
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Affiliation(s)
- Yehudit Bauernfreund
- Division of PsychiatryUniversity College LondonLondonUK
- Camden & Islington NHS Foundation TrustLondonUK
| | | | | | - Joseph F. Hayes
- Division of PsychiatryUniversity College LondonLondonUK
- Camden & Islington NHS Foundation TrustLondonUK
| | - David Osborn
- Division of PsychiatryUniversity College LondonLondonUK
- Camden & Islington NHS Foundation TrustLondonUK
| | - Elizabeth L. Sampson
- Division of PsychiatryUniversity College LondonLondonUK
- Department of Psychological MedicineEast London NHS Foundation Trust, Royal London HospitalLondonUK
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Woon C. A Literature Review: Violence and Aggression in Neuroscience Nursing. J Neurosci Nurs 2023; 55:60-64. [PMID: 36857134 DOI: 10.1097/jnn.0000000000000692] [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: 03/02/2023]
Abstract
ABSTRACT BACKGROUND: Violence and aggression is commonly encountered in nursing worldwide and is an increasing concern, although it is largely underreported by staff. Violence and aggression can take many forms, from verbal and physical abuse to sexual assault. This study aims to define agitation, violence, and aggression and to explore the prevalence of violence and aggression among neuroscience patients. This review also examines why violence and aggression occurs for neuroscience patients and to determine the effects on the patients, the environment, and the nursing staff. METHODS: A review of articles was conducted using CINAHL, PubMed, the Cochrane Database, and Google Scholar between 2012 and 2022. DISCUSSION: Agitation can escalate to violence and aggression. The reasons a neuroscience patient may become agitated are multifactorial. An injury to the brain may not cause agitation; however, the effect on the frontal lobe, hypothalamus, and hippocampus may cause a lack of self-control, impulsivity, an inability to control emotions, and an uncontrolled release of hormones, leading to a heightened sympathetic response. The effects of violence and aggression can be detrimental to the patient and include isolation, increased sedation, reduced observations, and even death. The effects on the nurse are profound including a decline in productivity at work, an increased risk of drug errors, and posttraumatic stress disorder or burnout as longer-term consequences. CONCLUSION: Violence and aggression is commonly experienced within neuroscience nursing, and the contributing factors are multifactorial. The effects for the patients and staff can be profound, and this is why prevention of agitation is fundamental to ensure the safety and retention of nursing staff.
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Affiliation(s)
- Caroline Woon
- Questions or comments about this article may be directed to Caroline Woon at . C.W. is a Neuroscience Clinical Nurse Educator, Wellington Hospital, Wellington, New Zealand
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Ramnarain D, Den Oudsten B, Oldenbeuving A, Pouwels S, De Vries J. Post-Intensive Care Syndrome in Patients Suffering From Acute Subarachnoid Hemorrhage: Results From an Outpatient Post-ICU Aftercare Clinic. Cureus 2023; 15:e36739. [PMID: 37123775 PMCID: PMC10139679 DOI: 10.7759/cureus.36739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2023] [Indexed: 03/29/2023] Open
Abstract
Introduction Survivors of an acute subarachnoid hemorrhage (aSAH) may suffer from a long-term neurological disability, cognitive impairment, anxiety, and depression, which can also be related to post-intensive care syndrome (PICS). The aim of this study was to examine the prevalence of PICS symptoms in post-intensive care (ICU) aftercare aSAH patients. Methods We conducted an observational cohort study in aSAH patients from a post-ICU aftercare clinic (ICU-AC). PICS symptoms were evaluated using the Impact of Event Scale-Revised (IES-R), Hospital Anxiety and Depression Scale (HADS), and a medical questionnaire for physical and cognitive functioning. Results A total of 110 patients were included. The prevalence of anxiety and depressive symptoms was 23.6% and 19.1%, respectively. Post-traumatic stress disorder (PTSD) was seen in 26.4%. Cognitive complaints were lack of concentration (63.6%), short-term memory loss (45.8%), and reduced speed of thinking (60.9%). The most reported physical complaints were fatigue (73.6%), limitations in daily activity (72.7%), muscle weakness (41.8%), pain (36.4%), and weight loss (30.9%). PICS symptoms related to all three domains were present in 30% of patients. Conclusion The prevalence of PICS in patients after aSAH is high. Even in patients without aSAH-related neurological impairment who were discharged home, a high prevalence of PICS symptoms was reported. Early screening for PICS should comprise all three domains and is important to facilitate a better tailored rehabilitation of these patients.
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Li YC, Wang R, A JY, Sun RB, Na SJ, Liu T, Ding XS, Ge WH. Cerebrospinal fluid metabolic profiling reveals divergent modulation of pentose phosphate pathway by midazolam, propofol and dexmedetomidine in patients with subarachnoid hemorrhage: a cohort study. BMC Anesthesiol 2022; 22:34. [PMID: 35086470 PMCID: PMC8793156 DOI: 10.1186/s12871-022-01574-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 01/20/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Agitation is common in subarachnoid hemorrhage (SAH), and sedation with midazolam, propofol and dexmedetomidine is essential in agitation management. Previous research shows the tendency of dexmedetomidine and propofol in improving long-term outcome of SAH patients, whereas midazolam might be detrimental. Brain metabolism derangement after SAH might be interfered by sedatives. However, how sedatives work and whether the drugs interfere with patient outcome by altering cerebral metabolism is unclear, and the comprehensive view of how sedatives regulate brain metabolism remains to be elucidated. METHODS For cerebrospinal fluid (CSF) and extracellular space of the brain exchange instantly, we performed a cohort study, applying CSF of SAH patients utilizing different sedatives or no sedation to metabolomics. Baseline CSF metabolome was corrected by selecting patients of the same SAH and agitation severity. CSF components were analyzed to identify the most affected metabolic pathways and sensitive biomarkers of each sedative. Markers might represent the outcome of the patients were also investigated. RESULTS Pentose phosphate pathway was the most significantly interfered (upregulated) pathway in midazolam (p = 0.0000107, impact = 0.35348) and propofol (p = 0.00000000000746, impact = 0.41604) groups. On the contrary, dexmedetomidine decreased levels of sedoheptulose 7-phosphate (p = 0.002) and NADP (p = 0.024), and NADP is the key metabolite and regulator in pentose phosphate pathway. Midazolam additionally augmented purine synthesis (p = 0.00175, impact = 0.13481) and propofol enhanced pyrimidine synthesis (p = 0.000203, impact = 0.20046), whereas dexmedetomidine weakened pyrimidine synthesis (p = 0.000000000594, impact = 0.24922). Reduced guanosine diphosphate (AUC of ROC 0.857, 95%CI 0.617-1, p = 0.00506) was the significant CSF biomarker for midazolam, and uridine diphosphate glucose (AUC of ROC 0.877, 95%CI 0.631-1, p = 0.00980) for propofol, and succinyl-CoA (AUC of ROC 0.923, 95%CI 0.785-1, p = 0.000810) plus adenosine triphosphate (AUC of ROC 0.908, 95%CI 0.6921, p = 0.00315) for dexmedetomidine. Down-regulated CSF succinyl-CoA was also associated with favorable outcome (AUC of ROC 0.708, 95% CI: 0.524-0.865, p = 0.029333). CONCLUSION Pentose phosphate pathway was a crucial target for sedatives which alter brain metabolism. Midazolam and propofol enhanced the pentose phosphate pathway and nucleotide synthesis in poor-grade SAH patients, as presented in the CSF. The situation of dexmedetomidine was the opposite. The divergent modulation of cerebral metabolism might further explain sedative pharmacology and how sedatives affect the outcome of SAH patients.
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Affiliation(s)
- Yi-Chen Li
- Department of Pharmacy, Nanjing Drum Tower Hospital Affiliated to Nanjing University Medical School, Nanjing, 210008, China
- Department of Neurosurgery, Nanjing Drum Tower Hospital Affiliated to Nanjing University Medical School, Nanjing, 210008, China
- Nanjing Medical Center of Clinical Pharmacy, Nanjing, 210008, China
| | - Rong Wang
- Department of Neurosurgery, Nanjing Drum Tower Hospital Affiliated to Nanjing University Medical School, Nanjing, 210008, China.
| | - Ji-Ye A
- Key Laboratory of Drug Metabolism and Pharmacokinetics, China Pharmaceutical University, Nanjing, 210009, China
| | - Run-Bin Sun
- Key Laboratory of Drug Metabolism and Pharmacokinetics, China Pharmaceutical University, Nanjing, 210009, China
| | - Shi-Jie Na
- Department of Neurosurgery, Nanjing Drum Tower Hospital Affiliated to Nanjing University Medical School, Nanjing, 210008, China
| | - Tao Liu
- Department of Neurosurgery, Nanjing Drum Tower Hospital Affiliated to Nanjing University Medical School, Nanjing, 210008, China
| | - Xuan-Sheng Ding
- Department of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, 210009, China
| | - Wei-Hong Ge
- Department of Pharmacy, Nanjing Drum Tower Hospital Affiliated to Nanjing University Medical School, Nanjing, 210008, China
- Nanjing Medical Center of Clinical Pharmacy, Nanjing, 210008, China
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Akiyama K, Inoue A, Hifumi T, Nakamura K, Taira T, Nakagawa S, Jinno K, Manabe A, Kinugasa S, Matsumura H, Shishido H, Yokoyama S, Okazaki T, Hamaya H, Takano K, Kiridume K, Shinohara N, Kawakita K, Kuroda Y. Association between physical restraint requirement and unfavorable neurologic outcomes in subarachnoid hemorrhage. J Intensive Care 2021; 9:24. [PMID: 33712088 PMCID: PMC7952502 DOI: 10.1186/s40560-021-00541-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 02/26/2021] [Indexed: 11/16/2022] Open
Abstract
Background Physical restraint has been commonly indicated to patients with brain dysfunction in neurocritical care. The effect of physical restraints on outcomes of critically ill adults remains controversial as no randomized controlled trials have compared its safety and efficacy, and the association between physical restraint requirement and neurological outcome in patients with subarachnoid hemorrhage (SAH) has not been fully examined. The aim of this study was to examine the association between physical restraint requirement and neurological outcomes in patients with SAH. Methods A single-center, retrospective study was conducted on patients with acute phase SAH treated for > 72 h in the intensive care unit from 2014 to 2020. Patients were divided into three groups based on the amount of time required for physical restraint during the first 24–72 h after admission: no, intermittent, and continuous use of physical restraint. Unfavorable neurologic outcome, assessed using the modified Rankin scale upon hospital discharge, has been considered as primary end point. Results Overall, 101 patients were included in the study, with 52 patients (51.5%) having unfavorable neurological outcomes. Among them, 46 patients (45.5%) did not use physical restraint, and 55 (54.5%) patients used physical restraint during the first 24–72 h after admission: 26 (25.7%) intermittent and 29 (28.7%) continuous. Multivariable logistic regression analysis showed that continuous use of physical restraint during the first 24–72 h after admission was significantly associated with unfavorable neurological outcomes in patients with SAH (odds ratio, 3.54; 95% confidence interval, 1.05–13.06; p = 0.042) compared with no physical restraint. Conclusions Continuous use of physical restraint during the first 24–72 h after admission was more significantly associated with unfavorable neurological outcomes than no physical restraint among patients with SAH during the acute phase. Supplementary Information The online version contains supplementary material available at 10.1186/s40560-021-00541-z.
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Affiliation(s)
- Kyoko Akiyama
- Department of Nursing, Kagawa University Hospital, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan
| | - Akihiko Inoue
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, 1-3-1 Wakinohamakaiganndori, Chuo-ku, Kobe, Hyogo, 651-0073, Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, 104-8560, Japan.
| | - Kentaro Nakamura
- Emergency Medical Center, Kagawa University Hospital, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan
| | - Takuya Taira
- Emergency Medical Center, Kagawa University Hospital, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan
| | - Shun Nakagawa
- Emergency Medical Center, Kagawa University Hospital, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan
| | - Keisuke Jinno
- Emergency Medical Center, Kagawa University Hospital, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan
| | - Arisa Manabe
- Emergency Medical Center, Kagawa University Hospital, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan
| | - Sayaka Kinugasa
- Emergency Medical Center, Kagawa University Hospital, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan
| | - Hikaru Matsumura
- Emergency Medical Center, Kagawa University Hospital, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan
| | - Hajime Shishido
- Emergency Medical Center, Kagawa University Hospital, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan
| | - Shota Yokoyama
- Emergency Medical Center, Kagawa University Hospital, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan
| | - Tomoya Okazaki
- Emergency Medical Center, Kagawa University Hospital, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan
| | - Hideyuki Hamaya
- Emergency Medical Center, Kagawa University Hospital, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan
| | - Koshiro Takano
- Emergency Medical Center, Kagawa University Hospital, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan
| | - Kazutaka Kiridume
- Emergency Medical Center, Kagawa University Hospital, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan
| | - Natsuyo Shinohara
- Emergency Medical Center, Kagawa University Hospital, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan
| | - Kenya Kawakita
- Emergency Medical Center, Kagawa University Hospital, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan
| | - Yasuhiro Kuroda
- Emergency Medical Center, Kagawa University Hospital, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan
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Reimann F, Rinner T, Lindner A, Kofler M, Ianosi BA, Schiefecker AJ, Beer R, Schmutzhard E, Pfausler B, Helbok R, Rass V. Hyperactive delirium in patients after non-traumatic subarachnoid hemorrhage. J Crit Care 2021; 64:45-52. [PMID: 33794466 DOI: 10.1016/j.jcrc.2021.02.010] [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] [Received: 11/12/2020] [Revised: 01/18/2021] [Accepted: 02/25/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE Hyperactive delirium is common after subarachnoid hemorrhage (SAH). We aimed to identify risk factors for delirium and to evaluate its impact on outcome. METHODS We collected daily Richmond Agitation Sedation Scale (RASS) and Intensive Care Delirium Screening Checklist (ICDSC) scores in 276 SAH patients. Hyperactive delirium was defined as ICDSC ≥4 when RASS was >0. We investigated risk factors for delirium and its association with 3-month functional outcome using generalized linear models. RESULTS Patients were 56 (IQR 47-67) years old and had a Hunt&Hess (H&H) grade of 3 (IQR 1-5). Sixty-five patients (24%) developed hyperactive delirium 6 (IQR 3-16) days after SAH. In multivariable analysis, mechanical ventilation>48 h (adjOR = 4.46; 95%-CI = 1.89-10.56; p = 0.001), the detection of an aneurysm (adjOR = 4.38; 95%-CI = 1.48-12.97; p = 0.008), a lower H&H grade (adjOR = 0.63; 95%-CI = 0.48-0.83; p = 0.001) and a pre-treated psychiatric disorder (adjOR = 3.17; 95%-CI = 1.14-8.83; p = 0.027) were associated with the development of delirium. Overall, delirium was not associated with worse outcome (p = 0.119). Interestingly, patients with delirium more often had a modified Rankin Scale Score (mRS) of 1-3 (77%) compared to an mRS of 0 (14%) or 4-6 (9%). CONCLUSION Our data indicate that hyperactive delirium is common after SAH patients and requires a certain degree of brain connectivity based ono the highest prevalence found in SAH patients with intermediate outcomes.
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Affiliation(s)
- Fabian Reimann
- Department of Neurology, Neurological Intensive Care Unit, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Thomas Rinner
- Department of Neurology, Neurological Intensive Care Unit, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Anna Lindner
- Department of Neurology, Neurological Intensive Care Unit, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Mario Kofler
- Department of Neurology, Neurological Intensive Care Unit, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Bogdan-Andrei Ianosi
- Department of Neurology, Neurological Intensive Care Unit, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria; Institute of Medical Informatics, UMIT: University for Health Sciences, Biomedical Informatics and Mechatronics, Medical Informatics and Technology, Eduard Wallnoefer-Zentrum 1, 6060 Hall i.T, Austria
| | - Alois Josef Schiefecker
- Department of Neurology, Neurological Intensive Care Unit, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Ronny Beer
- Department of Neurology, Neurological Intensive Care Unit, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Erich Schmutzhard
- Department of Neurology, Neurological Intensive Care Unit, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Bettina Pfausler
- Department of Neurology, Neurological Intensive Care Unit, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Raimund Helbok
- Department of Neurology, Neurological Intensive Care Unit, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.
| | - Verena Rass
- Department of Neurology, Neurological Intensive Care Unit, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
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12
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Williamson DR, Cherifa SI, Frenette AJ, Saavedra Mitjans M, Charbonney E, Cataford G, Williams V, Lainer Palacios J, Burry L, Mehta S, Arbour C, Bernard F. Agitation, confusion, and aggression in critically ill traumatic brain injury-a pilot cohort study (ACACIA-PILOT). Pilot Feasibility Stud 2020; 6:193. [PMID: 33308318 PMCID: PMC7729148 DOI: 10.1186/s40814-020-00736-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 11/30/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Agitated behaviors are problematic in intensive care unit (ICU) patients recovering from traumatic brain injury (TBI) as they create substantial risks and challenges for healthcare providers. To date, there have been no studies evaluating their epidemiology and impact in the ICU. Prior to planning a multicenter study, assessment of recruitment, feasibility, and pilot study procedures is needed. In this pilot study, we aimed to evaluate the feasibility of conducting a large multicenter prospective cohort study. METHODS This feasibility study recruited adult patients admitted to the ICU with TBI and an abnormal cerebral CT scan. In all patients, we documented Richmond Agitation Sedation Score (RASS) and agitated behaviors every 8-h nursing shift using a dedicated tool documenting 14 behaviors. Our feasibility objectives were to obtain consent from at least 2 patients per month; completion of screening logs for agitated behaviors by bedside nurses for more than 90% of 8-h shifts; completion of data collection in an average of 6 h or less; and obtain 6-month follow-up for surviving patients. The main clinical outcome was the incidence of agitation and individual agitated behaviors. RESULTS In total, 47 eligible patients were approached for inclusion and 30 (64% consent rate) were recruited over a 10-month period (3 patients/month). In total, 794 out of 827 (96%) possible 8-h periods of agitated behavior logs were completed by bedside nurses, with a median of 24 observations (IQR 28.0) per patient. During the ICU stay, 17 of 30 patients developed agitation (56.7%; 95% CI 0.37-0.75) defined as RASS ≥ 2 during at least one observation period and for a median of 4 days (IQR 5.5). At 6 months post-TBI, among the 24 available patients, an unfavorable score (GOS-E < 5 including death) was reported in 12 patients (50%). In the 14 patients who were alive and available at 6 months, the median QOLIBRI score was 74.5 (IQR 18.5). CONCLUSIONS This study demonstrates the feasibility of conducting a larger cohort study to evaluate the epidemiology and impact of agitated behaviors in critically ill TBI patients. This study also shows that agitated behaviors are frequent and are associated with adverse events.
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Affiliation(s)
- David R Williamson
- Faculté de Pharmacie, Université de Montréal, Montréal, Canada. .,Research centre, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montréal, Canada. .,Pharmacy Department, Hôpital du Sacré-Cœur de Montréal, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montréal, Canada.
| | - Sofia Ihsenne Cherifa
- Faculté de Pharmacie, Université de Montréal, Montréal, Canada.,Research centre, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montréal, Canada
| | - Anne Julie Frenette
- Faculté de Pharmacie, Université de Montréal, Montréal, Canada.,Research centre, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montréal, Canada.,Pharmacy Department, Hôpital du Sacré-Cœur de Montréal, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montréal, Canada
| | - Mar Saavedra Mitjans
- Faculté de Pharmacie, Université de Montréal, Montréal, Canada.,Research centre, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montréal, Canada
| | - Emmanuel Charbonney
- Research centre, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montréal, Canada.,Faculté de Médecine, Université de Montréal, Montréal, Canada.,Critical care, Hôpital du Sacré-Cœur de Montréal, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montréal, Canada
| | - Gabrielle Cataford
- Faculté de Pharmacie, Université de Montréal, Montréal, Canada.,Research centre, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montréal, Canada
| | - Virginie Williams
- Research centre, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montréal, Canada
| | - Julia Lainer Palacios
- Research centre, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montréal, Canada
| | - Lisa Burry
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada.,Pharmacy Department, Mount Sinai Hospital, Toronto, Canada
| | - Sangeeta Mehta
- Department of Medicine, Sinai Health System, and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Caroline Arbour
- Research centre, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montréal, Canada.,Faculté de sciences infirmières, Université de Montréal, Montréal, Canada
| | - Francis Bernard
- Research centre, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montréal, Canada.,Faculté de Médecine, Université de Montréal, Montréal, Canada.,Critical care, Hôpital du Sacré-Cœur de Montréal, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montréal, Canada
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13
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14
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Dispersion in Scores on the Richmond Agitation and Sedation Scale as a Measure of Delirium in Patients with Subdural Hematomas. Neurocrit Care 2020; 30:626-634. [PMID: 30506177 DOI: 10.1007/s12028-018-0649-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Delirium is a frequent complication of critical illness, but its diagnosis is more difficult in brain-injured patients due to language impairment and disorders of consciousness. We conducted a prospective cohort study to determine whether Richmond Agitation and Sedation Scale (RASS) scores could be used to reliably diagnose delirium in the setting of brain injury. We also examined clinical factors associated with delirium in patients with subdural hematomas (SDH) and assessed its impact on functional outcome at discharge. METHODS We prospectively enrolled 55 patients with the primary diagnosis of SDH admitted to the neurological intensive care unit (ICU) and screened them for delirium with the Confusion Assessment Method-ICU (CAM-ICU). As our primary outcome, we examined whether the standard deviation of RASS scores (RASS dispersion) could be used to diagnose delirium. We also looked at trends in RASS scores as a way to distinguish different causes of delirium. Then, using logistic regression, we identified factors associated with delirium in patients with SDH and quantified the impact of delirium on the modified Rankin Scale at discharge. RESULTS Delirium as defined by the CAM-ICU was present in 35% (N = 19) of patients. RASS dispersion correlated well with the CAM-ICU (AUC of the ROC was 0.84). Analyzing the temporal trend of changes in the RASS was helpful in identifying new brain injuries as the underlying etiology of CAM-ICU positivity. Age, APACHE II scores on admission, baseline functional impairment, midline shift on initial imaging, and infections were associated with an increased risk of delirium. Delirium was associated with a worse functional outcome. CONCLUSIONS RASS dispersion correlates highly with CAM-ICU positivity, and monitoring trends in RASS scores can identify delirium caused by new brain injuries. Delirium as defined by the CAM-ICU is common in patients with SDH and portends worse outcomes.
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15
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Deconstructing Poststroke Delirium in a Prospective Cohort of Patients With Intracerebral Hemorrhage*. Crit Care Med 2020; 48:111-118. [DOI: 10.1097/ccm.0000000000004031] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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17
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Guenna Holmgren A, Juth N, Lindblad A, von Vogelsang AC. Restraint in a Neurosurgical Setting: A Mixed-Methods Study. World Neurosurg 2019; 133:104-111. [PMID: 31568917 DOI: 10.1016/j.wneu.2019.09.105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 09/18/2019] [Accepted: 09/19/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To investigate the extent to which restraint is used in neurosurgical care, under what circumstances, and how it is documented. METHODS A cross-sectional study with a mixed-methods approach was used to identify neurosurgical inpatients subjected to restraint. The data were collected in 2 phases: (1) a study-specific questionnaire was distributed to nurses in which they identified if restraints had occurred during their shifts, and if so, which restraint and to which patient; and (2) scrutinizing of electronic medical records of patients identified by the questionnaires. Numeric data were analyzed using descriptive and analytic statistical methods, and textual data were analyzed using qualitative content analysis. The findings from the different data sources were compared and merged. RESULTS Of the 517 patients admitted to the studied department during the study period, 58 (11%) were reported to have been subjected to restraint and most of the restraining events occurred in the neurointensive care unit. Most restraint measures were not documented in the electronic medical records. The identified patients were predominantly diagnosed with traumatic brain injury or subarachnoid hemorrhage. The qualitative content analysis showed the circumstances when restraints were used: when patients were considered a danger to self or others (theme) and which symptoms and behaviors (categories) were observed in relation to the use of restraint. CONCLUSIONS Restraint in neurosurgical care is mostly used to prevent patients from harming themselves or others. Because of the lack of documentation, restraint measures cannot be openly assessed, thus putting patients' safety at risk.
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Affiliation(s)
- Amina Guenna Holmgren
- Department of Learning, Informatics, Management and Ethics (LIME), Stockholm Centre for Healthcare Ethics (CHE), Karolinska Institutet, Stockholm, Sweden; Neuro Theme, Karolinska University Hospital, Stockholm, Sweden.
| | - Niklas Juth
- Department of Learning, Informatics, Management and Ethics (LIME), Stockholm Centre for Healthcare Ethics (CHE), Karolinska Institutet, Stockholm, Sweden
| | - Anna Lindblad
- Department of Learning, Informatics, Management and Ethics (LIME), Stockholm Centre for Healthcare Ethics (CHE), Karolinska Institutet, Stockholm, Sweden
| | - Ann-Christin von Vogelsang
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
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18
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Reznik ME, Mahta A, Schmidt JM, Frey HP, Park S, Roh DJ, Agarwal S, Claassen J. Duration of Agitation, Fluctuations of Consciousness, and Associations with Outcome in Patients with Subarachnoid Hemorrhage. Neurocrit Care 2019; 29:33-39. [PMID: 29313314 DOI: 10.1007/s12028-017-0491-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Agitation is common after subarachnoid hemorrhage (SAH) and may be independently associated with outcomes. We sought to determine whether the duration of agitation and fluctuating consciousness were also associated with outcomes in patients with SAH. METHODS We identified all patients with positive Richmond Agitation Sedation Scale (RASS) scores from a prospective observational cohort of patients with SAH from 2011 to 2015. Total duration of agitation was extrapolated for each patient using available RASS scores, and 24-h mean and standard deviation (SD) of RASS scores were calculated for each patient. We also calculated each patient's duration of substantial fluctuation of consciousness, defined as the number of days with 24-h RASS SD > 1. Patients were stratified by 3-month outcome using the modified Rankin scale, and associations with outcome were assessed via logistic regression. RESULTS There were 98 patients with at least one positive RASS score, with median total duration of agitation 8 h (interquartile range [IQR] 4-18), and median duration of substantially fluctuating consciousness 2 days (IQR 1-3). Unfavorable 3-month outcome was significantly associated with a longer duration of fluctuating consciousness (odds ratio [OR] per day, 1.51; 95% confidence interval [CI], 1.04-2.20; p = 0.031), but a briefer duration of agitation (OR per hour, 0.94; 95% CI, 0.89-0.99; p = 0.031). CONCLUSION Though a longer duration of fluctuating consciousness was associated with worse outcomes in our cohort, total duration of agitation was not, and may have had the opposite effect. Our findings should therefore challenge the intensity with which agitation is often treated in SAH patients.
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Affiliation(s)
- Michael E Reznik
- Department of Neurology, Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Ali Mahta
- Department of Neurology, Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - J Michael Schmidt
- Department of Neurology, Columbia University Medical Center, 177 Fort Washington Avenue, Milstein Hospital Building, Suite 8GS-300, New York, NY, 10032, USA
| | - Hans-Peter Frey
- Department of Neurology, Columbia University Medical Center, 177 Fort Washington Avenue, Milstein Hospital Building, Suite 8GS-300, New York, NY, 10032, USA
| | - Soojin Park
- Department of Neurology, Columbia University Medical Center, 177 Fort Washington Avenue, Milstein Hospital Building, Suite 8GS-300, New York, NY, 10032, USA
| | - David J Roh
- Department of Neurology, Columbia University Medical Center, 177 Fort Washington Avenue, Milstein Hospital Building, Suite 8GS-300, New York, NY, 10032, USA
| | - Sachin Agarwal
- Department of Neurology, Columbia University Medical Center, 177 Fort Washington Avenue, Milstein Hospital Building, Suite 8GS-300, New York, NY, 10032, USA
| | - Jan Claassen
- Department of Neurology, Columbia University Medical Center, 177 Fort Washington Avenue, Milstein Hospital Building, Suite 8GS-300, New York, NY, 10032, USA.
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Paavola JT, Väntti N, Junkkari A, Huttunen TJ, von und zu Fraunberg M, Koivisto T, Kämäräinen OP, Lång M, Meretoja A, Räikkönen K, Viinamäki H, Jääskeläinen JE, Huttunen J, Lindgren AE. Antipsychotic Use Among 1144 Patients After Aneurysmal Subarachnoid Hemorrhage. Stroke 2019; 50:1711-1718. [DOI: 10.1161/strokeaha.119.024914] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background and Purpose—
At acute phase and neurointensive care, patients with aneurysmal subarachnoid hemorrhage (aSAH) may become agitated or delirious. We found no previous studies on psychotic disorders or antipsychotic drug (APD) use by long-term aSAH survivors. We defined the APD use and its risk factors among 12-month survivors of aSAH in an Eastern Finnish population–based cohort with long-term follow-up.
Methods—
We analyzed APD use in 1144 consecutive patients with aSAH alive at 12 months of the Kuopio intracranial aneurysm patient and family database and their age, sex, and birth municipality matched controls (3:1; n=3432) from 1995 to 2013 and median follow-up of 9 years. Using the Finish nationwide health registries, we obtained drug purchase and hospital discharge data.
Results—
In total, 140 (12%) of the 1144 patients started APD use first time after aSAH (index date), in contrast to 145 (4%) of the 3432 matched population controls. The cumulative rate of starting APD was 6% at 1 year and 9% at 5 years, in contrast to 1% and 2% in the controls, respectively. The rates at 1 and 5 years were only 1% and 2% in the 489 patients with a good condition (modified Rankin Scale score, 0 or 1 at 12 months; no shunt, intracerebral hemorrhage, or intraventricular hemorrhage). Instead, the highest rate of APD use, 23% at 5 years was among the 192 patients shunted for hydrocephalus after aSAH. Eighty-eight (63%) of the 140 aSAH patients with APD use had also concomitant antidepressant or antiepileptic drug use.
Conclusions—
The 12-month survivors of aSAH were significantly more likely to be started on APD after aSAH than their matched population controls. These patients often used antidepressant and antiepileptic drugs concomitantly. The use of APDs strongly correlated with signs of brain injury after aSAH, with low use if no signs of significant brain injury were present.
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Affiliation(s)
- Juho T. Paavola
- From the Neurosurgery of NeuroCenter (J.T.P., N.V., A.J., T.J.H., M.v.u.z.F., T.K., O.-P.K., J.E.J., J.H., A.E.L.), Kuopio University Hospital and Institute of Clinical Medicine, Finland
- School of Medicine (J.T.P., N.V., O.-P.K., H.V., J.E.J., J.H.), University of Eastern Finland, Kuopio
| | - Nelli Väntti
- From the Neurosurgery of NeuroCenter (J.T.P., N.V., A.J., T.J.H., M.v.u.z.F., T.K., O.-P.K., J.E.J., J.H., A.E.L.), Kuopio University Hospital and Institute of Clinical Medicine, Finland
- School of Medicine (J.T.P., N.V., O.-P.K., H.V., J.E.J., J.H.), University of Eastern Finland, Kuopio
| | - Antti Junkkari
- From the Neurosurgery of NeuroCenter (J.T.P., N.V., A.J., T.J.H., M.v.u.z.F., T.K., O.-P.K., J.E.J., J.H., A.E.L.), Kuopio University Hospital and Institute of Clinical Medicine, Finland
| | - Terhi J. Huttunen
- From the Neurosurgery of NeuroCenter (J.T.P., N.V., A.J., T.J.H., M.v.u.z.F., T.K., O.-P.K., J.E.J., J.H., A.E.L.), Kuopio University Hospital and Institute of Clinical Medicine, Finland
| | - Mikael von und zu Fraunberg
- From the Neurosurgery of NeuroCenter (J.T.P., N.V., A.J., T.J.H., M.v.u.z.F., T.K., O.-P.K., J.E.J., J.H., A.E.L.), Kuopio University Hospital and Institute of Clinical Medicine, Finland
| | - Timo Koivisto
- From the Neurosurgery of NeuroCenter (J.T.P., N.V., A.J., T.J.H., M.v.u.z.F., T.K., O.-P.K., J.E.J., J.H., A.E.L.), Kuopio University Hospital and Institute of Clinical Medicine, Finland
| | - Olli-Pekka Kämäräinen
- From the Neurosurgery of NeuroCenter (J.T.P., N.V., A.J., T.J.H., M.v.u.z.F., T.K., O.-P.K., J.E.J., J.H., A.E.L.), Kuopio University Hospital and Institute of Clinical Medicine, Finland
- School of Medicine (J.T.P., N.V., O.-P.K., H.V., J.E.J., J.H.), University of Eastern Finland, Kuopio
| | - Maarit Lång
- Neurointensive Care, Institute of Clinical Medicine (M.L.), University of Eastern Finland, Kuopio
| | - Atte Meretoja
- Department of Neurology, Helsinki University Hospital, Finland (A.M.)
- Department of Medicine at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (A.M.)
| | - Katri Räikkönen
- Department of Psychology and Logopedics, University of Helsinki, Finland (K.R.)
| | - Heimo Viinamäki
- Psychiatry (H.V.), Kuopio University Hospital and Institute of Clinical Medicine, Finland
- School of Medicine (J.T.P., N.V., O.-P.K., H.V., J.E.J., J.H.), University of Eastern Finland, Kuopio
| | - Juha E. Jääskeläinen
- From the Neurosurgery of NeuroCenter (J.T.P., N.V., A.J., T.J.H., M.v.u.z.F., T.K., O.-P.K., J.E.J., J.H., A.E.L.), Kuopio University Hospital and Institute of Clinical Medicine, Finland
- School of Medicine (J.T.P., N.V., O.-P.K., H.V., J.E.J., J.H.), University of Eastern Finland, Kuopio
| | - Jukka Huttunen
- From the Neurosurgery of NeuroCenter (J.T.P., N.V., A.J., T.J.H., M.v.u.z.F., T.K., O.-P.K., J.E.J., J.H., A.E.L.), Kuopio University Hospital and Institute of Clinical Medicine, Finland
- School of Medicine (J.T.P., N.V., O.-P.K., H.V., J.E.J., J.H.), University of Eastern Finland, Kuopio
| | - Antti E. Lindgren
- From the Neurosurgery of NeuroCenter (J.T.P., N.V., A.J., T.J.H., M.v.u.z.F., T.K., O.-P.K., J.E.J., J.H., A.E.L.), Kuopio University Hospital and Institute of Clinical Medicine, Finland
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Risk Factors for Mild Cognitive Impairment in Patients with Aneurysmal Subarachnoid Hemorrhage Treated with Endovascular Coiling. World Neurosurg 2018; 119:e527-e533. [PMID: 30075259 DOI: 10.1016/j.wneu.2018.07.196] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 07/21/2018] [Accepted: 07/23/2018] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To assess the potential early risk factors of mild cognitive impairment after aneurysmal subarachnoid hemorrhage. METHODS We prospectively enrolled patients with aneurysmal subarachnoid hemorrhage treated with endovascular coiling during a 5-year period. The demographic characteristics and radiologic and laboratory data were collected. Cognitive assessments were carried out using the Montreal Cognitive Assessment at 6 months after ictus. Multivariate logistic regression was used to determine the risk factors associated with the development of mild cognitive impairment. RESULTS Of 152 patients, 59 patients (39%) developed cognitive impairment 6 months later. Univariate analysis showed that the patients with anterior communicating artery or anterior cerebral artery aneurysms (P < 0.001) with Glasgow Outcome Scale score of 7 or less at ictus (P = 0.002), Hunt and Hess grade of 3 or higher (P = 0.002), and Fisher grade of 3 or higher (P = 0.032) were more likely to develop mild cognitive impairment. The risk of mild cognitive impairment was increased for patients who had delayed cerebral ischemia (P = 0.040) and hydrocephalus (P = 0.002). In multivariate logistic regression analysis, mild cognitive impairment was independently associated with anterior communicating artery or anterior cerebral aneurysms (odds ratio [OR], 11.046; 95% confidence interval [CI], 3.371-36.198; P < 0.001), delayed cerebral ischemia (OR, 6.153; 95% CI, 1.587-23.855; P = 0.009), and hydrocephalus (OR, 8.768; 95% CI, 2.115-36.345; P = 0.003). CONCLUSIONS The location of the aneurysm, delayed cerebral ischemia, and hydrocephalus were independently associated with the occurrence of mild cognitive impairment after aneurysmal subarachnoid hemorrhage and can contribute to improved identification of patients at high risk for mild cognitive impairment.
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Sauvigny T, Mohme M, Grensemann J, Dührsen L, Regelsberger J, Kluge S, Schmidt NO, Westphal M, Czorlich P. Rate and risk factors for a hyperactivity delirium in patients with aneurysmal subarachnoid haemorrhage. Neurosurg Rev 2018; 42:481-488. [DOI: 10.1007/s10143-018-0990-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 05/21/2018] [Accepted: 05/30/2018] [Indexed: 11/30/2022]
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Mahmood S, Mahmood O, El-Menyar A, Asim M, Al-Thani H. Predisposing factors, clinical assessment, management and outcomes of agitation in the trauma intensive care unit. World J Emerg Med 2018; 9:105-112. [PMID: 29576822 DOI: 10.5847/wjem.j.1920-8642.2018.02.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Agitation occurs frequently among critically ill patients admitted to the intensive care unit (ICU). We aimed to evaluate the frequency, predisposing factors and outcomes of agitation in trauma ICU. METHODS A retrospective analysis was conducted to include patients who were admitted to the trauma ICU between April 2014 and March 2015. Data included patient's demographics, initial vitals, associated injuries, Ramsey Sedation Scale, Glasgow Coma Scale, head injury lesions, use of sedatives and analgesics, head interventions, ventilator days, and ICU length of stay. Patients were divided into two groups based on the agitation status. RESULTS A total of 102 intubated patients were enrolled; of which 46 (45%) experienced agitation. Patients in the agitation group were 7 years younger, had significantly lower GCS and sustained higher frequency of head injuries (P<0.05). Patients who developed agitation were more likely to be prescribed propofol alone or in combination with midazolam and to have frequent ICP catheter insertion, longer ventilatory days and higher incidence of pneumonia (P<0.05). On multivariate analysis, use of propofol alone (OR=4.97; 95% CI=1.35-18.27), subarachnoid hemorrhage (OR=5.11; 95% CI=1.38-18.91) and ICP catheter insertion for severe head injury (OR=4.23; 95% CI=1.16-15.35) were independent predictors for agitation (P<0.01). CONCLUSION Agitation is a frequent problem in trauma ICU and is mainly related to the type of sedation and poor outcomes in terms of prolonged mechanical ventilation and development of nosocomial pneumonia. Therefore, understanding the main predictors of agitation facilitates early risk-stratification and development of better therapeutic strategies in trauma patients.
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Affiliation(s)
- Saeed Mahmood
- Trauma Surgery Section, Department of Surgery, Hamad General Hospital (HGH), Doha, Qatar
| | | | - Ayman El-Menyar
- Clinical Research, Trauma Surgery Section, Department of Surgery, HGH, Doha, Qatar.,Clinical Medicine, Weill Cornell Medical School, Doha, Qatar
| | - Mohammad Asim
- Clinical Research, Trauma Surgery Section, Department of Surgery, HGH, Doha, Qatar
| | - Hassan Al-Thani
- Trauma Surgery Section, Department of Surgery, Hamad General Hospital (HGH), Doha, Qatar
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