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Güvec E, Koedel U, Horster S, Pedersen V, Völk S, Waldow M, Weber F, Klein M. Videodistraction to reduce agitation in elderly patients in the emergency department: an open label parallel group randomized controlled trial. Eur J Emerg Med 2024:00063110-990000000-00148. [PMID: 39264443 DOI: 10.1097/mej.0000000000001179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2024]
Abstract
BACKGROUND AND IMPORTANCE Agitation of elderly patients in the emergency department (ED) often complicates workup and therapy. OBJECTIVE In this study, we investigated if agitation in the ED can be reduced by showing calming video sequences in elderly agitated patients. DESIGNS Prospective randomized intervention study. SETTINGS AND PARTICIPANTS ED patients aged ≥65 years were screened for the risk of agitation/delirium using the 4-A's test (4-AT) test. In case of ≥4 4-AT points, patients were scored using the Richmond Agitation-Sedation Scale (RASS) and the Nursing Delirium Screening Scale (Nu-DESC). They were included in the study if RASS was ≥+2 and Nu-DESC ≥ 4 after informed consent of the legal representative. Patients were then randomized to the intervention or control group. A total of n = 57 patients were included in the study. INTERVENTION Patients in the intervention group were exposed to projections of calming video sequences for 60 min. Patients in the control group received standard care. OUTCOME MEASURES AND ANALYSIS Changes in RASS and Nu-DESC were assessed 30 and 60 min after the intervention was started. MAIN RESULTS A total of 57 patients were included in the study, with 30 patients in the intervention group and 27 patients in the control group. Before the intervention, the median (interquartile range) RASS scores were comparable between the intervention group [3 (2-3)] and the control group [3 (2-3)]. After 30 min of exposure to calming video sequences, patients in the intervention group showed significantly lower RASS and Nu-DESC scores compared to the control group [RASS: 1 (0-1) vs. 2 (1.5-3), P < 0.001; Nu-DESC: 3 (2-4) vs. 5 (4-6), P < 0.001]. This difference persisted at 60 min [RASS: 0 (0-1) vs. 2 (1-2.5), P < 0.001; Nu-DESC: 2 (2-3) vs. 5 (4-6), P < 0.001]. Additionally, fewer patients in the intervention group required additional sedating or antipsychotic medication (1/30) compared to the control group (9/27), with this difference being statistically significant (P = 0.004). CONCLUSION In this randomized controlled trial, the use of calming video sequences in elderly patients with agitation in the ED resulted in significant reductions in agitation and the need for additional sedative or antipsychotic medication.
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Affiliation(s)
- Enver Güvec
- Department of Neurology
- Emergency Department, Ludwig Maximilians University (LMU) Hospital, Munich
| | | | - Sophia Horster
- Emergency Department, Ludwig Maximilians University (LMU) Hospital, Munich
| | - Vera Pedersen
- Emergency Department, University Hospital Mannheim, Mannheim
- Department of Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), Ludwig Maximilians University (LMU) Hospital, Munich, Germany
| | | | - Michaela Waldow
- Emergency Department, Ludwig Maximilians University (LMU) Hospital, Munich
| | - Florian Weber
- Emergency Department, Ludwig Maximilians University (LMU) Hospital, Munich
| | - Matthias Klein
- Department of Neurology
- Emergency Department, Ludwig Maximilians University (LMU) Hospital, Munich
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Rowe CJ, Nwaolu U, Martin L, Huang BJ, Mang J, Salinas D, Schlaff CD, Ghenbot S, Lansford JL, Potter BK, Schobel SA, Gann ER, Davis TA. Systemic inflammation following traumatic injury and its impact on neuroinflammatory gene expression in the rodent brain. J Neuroinflammation 2024; 21:211. [PMID: 39198925 PMCID: PMC11360339 DOI: 10.1186/s12974-024-03205-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 08/16/2024] [Indexed: 09/01/2024] Open
Abstract
BACKGROUND Trauma can result in systemic inflammation that leads to organ dysfunction, but the impact on the brain, particularly following extracranial insults, has been largely overlooked. METHODS Building upon our prior findings, we aimed to understand the impact of systemic inflammation on neuroinflammatory gene transcripts in eight brain regions in rats exposed to (1) blast overpressure exposure [BOP], (2) cutaneous thermal injury [BU], (3) complex extremity injury, 3 hours (h) of tourniquet-induced ischemia, and hind limb amputation [CEI+tI+HLA], (4) BOP+BU or (5) BOP+CEI and delayed HLA [BOP+CEI+dHLA] at 6, 24, and 168 h post-injury (hpi). RESULTS Globally, the number and magnitude of differentially expressed genes (DEGs) correlated with injury severity, systemic inflammation markers, and end-organ damage, driven by several chemokines/cytokines (Csf3, Cxcr2, Il16, and Tgfb2), neurosteroids/prostaglandins (Cyp19a1, Ptger2, and Ptger3), and markers of neurodegeneration (Gfap, Grin2b, and Homer1). Regional neuroinflammatory activity was least impacted following BOP. Non-blast trauma (in the BU and CEI+tI+HLA groups) contributed to an earlier, robust and diverse neuroinflammatory response across brain regions (up to 2-50-fold greater than that in the BOP group), while combined trauma (in the BOP+CEI+dHLA group) significantly advanced neuroinflammation in all regions except for the cerebellum. In contrast, BOP+BU resulted in differential activity of several critical neuroinflammatory-neurodegenerative markers compared to BU. t-SNE plots of DEGs demonstrated that the onset, extent, and duration of the inflammatory response are brain region dependent. Regardless of injury type, the thalamus and hypothalamus, which are critical for maintaining homeostasis, had the most DEGs. Our results indicate that neuroinflammation in all groups progressively increased or remained at peak levels over the study duration, while markers of end-organ dysfunction decreased or otherwise resolved. CONCLUSIONS Collectively, these findings emphasize the brain's sensitivity to mediators of systemic inflammation and provide an example of immune-brain crosstalk. Follow-on molecular and behavioral investigations are warranted to understand the short- to long-term pathophysiological consequences on the brain, particularly the mechanism of blood-brain barrier breakdown, immune cell penetration-activation, and microglial activation.
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Affiliation(s)
- Cassie J Rowe
- Cell Biology and Regenerative Medicine Program, Department of Surgery, Uniformed Services University, 4301 Jones Bridge Road, Building A Room 3009E, Bethesda, MD, 20814, USA.
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, MD, USA.
| | - Uloma Nwaolu
- Cell Biology and Regenerative Medicine Program, Department of Surgery, Uniformed Services University, 4301 Jones Bridge Road, Building A Room 3009E, Bethesda, MD, 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, MD, USA
| | - Laura Martin
- Cell Biology and Regenerative Medicine Program, Department of Surgery, Uniformed Services University, 4301 Jones Bridge Road, Building A Room 3009E, Bethesda, MD, 20814, USA
- F. Edward Hébert School of Medicine, Uniformed Service University, Bethesda, MD, USA
| | - Benjamin J Huang
- Cell Biology and Regenerative Medicine Program, Department of Surgery, Uniformed Services University, 4301 Jones Bridge Road, Building A Room 3009E, Bethesda, MD, 20814, USA
- F. Edward Hébert School of Medicine, Uniformed Service University, Bethesda, MD, USA
| | - Josef Mang
- Cell Biology and Regenerative Medicine Program, Department of Surgery, Uniformed Services University, 4301 Jones Bridge Road, Building A Room 3009E, Bethesda, MD, 20814, USA
- F. Edward Hébert School of Medicine, Uniformed Service University, Bethesda, MD, USA
| | - Daniela Salinas
- Cell Biology and Regenerative Medicine Program, Department of Surgery, Uniformed Services University, 4301 Jones Bridge Road, Building A Room 3009E, Bethesda, MD, 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, MD, USA
| | - Cody D Schlaff
- Cell Biology and Regenerative Medicine Program, Department of Surgery, Uniformed Services University, 4301 Jones Bridge Road, Building A Room 3009E, Bethesda, MD, 20814, USA
| | - Sennay Ghenbot
- Cell Biology and Regenerative Medicine Program, Department of Surgery, Uniformed Services University, 4301 Jones Bridge Road, Building A Room 3009E, Bethesda, MD, 20814, USA
| | - Jefferson L Lansford
- Cell Biology and Regenerative Medicine Program, Department of Surgery, Uniformed Services University, 4301 Jones Bridge Road, Building A Room 3009E, Bethesda, MD, 20814, USA
| | - Benjamin K Potter
- Cell Biology and Regenerative Medicine Program, Department of Surgery, Uniformed Services University, 4301 Jones Bridge Road, Building A Room 3009E, Bethesda, MD, 20814, USA
- F. Edward Hébert School of Medicine, Uniformed Service University, Bethesda, MD, USA
- Surgical Critical Care Initiative (SC2i), Uniformed Services University, Bethesda, MD, USA
| | - Seth A Schobel
- Surgical Critical Care Initiative (SC2i), Uniformed Services University, Bethesda, MD, USA
| | - Eric R Gann
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, MD, USA
- Surgical Critical Care Initiative (SC2i), Uniformed Services University, Bethesda, MD, USA
| | - Thomas A Davis
- Cell Biology and Regenerative Medicine Program, Department of Surgery, Uniformed Services University, 4301 Jones Bridge Road, Building A Room 3009E, Bethesda, MD, 20814, USA
- F. Edward Hébert School of Medicine, Uniformed Service University, Bethesda, MD, USA
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Li HR, Guo Y. High-risk factors for delirium in severely ill patients and the application of emotional nursing combined with pain nursing. World J Psychiatry 2024; 14:1027-1033. [PMID: 39050209 PMCID: PMC11262928 DOI: 10.5498/wjp.v14.i7.1027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 05/15/2024] [Accepted: 06/04/2024] [Indexed: 07/12/2024] Open
Abstract
BACKGROUND Delirium is a neuropsychiatric syndrome characterized by acute disturbances of consciousness with rapid onset, rapid progression, obvious fluctuations, and preventable, reversible, and other characteristics. Patients with delirium in the intensive care unit (ICU) are often missed or misdiagnosed and do not receive adequate attention. AIM To analyze the risk factors for delirium in ICU patients and explore the application of emotional nursing with pain nursing in the management of delirium. METHODS General data of 301 critically ill patients were retrospectively collected, including histories (cardiovascular and cerebrovascular diseases, hypertension, smoking, alcoholism, and diabetes), age, sex, diagnosis, whether surgery was performed, and patient origin (emergency/clinic). Additionally, the duration of sedation, Richmond Agitation Sedation Scale score, combined emotional and pain care, ventilator use duration, vasoactive drug use, drainage tube retention, ICU stay duration, C-reactive protein, procalcitonin, white blood cell count, body temperature, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and Sequential Organ Failure Assessment score were recorded within 24 h after ICU admission. Patients were assessed for delirium according to confusion assessment method for the ICU, and univariate and multivariate logistic regression analyses were performed to identify the risk factors for delirium in the patients. RESULTS Univariate logistic regression analysis was performed on the 24 potential risk factors associated with delirium in ICU patients. The results showed that 16 risk factors were closely related to delirium, including combined emotional and pain care, history of diabetes, and patient origin. Multivariate logistic regression analysis revealed that no combined emotional and pain care, history of diabetes, emergency source, surgery, long stay in the ICU, smoking history, and high APACHE II score were independent risk factors for delirium in ICU patients. CONCLUSION Patients with diabetes and/or smoking history, postoperative patients, patients with a high APACHE II score, and those with emergency ICU admission need emotional and pain care, flexible visiting modes, and early intervention to reduce delirium incidence.
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Affiliation(s)
- Hong-Ru Li
- Emergency Intensive Care Unit, The Fourth Affiliated Hospital of Soochow University (Suzhou Dushu Lake Hospital), Suzhou 215000, Jiangsu Province, China
| | - Yu Guo
- Emergency Intensive Care Unit, The Fourth Affiliated Hospital of Soochow University (Suzhou Dushu Lake Hospital), Suzhou 215000, Jiangsu Province, China
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Fu M, Yuan Q, Yang Q, Song W, Yu Y, Luo Y, Xiong X, Yu G. Risk factors and incidence of postoperative delirium after cardiac surgery in children: a systematic review and meta-analysis. Ital J Pediatr 2024; 50:24. [PMID: 38331831 PMCID: PMC10854157 DOI: 10.1186/s13052-024-01603-2] [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: 11/28/2023] [Accepted: 01/28/2024] [Indexed: 02/10/2024] Open
Abstract
Delirium, a form of acute cerebral dysfunction, is a common complication of postoperative cardiac surgery in children. It is strongly associated with adverse outcomes, including prolonged hospitalization, increased mortality, and cognitive dysfunction. This study aimed to identify risk factors and incidence of delirium after cardiac surgery in children to facilitate early identification of delirium risk and provide a reference for the implementation of effective prevention and management. A systematic literature search was conducted in PubMed, Web of Science, Embase, Cochrane Library, Scopus, CNKI, Sinomed, and Wanfang for studies published in English or Chinese from the inception of each database to November 2023. The PRISMA guidelines were followed in all phases of this systematic review. The Risk of Bias Assessment for Nonrandomized Studies tool was used to assess methodological quality. A total of twelve studies were included in the analysis, with four studies classified as overall low risk of bias, seven studies as moderate risk of bias, and one study as high risk of bias. The studies reported 39 possible predictors of delirium, categorized into four broad groups: intrinsic and parent-related factors, disease-related factors, surgery and treatment-related factors, and clinical scores and laboratory parameters. By conducting qualitative synthesis and quantitative meta-analysis, we identified two definite factors, four possible factors, and 32 unclear factors related to delirium. Definite risk factors included age and mechanical ventilation duration. Possible factors included developmental delay, cyanotic heart disease, cardiopulmonary bypass time, and pain score. With only a few high-quality studies currently available, well-designed and more extensive prospective studies are still needed to investigate the risk factors affecting delirium and explore delirium prevention strategies in high-risk children.
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Affiliation(s)
- Maoling Fu
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Road, Qiaokou District, Wuhan, Hubei, China
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Quan Yuan
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Road, Qiaokou District, Wuhan, Hubei, China
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Qiaoyue Yang
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Road, Qiaokou District, Wuhan, Hubei, China
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Wenshuai Song
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Road, Qiaokou District, Wuhan, Hubei, China
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yaqi Yu
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Road, Qiaokou District, Wuhan, Hubei, China
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Ying Luo
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Road, Qiaokou District, Wuhan, Hubei, China
| | - Xiaoju Xiong
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Road, Qiaokou District, Wuhan, Hubei, China
| | - Genzhen Yu
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Road, Qiaokou District, Wuhan, Hubei, China.
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Cheng J, Lao Y, Chen X, Qiao X, Sui W, Gong X, Zhuang Y. Dynamic Nomogram for Subsyndromal Delirium in Adult Intensive Care Unit: A Prospective Cohort Study. Neuropsychiatr Dis Treat 2023; 19:2535-2548. [PMID: 38029051 PMCID: PMC10676691 DOI: 10.2147/ndt.s432776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 11/13/2023] [Indexed: 12/01/2023] Open
Abstract
Purpose To develop a dynamic nomogram of subsyndromal delirium (SSD) in intensive care unit (ICU) patients and internally validate its efficacy in predicting SSD. Patients and Methods Patients who met the inclusion and exclusion criteria in the ICU of a tertiary hospital in Zhejiang from September 2021 to June 2022 were selected as the research objects. The patient data were randomly divided into the training set and validation set according to the ratio of 7:3. The least absolute shrinkage and selection operator (LASSO) and multivariate logistic regression were used to screen the predictors of SSD, and R software was used to construct a dynamic nomogram. Receiver operating characteristic (ROC) curve, calibration band and decision curve were used to evaluate the discrimination, calibration and clinical effectiveness of the model. Results A total of 1000 eligible patients were included, including 700 in the training set and 300 in the validation set. Age, drinking history, C reactive protein level, APACHE II, indwelling urinary catheter, mechanical ventilation, cerebrovascular disease, respiratory failure, constraint, dexmedetomidine, and propofol were predictors of SSD in ICU patients. The ROC curve values of the training set was 0.902 (95% confidence interval: 0.879-0.925), the best cutoff value was 0.264, the specificity was 78.4%, and the sensitivity was 88.0%. The ROC curve values of the validation set was 0.888 (95% confidence interval: 0.850-0.930), the best cutoff value was 0.543, the specificity was 94.9%, and the sensitivity was 70.9%. The calibration band showed good calibration in the training and validation set. Decision curve analysis showed that the net benefit in the model was significantly high. Conclusion The dynamic nomogram has good predictive performance, so it is a precise and effective tool for medical staff to predict and manage SSD in the early stage.
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Affiliation(s)
- Junning Cheng
- Nursing Department, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, People’s Republic of China
| | - Yuewen Lao
- Nursing Department, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, People’s Republic of China
| | - Xiangping Chen
- Nursing Department, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, People’s Republic of China
| | - Xiaoting Qiao
- Nursing Department, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, People’s Republic of China
| | - Weijing Sui
- Nursing Department, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, People’s Republic of China
| | - Xiaoyan Gong
- Nursing Department, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, People’s Republic of China
| | - Yiyu Zhuang
- Nursing Department, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, People’s Republic of China
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Evered LA, Pryor KO. Benzodiazepines and postoperative delirium: should we be as cautious as we are? Br J Anaesth 2023; 131:629-631. [PMID: 37544837 DOI: 10.1016/j.bja.2023.07.004] [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: 05/22/2023] [Revised: 07/11/2023] [Accepted: 07/13/2023] [Indexed: 08/08/2023] Open
Abstract
A recent systematic review and meta-analysis by Wang and colleagues in the British Journal of Anaesthesia calls into question the concept that perioperative benzodiazepine administration is associated with development of postoperative delirium in older individuals after anaesthesia and surgery. This editorial focuses on potential bias within the systematic review and addresses major concerns surrounding benzodiazepine use in the older perioperative population.
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Affiliation(s)
- Lisbeth A Evered
- Department of Critical Care, School of Medicine, University of Melbourne, Victoria, Australia; Department of Anaesthesia and Acute Pain Medicine, St. Vincent's Hospital Melbourne, Victoria, Australia; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA.
| | - Kane O Pryor
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
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7
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Wang K, Su X, Ma JH, Wang DX. Optimal strategy for delirium detection in older patients admitted to intensive care unit after non-cardiac surgery. Front Surg 2023; 10:1095329. [PMID: 37051569 PMCID: PMC10083243 DOI: 10.3389/fsurg.2023.1095329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 03/07/2023] [Indexed: 03/28/2023] Open
Abstract
BackgroundDelirium detection is challenging due to the fluctuating nature and frequent hypoactive presentation. This study aimed to determine an optimal strategy that detects delirium with higher sensitivity but lower effort in older patients admitted to the intensive care unit (ICU) after surgery.MethodsThis was a secondary analysis of the database from a randomized trial. Seven hundred older patients (aged ≥65 years) who were admitted to the ICU after elective noncardiac surgery were enrolled. Delirium was assessed with the Confusion Assessment Method for the ICU (CAM-ICU) twice daily during the first 7 days postoperatively. The sensitivity of different strategies in detecting delirium were analyzed and compared.ResultsOf all enrolled patients, 111 (15.9%; 95% CI: 13.3% to 18.8%) developed at least one episode of delirium during the first 7 postoperative days. Among patients who developed delirium, 60.4% (67/111) had their first delirium onset on postoperative day 1, 84.7% (94/111) by the end of day 2, 91.9% (102/111) by the end of day 3, and 99.1% (110/111) by the end of day 4. Compared with delirium assessment twice daily for 7 days, twice-daily measurements for 5 days detected 100% of delirium patients with 71% efforts; twice-daily measurements for 4 days detected 99% (95% CI: 94% to 100%) of delirium patients with 57% efforts; twice-daily assessment for 3 days detected 92% (95% CI: 85% to 96%) of delirium patients with only 43% efforts.ConclusionsFor older patients admitted to the ICU after elective noncardiac surgery, it is reasonable to detect delirium with the CAM-ICU twice daily for no more than 5 days, and if the personnel and funds are insufficient, 4 days could be sufficient.
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Affiliation(s)
- Kun Wang
- Department of Anesthesiology, Peking University First Hospital, Beijing, China
| | - Xian Su
- Department of Anesthesiology, Peking University First Hospital, Beijing, China
| | - Jia-Hui Ma
- Department of Anesthesiology, Peking University First Hospital, Beijing, China
| | - Dong-Xin Wang
- Department of Anesthesiology, Peking University First Hospital, Beijing, China
- Department of Outcomes Research, Outcomes Research Consortium, Cleveland, OH, United States
- Correspondence: Dong-Xin Wang ;
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van der Heijden EFM, Kooken RWJ, Zegers M, Simons KS, van den Boogaard M. Differences in long-term outcomes between ICU patients with persistent delirium, non-persistent delirium and no delirium: A longitudinal cohort study. J Crit Care 2023; 76:154277. [PMID: 36804824 DOI: 10.1016/j.jcrc.2023.154277] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 01/18/2023] [Accepted: 02/03/2023] [Indexed: 02/20/2023]
Abstract
PURPOSE Determine differences in physical, mental and cognitive outcomes 1-year post-ICU between patients with persistent delirium (PD), non-persistent delirium (NPD) and no delirium (ND). MATERIALS AND METHODS A longitudinal cohort study was performed in adult ICU patients of two hospitals admitted between July 2016-February 2020. Questionnaires on physical, mental and cognitive health, frailty and QoL were completed regarding patients' pre-ICU health status and 1-year post-ICU. Delirium data were from patients' total hospital stay. Patients were divided in PD (≥14 days delirium), NPD (<14 days delirium) or ND patients. RESULTS 2400 patients completed both questionnaires, of whom 529 (22.0%) patients developed delirium; 35 (6.6%) patients had PD and 494 (93.4%) had NPD. Patients with delirium (PD or NPD) had worse outcomes in all domains compared to ND patients. Compared to NPD, more PD patients were frail (34.3% vs. 14.6%, p = 0.006) and fatigued (85.7% vs. 61.1%, p = 0.012). After adjustment, PD was significantly associated with long-term cognitive impairment only (aOR 3.90; 95%CI 1.31-11.63). CONCLUSIONS Patients with PD had a higher likelihood to develop cognitive impairment 1-year post-ICU compared to NPD or ND. Patients with PD and NPD were more likely to experience impairment on all health domains (i.e. physical, mental and cognitive), compared to ND patients.
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Affiliation(s)
- Emma F M van der Heijden
- Jeroen Bosch Hospital, Department of Intensive Care Medicine, Henri Dunantstraat 1, 5223 GZ 's-Hertogenbosch, the Netherlands.
| | - Rens W J Kooken
- Radboud University Medical Center, Department of Intensive Care, Radboud Institute for Health Science710 - Research IC (room 24), P.O. 9101, zipcode 6500HB, Nijmegen, the Netherlands.
| | - Marieke Zegers
- Radboud University Medical Center, Department of Intensive Care, Radboud Institute for Health Science710 - Research IC (room 24), P.O. 9101, zipcode 6500HB, Nijmegen, the Netherlands.
| | - Koen S Simons
- Jeroen Bosch Hospital, Department of Intensive Care Medicine, Henri Dunantstraat 1, 5223 GZ 's-Hertogenbosch, the Netherlands.
| | - Mark van den Boogaard
- Radboud University Medical Center, Department of Intensive Care, Radboud Institute for Health Science710 - Research IC (room 24), P.O. 9101, zipcode 6500HB, Nijmegen, the Netherlands.
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[Delirium in the context of intensive care medicine-Part 2: diagnosis, prevention and treatment]. DER NERVENARZT 2023; 94:99-105. [PMID: 36269366 DOI: 10.1007/s00115-022-01399-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/05/2022] [Indexed: 02/04/2023]
Abstract
Despite the high prevalence and the enormous medical and health economic impact, delirium syndromes are often underdiagnosed, which is mainly attributable to the high frequency of hypoactive delirium and to the frequently subtle and fluctuating psychopathology in the initial phase of delirium. These aspects also justify the need for a consequent and continuous application of standardized screening tools to detect delirium as early as possible. A multidimensional, nonpharmacological prevention of delirium is effective and still underutilized in the clinical practice. So far, there are no consensus recommendations regarding the pharmacological prevention of delirium. From a therapeutic perspective a causal approach is prioritized. Pharmacological treatment of delirium can only be considered under strict observance of specific indicators. When treating non-withdrawal-related delirium benzodiazepines should be avoided.
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Haußmann R, Postler A, Mirus M. [Delirium in the context of intensive care medicine-Part 1: epidemiology, definitions, pathophysiology]. DER NERVENARZT 2023; 94:93-98. [PMID: 36269367 DOI: 10.1007/s00115-022-01398-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/05/2022] [Indexed: 02/04/2023]
Abstract
The prevalence of delirium syndromes is high, they are often underdiagnosed and therefore medically as well as economically highly relevant syndromes due to the long-term sequelae. In the majority of cases, delirium has a multifactorial etiology, which is why a comprehensive search for the cause is of highest priority. Surgery, administration of potentially proinflammatory drugs as well as the intensive care environment, including the underlying disease and drugs used, represent relevant etiological factors. Pathophysiology and psychopathology are complex and vary depending on the etiological factors present. Prominent impairment of attention and consciousness are central symptoms of delirium allowing the differentiation from important differential diagnoses, such as encephalopathy, depression, psychosis and dementia.
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Affiliation(s)
- R Haußmann
- Klinik und Poliklinik für Psychiatrie und Psychotherapie, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland.
| | - A Postler
- UniversitätsCentrum für Orthopädie, Unfall- & Plastische Chirurgie, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Deutschland
| | - M Mirus
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Deutschland
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11
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Peng Y, Wu B, Xing C, Mao H. Increased mean perfusion pressure variability is associated with subsequent deterioration of renal function in critically ill patients with central venous pressure monitoring: a retrospective observational study. Ren Fail 2022; 44:1976-1984. [DOI: 10.1080/0886022x.2022.2120822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Yudie Peng
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Buyun Wu
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Changying Xing
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Huijuan Mao
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
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12
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Zhang Y, Zhang Y, Zhou Z, Sang X, Qin M, Dai G, Zhao Z, Yan F, Zhang X. Higher intraoperative mean arterial blood pressure does not reduce postoperative delirium in elderly patients following gastrointestinal surgery: A prospective randomized controlled trial. PLoS One 2022; 17:e0278827. [PMID: 36548296 PMCID: PMC9778934 DOI: 10.1371/journal.pone.0278827] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 11/22/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND This study aimed to describe the relationship between the different levels of intraoperative mean arterial blood pressure (MAP) and postoperative delirium in elderly patients undergoing gastrointestinal laparoscopic surgery. MATERIALS AND METHODS This prospective controlled clinical trial enrolled 116 patients aged 65 to 85 years who underwent gastrointestinal laparoscopic surgery. These patients were randomized 1:1 to a MAP goal of 65 to 85 mmHg (L group) or an 86 to 100 mmHg (H group). The primary endpoint was the incidence of postoperative delirium, assessed twice daily with the Confusion Assessment Method (CAM) and Richmond Agitation-Sedation Scale (RASS) during the first five postoperative days. Delirium severity was evaluated with the Delirium-O-Meter (D-O-M). RESULTS 108 patients (L group n = 55, H group n = 53) were eventually included in intention-to-treat analyses. Postoperative delirium occurred in 18 (32.7%) of 55 cases of L group and in 15 (28.3%) of 53 cases of H group. The incidence of delirium subtypes between the two groups: hypoactive delirium 14.5% (8/55) vs 11.3% (6/53); hyperactive delirium 7.3% (4/55) vs 3.8% (2/53); mixed delirium 10.9% (6/55) vs 13.2% (7/53). However, the L group showed higher D-O-M scores of the first episode of delirium: 14.5 (Q1 = 12, Q3 = 18.5) vs 12 (Q1 = 10, Q3 = 14), which means the delirium is more severe. CONCLUSIONS Compared with 65 to 85 mmHg, maintaining intraoperative MAP at 86-100 mmHg did not reduce the incidence of postoperative delirium in elderly patients undergoing gastrointestinal laparoscopic surgery. However, the severity of delirium could be reduced and blood loss is a risk factor for postoperative delirium.
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Affiliation(s)
- Yanke Zhang
- Department of Anesthesiology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China
| | - Ying Zhang
- Department of Anesthesiology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China
| | - Zhou Zhou
- Department of Anesthesiology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China
| | - Xiaoqiao Sang
- Department of Anesthesiology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China
| | - Miaomiao Qin
- Department of Anesthesiology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China
| | - Guangrong Dai
- Department of Anesthesiology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China
| | - Zhibin Zhao
- Department of Anesthesiology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China
| | - Fang Yan
- Department of Basic Medical Science, Kangda College of Nanjing Medical University, Lianyungang, China
| | - Xiaobao Zhang
- Department of Anesthesiology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China
- Department of Anesthesiology, Kangda College of Nanjing Medical University, Lianyungang, China
- * E-mail:
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13
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Wu N, Zhang Y, Wang S, Zhao Y, Zhong X. Incidence, prevalence and risk factors of delirium in
ICU
patients: A systematic review and meta‐analysis. Nurs Crit Care 2022. [DOI: 10.1111/nicc.12857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Nan‐Nan Wu
- The First Affiliated Hospital of Zhengzhou University Zhengzhou China
| | - Ya‐Bin Zhang
- The First Affiliated Hospital of Zhengzhou University Zhengzhou China
| | - Shu‐Yun Wang
- The First Affiliated Hospital of Zhengzhou University Zhengzhou China
| | - Yu‐Hua Zhao
- The First Affiliated Hospital of Zhengzhou University Zhengzhou China
| | - Xue‐Mei Zhong
- Guangdong Women and Children Hospital Guangzhou China
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14
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Sadhu A, Valencia C, Fatima H, Nwankwo I, Anam M, Maharjan S, Amjad Z, Abaza A, Vasavada AM, Khan S. Haloperidol Versus Atypical Antipsychotics for Treating Delirium in Intensive Care Unit Patients: A Systematic Review. Cureus 2022; 14:e30641. [PMID: 36439558 PMCID: PMC9683743 DOI: 10.7759/cureus.30641] [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: 08/15/2022] [Accepted: 10/23/2022] [Indexed: 06/16/2023] Open
Abstract
Delirium is a severe and variable neuropsychiatric illness that causes cognitive and behavioral problems as well as abrupt impairment in consciousness and focus. Due to the complex, dynamic, and multifaceted interactions between several risk factors, the etiology of delirium is unclear. Although its efficacy has not been thoroughly studied, haloperidol, a common antipsychotic medicine, is frequently used to prevent delirium in critically ill patients. When evaluating the atypical antipsychotic response rates for treating delirium, only a few trials have taken age into account. Articles were searched for from PubMed, PubMed Central (PMC), and Science Direct, and reviewed systematically. A complete 225 articles were identified after applying the search strategy to these databases. Out of these, 12 were finalized for review. We reviewed the efficacy and safety of haloperidol with atypical antipsychotics for treating delirium in intensive care unit patients.
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Affiliation(s)
- Akhil Sadhu
- Family Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Carla Valencia
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Hameeda Fatima
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- Internal Medicine, Dr. Ruth K. M. Pfau Civil Hospital Karachi, Karachi, PAK
| | - Ijeoma Nwankwo
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Mahvish Anam
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Shrinkhala Maharjan
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Zainab Amjad
- Internal Medicine, King Faisal University, Al-Ahsa, SAU
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Abdelrahman Abaza
- Pathology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Advait M Vasavada
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- Medicine, Meghji Pethraj Shah Medical College, Jamnagar, IND
- Emergency Medicine, All India Institute of Medical Sciences, New Delhi, IND
- Plastic Surgery, All India Institute of Medical Sciences, New Delhi, IND
| | - Safeera Khan
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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15
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Grigg-Damberger MM, Hussein O, Kulik T. Sleep Spindles and K-Complexes Are Favorable Prognostic Biomarkers in Critically Ill Patients. J Clin Neurophysiol 2022; 39:372-382. [PMID: 35239561 DOI: 10.1097/wnp.0000000000000830] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
SUMMARY In this narrative review, we summarize recent research on the prognostic significance of biomarkers of sleep in continuous EEG and polysomnographic recordings in intensive care unit patients. Recent studies show the EEG biosignatures of non-rapid eye movement 2 sleep (sleep spindles and K-complexes) on continuous EEG in critically ill patients better predict functional outcomes and mortality than the ictal-interictal continuum patterns. Emergence of more complex and better organized sleep architecture has been shown to parallel neurocognitive recovery and correlate with functional outcomes in traumatic brain injury and strokes. Particularly interesting are studies which suggest intravenous dexmedetomidine may induce a more biomimetic non-rapid eye movement sleep state than intravenous propofol, potentially providing more restorative sleep and lessening delirium. Protocols to improve intensive care unit sleep and neurophysiological studies evaluating the effect of these on sleep and sleep architecture are here reviewed.
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16
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Levy I, Gavrieli S, Hefer T, Attias S, Schiff A, Oliven R, Wisberg-Levi S, Hanchinsky R, Schiff E. Acupuncture Treatment of Delirium in Older Adults Hospitalized in Internal Medicine Departments: An Open-Label Pragmatic Randomized-Controlled Trial. J Geriatr Psychiatry Neurol 2022; 35:333-343. [PMID: 33685268 DOI: 10.1177/0891988721996804] [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] [Indexed: 11/17/2022]
Abstract
BACKGROUND Acupuncture seems to improve cognitive function in experimental models and to reduce agitation in dementia. The addition of acupuncture to standard-of-care (SOC) may improve clinical outcomes related to delirium in hospitalized older adults. METHODS This pragmatic open-label randomized-controlled trial evaluated 81 older adults hospitalized in an internal medicine ward and diagnosed with delirium. Fifty were randomized to daily acupuncture combined with SOC and 31 to SOC only for up to 1 week. Delirium was diagnosed using Confusion Assessment Method (CAM) tool, and its severity was assessed by the long CAM-Severity (CAM-S) tool. The primary study outcome was delirium resolution evaluated as time-to-first delirium remission (over 7 days) and the number of days spent delirium-free. RESULTS Time-to-first delirium remission was shorter in the acupuncture arm as compared to the SOC only arm (p < 0.001). A multivariate Cox regression analysis showed a shorter time-to-first remission of delirium in the acupuncture arm as compared with SOC arm [Hazard Ratio 0.267 (95% CI 0.098-0.726, p = 0.010)]. In the 7 days of evaluation, a significantly higher number of delirium-free days was found in the acupuncture arm compared to the SOC arm (p < 0.001), and CAM-S sum from day 2 to day 7 of evaluation was significantly lower in the acupuncture group compared to the control group (p = 0.002). No adverse safety event was found in the acupuncture group. CONCLUSION Acupuncture seems to be safe and effective in the treatment of delirium in older patients hospitalized in internal medicine departments.
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Affiliation(s)
- Ilana Levy
- Internal Medicine B Department, 37772Bnai Zion Medical Center, Haifa, Israel.,Complementary Medicine Department, 37772Bnai Zion Medical Center, Haifa, Israel.,Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.,Hematology Unit, 37772Bnai Zion Medical Center, Haifa, Israel
| | - Sagi Gavrieli
- Complementary Medicine Department, 37772Bnai Zion Medical Center, Haifa, Israel
| | - Talia Hefer
- Internal Medicine B Department, 37772Bnai Zion Medical Center, Haifa, Israel
| | - Samuel Attias
- Complementary Medicine Department, 37772Bnai Zion Medical Center, Haifa, Israel.,School of Public Health, University of Haifa, Haifa, Israel
| | - Ariel Schiff
- Faculty of Medicine, Ben-Gurion University of the Negev, Beer Sheba, Israel
| | - Ron Oliven
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.,Internal Medicine C Department, 37772Bnai Zion Medical Center, Haifa, Israel.,Geriatric Unit, 37772Bnai Zion Medical Center, Haifa, Israel
| | - Shikma Wisberg-Levi
- Internal Medicine B Department, 37772Bnai Zion Medical Center, Haifa, Israel
| | - Rina Hanchinsky
- Internal Medicine C Department, 37772Bnai Zion Medical Center, Haifa, Israel
| | - Elad Schiff
- Internal Medicine B Department, 37772Bnai Zion Medical Center, Haifa, Israel.,Complementary Medicine Department, 37772Bnai Zion Medical Center, Haifa, Israel.,Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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17
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Qiu Y, Rivas E, Tanios M, Sreedharan R, Mao G, Ince I, Salih A, Saab R, Devarajan J, Ruetzler K, Turan A. Effect of seasons on delirium in postoperative critically ill patients: a retrospective analysis. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2022; 73:3-9. [PMID: 35182552 PMCID: PMC9801211 DOI: 10.1016/j.bjane.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 01/06/2022] [Accepted: 02/06/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND AND OBJECTIVES Postoperative delirium is common in critically ill patients and is known to have several predisposing and precipitating factors. Seasonality affects cognitive function which has a more dysfunctional pattern during winter. We, therefore, aimed to test whether seasonal variation is associated with the occurrence of delirium and hospital Length Of Stay (LOS) in critically ill non-cardiac surgical populations. METHODS We conducted a retrospective analysis of adult patients recovering from non-cardiac surgery at the Cleveland Clinic between March 2013 and March 2018 who stayed in Surgical Intensive Care Unit (SICU) for at least 48 hours and had daily Confusion Assessment Method Intensive Care Unit (CAM-ICU) assessments for delirium. The incidence of delirium and LOS were summarized by season and compared using chi-square test and non-parametric tests, respectively. A logistic regression model was used to assess the association between delirium and LOS with seasons, adjusted for potential confounding variables. RESULTS Among 2300 patients admitted to SICU after non-cardiac surgeries, 1267 (55%) had postoperative delirium. The incidence of delirium was 55% in spring, 54% in summer, 55% in fall and 57% in winter, which was not significantly different over the four seasons (p = 0.69). The median LOS was 12 days (IQR = [8, 19]) overall. There was a significant difference in LOS across the four seasons (p = 0.018). LOS during summer was 12% longer (95% CI: 1.04, 1.21; p = 0.002) than in winter. CONCLUSIONS In adult non-cardiac critically ill surgical patients, the incidence of postoperative delirium is not associated with season. Noticeably, LOS was longer in summer than in winter.
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Affiliation(s)
- Yuwei Qiu
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA,Shanghai Jiao Tong University, Shanghai Chest Hospital, Department of Anesthesiology, Shanghai, China
| | - Eva Rivas
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA,Universidad de Barcelona, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Department of Anesthesiology, Barcelona, Spain
| | - Marianne Tanios
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA
| | - Roshni Sreedharan
- Cleveland Clinic, Anesthesiology Institute, Department of Intensive Care and Resuscitation, Cleveland, USA
| | - Guangmei Mao
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA,Cleveland Clinic, Department of Quantitative Health Sciences, Cleveland, USA
| | - Ilker Ince
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA,Altinbas University, School of Medicine, Department of Anesthesiology and Reanimation, Bahcelievler Medical Park Hospital, Istanbul, Turkey
| | - Ahmed Salih
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA
| | - Remie Saab
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA
| | - Jagan Devarajan
- Medina Hospital, Cleveland Clinic, Anesthesiology Institute, Department of General Anesthesiology, Medina, USA
| | - Kurt Ruetzler
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA,Cleveland Clinic, Anesthesiology Institute, Department of General Anesthesiology, Cleveland, USA
| | - Alparslan Turan
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA; Cleveland Clinic, Anesthesiology Institute, Department of General Anesthesiology, Cleveland, USA.
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18
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Abstract
Delirium remains a challenging clinical problem in hospitalized older adults, especially for postoperative patients. This complication, with a high risk of postoperative mortality and an increased length of stay, frequently occurs in older adult patients. This brief narrative paper aims to review the recent literature regarding delirium and its most recent update. We also offer physicians a brief and essential clinical practice guide to managing this acute and common disease.
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19
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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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20
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Grover S, Gupta BM. A scientometric study of publications on delirium from 2001 to 2020. Asian J Psychiatr 2021; 66:102889. [PMID: 34717112 DOI: 10.1016/j.ajp.2021.102889] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 10/02/2021] [Accepted: 10/16/2021] [Indexed: 11/28/2022]
Abstract
AIM This study aims to evaluate the publications on delirium by using bibliometric analysis. METHODOLOGY The Scopus database was evaluated for publications on delirium, during the period of 2001-20. The search results were analyzed for the origin of country, origin of institution, authorship, collaborations, type of article, source of funding, and number of citations. RESULTS The searches of Scopus database yielded 22,941 publications, originating from 139 countries. Compared to the decade of 2001-2010, the number of publications on delirium doubled in the decade of 2011-2020. The majority of the papers were research articles (58.26%), and the papers were cited for mean number of 20.53 times. Only a small proportion of the papers were based on funding (13.14%). Maximum number of papers emerged from United States of America. In terms of institutional affiliations, among the authors from top 20 institutes, 15 were from United States, 2 from Netherlands and 1 each from Canada, Germany and United Kingdom. In terms of authors, the research productivity of the top 20 most productive authors varied from 172 to 612 publications with 12 authors belonging to United States, 2 from Italy and 1 each from Canada, Greece, India, Ireland, Netherland and the United Kingdom. The maximum number of papers were published in Journal of the American Geriatric Society and based on the number of citations the New England Journal of Medicine was the most impactful journal. CONCLUSION Over the years number of publications on delirium have increased, majority of the publications have emerged from United States.
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Affiliation(s)
- Sandeep Grover
- Post Graduate Institute of Medical Education & Research, Chandigarh, India.
| | - B M Gupta
- Formerly with CSIR-NISTADS, New Delhi 11012, India
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21
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DeMaagd GA, DeMaagd DR, Philip A. Delirium and its Pharmacological Causes in Older People, Part Two. Sr Care Pharm 2021; 36:534-547. [PMID: 34717785 DOI: 10.4140/tcp.n.2021.534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Delirium is a syndrome that can arise from many causes or underlying conditions, and though it has been reported in younger patients, it is more prevalent in older people, though it can occur in other age groups as well. Identifying delirium is challenging in older people because of the coexistence of underlying dementia or depression, which may further complicate the presentation. Drug-induced delirium is one of the major causes of delirium, and evaluation of this potential cause or contribution is an important component of the evaluation process, since it can lead to poor patient outcomes. Part one of this three part series reviewed the epidemiology, pathophysiology, evaluation, diagnostic process, and causes of delirium in older people, with a focus on the pharmacological causes. Part two of this series continues to review drugs and drug classes that can cause or contribute to delirium in older people.
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Affiliation(s)
| | | | - Ashok Philip
- Union University College of Pharmacy, Jackson, Tennessee
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22
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Kooken RWJ, van den Berg M, Slooter AJC, Pop-Purceleanu M, van den Boogaard M. Factors associated with a persistent delirium in the intensive care unit: A retrospective cohort study. J Crit Care 2021; 66:132-137. [PMID: 34547553 DOI: 10.1016/j.jcrc.2021.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/29/2021] [Accepted: 09/03/2021] [Indexed: 11/16/2022]
Abstract
PURPOSE To explore differences between ICU patients with persistent delirium (PD), non-persistent delirium (NPD) and no delirium (ND), and to determine factors associated with PD. MATERIALS AND METHODS Retrospective cohort study including all ICU adults admitted for ≥12 h (January 2015-February 2020), assessable for delirium and followed during their entire hospitalization. PD was defined as ≥14 days of delirium. Factors associated with PD were determined using multivariable logistic regression analysis. RESULTS Out of 10,295 patients, 3138 (30.5%) had delirium, and 284 (2.8%) had PD. As compared to NPD (n = 2854, 27.7%) and ND (n = 7157, 69.5%), PD patients were older, sicker, more physically restrained, longer comatose and mechanically ventilated, had a longer ICU and hospital stay, more ICU readmissions and a higher mortality rate. Factors associated with PD were age (adjusted odds ratio [aOR] 1.03; 95% confidence interval [CI] 1.02-1.04); emergency surgical (aOR 1.84; 95%CI 1.26-2.68) and medical (aOR 1.57; 95%CI 1.12-2.21) referral, mean Sequential Organ Failure Assessment (SOFA) score before delirium onset (aOR 1.18; 95%CI 1.13-1.24) and use of physical restraints (aOR 5.02; 95%CI 3.09-8.15). CONCLUSIONS Patients with persistent delirium differ in several characteristics and had worse short-term outcomes. Physical restraints were the most strongly associated with PD.
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Affiliation(s)
- Rens W J Kooken
- Department of Intensive Care, Radboud Institute for Health Science, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Maarten van den Berg
- Department of Intensive Care, Radboud Institute for Health Science, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Arjen J C Slooter
- Department of Intensive Care and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Department of Neurology, UZ Brussel and Vrije Universiteit Brussel, Brussels, Belgium
| | - Monica Pop-Purceleanu
- Department of Psychiatry, Radboud Institute for Health Science, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Mark van den Boogaard
- Department of Intensive Care, Radboud Institute for Health Science, Radboud University Medical Center, Nijmegen, the Netherlands.
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23
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Bowman EML, Cunningham EL, Page VJ, McAuley DF. Phenotypes and subphenotypes of delirium: a review of current categorisations and suggestions for progression. Crit Care 2021; 25:334. [PMID: 34526093 PMCID: PMC8441952 DOI: 10.1186/s13054-021-03752-w] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 08/31/2021] [Indexed: 02/08/2023] Open
Abstract
Delirium is a clinical syndrome occurring in heterogeneous patient populations. It affects 45-87% of critical care patients and is often associated with adverse outcomes including acquired dementia, institutionalisation, and death. Despite an exponential increase in delirium research in recent years, the pathophysiological mechanisms resulting in the clinical presentation of delirium are still hypotheses. Efforts have been made to categorise the delirium spectrum into clinically meaningful subgroups (subphenotypes), using psychomotor subtypes such as hypoactive, hyperactive, and mixed, for example, and also inflammatory and non-inflammatory delirium. Delirium remains, however, a constellation of symptoms resulting from a variety of risk factors and precipitants with currently no successful targeted pharmacological treatment. Identifying specific clinical and biological subphenotypes will greatly improve understanding of the relationship between the clinical symptoms and the putative pathways and thus risk factors, precipitants, natural history, and biological mechanism. This will facilitate risk factor mitigation, identification of potential methods for interventional studies, and informed patient and family counselling. Here, we review evidence to date and propose a framework to identify subphenotypes. Endotype identification may be done by clustering symptoms with their biological mechanism, which will facilitate research of targeted treatments. In order to achieve identification of delirium subphenotypes, the following steps must be taken: (1) robust records of symptoms must be kept at a clinical level. (2) Global collaboration must facilitate large, heterogeneous research cohorts. (3) Patients must be clustered for identification, validation, and mapping of subphenotype stability.
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Affiliation(s)
- Emily M L Bowman
- Centre for Public Health, Block B, Institute of Clinical Sciences, Royal Victoria Hospital Site, Queen's University Belfast, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland.
| | - Emma L Cunningham
- Centre for Public Health, Block B, Institute of Clinical Sciences, Royal Victoria Hospital Site, Queen's University Belfast, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland
| | - Valerie J Page
- Department of Anaesthetics, Watford General Hospital, Vicarage Road, Watford, WD19 4DZ, UK
| | - Daniel F McAuley
- Centre for Experimental Medicine, Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland
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Vogel G, Joelsson-Alm E, Forinder U, Svensen C, Sandgren A. Stabilizing life: A grounded theory of surviving critical illness. Intensive Crit Care Nurs 2021; 67:103096. [PMID: 34244030 DOI: 10.1016/j.iccn.2021.103096] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 05/11/2021] [Accepted: 05/15/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The experience of critical illness among patients is both complex and multifaceted. It can make patients vulnerable to long-term consequences such as impairment in cognition, mental health and physical functional ability which affects health related quality of life. This study aims to explore patients' patterns of behaviour during the process from becoming critical ill to recovery at home. DESIGN We used a classic grounded theory methodology to explore the main concern for intensive care patients. Thirteen participants were interviewed and seven different participants were observed. SETTING Three general intensive care units in Sweden, consisting of a university hospital, a county hospital and a district hospital. FINDINGS The theory Stabilizing life explains how patients' main concern, being out of control, can be resolved. This theory involves two processes, recapturing life and recoding life, and one underlying strategy, emotional balancing that is used during the whole process. CONCLUSION The process from becoming critically ill until recovery home is perceived as a constant fight in actions and mind to achieve control and stabilize life. This theory can form the basis for further qualitative and quantitative research about interventions that promotes wellbeing during the whole process.
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Affiliation(s)
- Gisela Vogel
- Department of Clinical Science and Education, Karolinska Institutet, Unit of Anaesthesiology and Intensive Care, Södersjukhuset, Sjukhusbacken 10, 118 83 Stockholm, Sweden.
| | - Eva Joelsson-Alm
- Department of Clinical Science and Education, Karolinska Institutet, Unit of Anaesthesiology and Intensive Care, Södersjukhuset, Sjukhusbacken 10, 118 83 Stockholm, Sweden.
| | - Ulla Forinder
- Faculty of Health and Occupational Studies, University of Gävle, Kungsbäcksvägen 47, 801 76 Gävle, Sweden.
| | - Christer Svensen
- Department of Clinical Science and Education, Karolinska Institutet, Unit of Anaesthesiology and Intensive Care, Södersjukhuset, Sjukhusbacken 10, 118 83 Stockholm, Sweden.
| | - Anna Sandgren
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University, Växjö, Universitetsplatsen 1, 352 52 Växjö, Sweden.
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Goldberg TE, Chen C, Wang Y, Jung E, Swanson A, Ing C, Garcia PS, Whittington RA, Moitra V. Association of Delirium With Long-term Cognitive Decline: A Meta-analysis. JAMA Neurol 2021; 77:1373-1381. [PMID: 32658246 DOI: 10.1001/jamaneurol.2020.2273] [Citation(s) in RCA: 225] [Impact Index Per Article: 75.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Importance Delirium is associated with increased hospital costs, health care complications, and increased mortality. Long-term consequences of delirium on cognition have not been synthesized and quantified via meta-analysis. Objective To determine if an episode of delirium was an independent risk factor for long-term cognitive decline, and if it was, whether it was causative or an epiphenomenon in already compromised individuals. Data Sources A systematic search in PubMed, Cochrane, and Embase was conducted from January 1, 1965, to December 31, 2018. A systematic review guided by Preferred Reporting Items for Systematic Reviews and Meta-analyses was conducted. Search terms included delirium AND postoperative cognitive dysfunction; delirium and cognitive decline; delirium AND dementia; and delirium AND memory. Study Selection Inclusion criteria for studies included contrast between groups with delirium and without delirium; an objective continuous or binary measure of cognitive outcome; a final time point of 3 or more months after the delirium episode. The electronic search was conducted according to established methodologies and was executed on October 17, 2018. Data Extraction and Synthesis Three authors extracted data on individual characteristics, study design, and outcome, followed by a second independent check on outcome measures. Effect sizes were calculated as Hedges g. If necessary, binary outcomes were also converted to g. Only a single effect size was calculated for each study. Main Outcomes and Measures The planned main outcome was magnitude of cognitive decline in Hedges g effect size in delirium groups when contrasted with groups that did not experience delirium. Results Of 1583 articles, data subjected from the 24 studies (including 3562 patients who experienced delirium and 6987 controls who did not) were included in a random-effects meta-analysis for pooled effect estimates and random-effects meta-regressions to identify sources of study variance. One study was excluded as an outlier. There was a significant association between delirium and long-term cognitive decline, as the estimated effect size (Hedges g) for 23 studies was 0.45 (95% CI, 0.34-0.57; P < .001). In all studies, the group that experienced delirium had worse cognition at the final time point. The I2 measure of between-study variability in g was 0.81. A multivariable meta-regression suggested that duration of follow-up (longer with larger gs), number of covariates controlled (greater numbers were associated with smaller gs), and baseline cognitive matching (matching was associated with larger gs) were significant sources of variance. More specialized subgroup and meta-regressions were consistent with predictions that suggested that delirium may be a causative factor in cognitive decline. Conclusions and Relevance In this meta-analysis, delirium was significantly associated with long-term cognitive decline in both surgical and nonsurgical patients.
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Affiliation(s)
- Terry E Goldberg
- Department of Psychiatry, Columbia University Irving Medical Center, New York, New York.,Department of Anesthesiology, Columbia University Irving Medical Center, New York, New York
| | - Chen Chen
- Department of Psychiatry, Columbia University Irving Medical Center, New York, New York
| | - Yuanjia Wang
- Department of Psychiatry, Columbia University Irving Medical Center, New York, New York.,Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York
| | - Eunice Jung
- Department of Psychiatry, Columbia University Irving Medical Center, New York, New York
| | - Antoinette Swanson
- Department of Psychiatry, Columbia University Irving Medical Center, New York, New York
| | - Caleb Ing
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, New York
| | - Paul S Garcia
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, New York
| | - Robert A Whittington
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, New York
| | - Vivek Moitra
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, New York
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Liviskie C, McPherson C, Luecke C. Assessment and Management of Delirium in the Pediatric Intensive Care Unit: A Review. J Pediatr Intensive Care 2021; 12:94-105. [PMID: 37082469 PMCID: PMC10113017 DOI: 10.1055/s-0041-1730918] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 03/31/2021] [Indexed: 10/21/2022] Open
Abstract
AbstractMany critically ill patients suffer from delirium which is associated with significant morbidity and mortality. There is a paucity of data about the incidence, symptoms, or treatment of delirium in the pediatric intensive care unit (PICU). Risk factors for delirium are common in the PICU including central nervous system immaturity, developmental delay, mechanical ventilation, and use of anticholinergic agents, corticosteroids, vasopressors, opioids, or benzodiazepines. Hypoactive delirium is the most common subtype in pediatric patients; however, hyperactive delirium has also been reported. Various screening tools are validated in the pediatric population, with the Cornell Assessment of Pediatric Delirium (CAPD) applicable to the largest age range and able to detect signs and symptoms consistent with both hypo- and hyperactive delirium. Treatment of delirium should always include identification and reversal of the underlying etiology, reserving pharmacologic management for those patients without symptom resolution, or with significant impact to medical care. Atypical antipsychotics (olanzapine, quetiapine, and risperidone) should be used first-line in patients requiring pharmacologic treatment owing to their apparent efficacy and low incidence of reported adverse effects. The choice of atypical antipsychotic should be based on adverse effect profile, available dosage forms, and consideration of medication interactions. Intravenous haloperidol may be a potential treatment option in patients unable to tolerate oral medications and with significant symptoms. However, given the high incidence of serious adverse effects with intravenous haloperidol, routine use should be avoided. Dexmedetomidine should be used when sedation is needed and when clinically appropriate, given the positive impact on delirium. Additional well-designed trials assessing screening and treatment of PICU delirium are needed.
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Affiliation(s)
- Caren Liviskie
- Department of Pharmacy, St. Louis Children's Hospital, St. Louis, Missouri, United States
| | - Christopher McPherson
- Department of Pharmacy, St. Louis Children's Hospital, St. Louis, Missouri, United States
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, United States
| | - Caitlyn Luecke
- Department of Pharmacy, St. Louis Children's Hospital, St. Louis, Missouri, United States
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Wang G, Zhang L, Qi Y, Chen G, Zhou J, Zhu H, Hao Y. Development and Validation of a Postoperative Delirium Prediction Model for Elderly Orthopedic Patients in the Intensive Care Unit. JOURNAL OF HEALTHCARE ENGINEERING 2021; 2021:9959077. [PMID: 34211683 PMCID: PMC8205566 DOI: 10.1155/2021/9959077] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/23/2021] [Accepted: 05/28/2021] [Indexed: 11/17/2022]
Abstract
We developed a prediction model for delirium in elderly patients in the intensive care unit who underwent orthopedic surgery and then temporally validated its predictive power in the same hospital. In the development stage, we designed a prospective cohort study, and 319 consecutive patients aged over 65 years from January 2018 to December 2019 were screened. Demographic characteristics and clinical variables were evaluated, and a final prediction model was developed using the multivariate logistic regression analysis. In the validation stage, 108 patients were included for temporal validation between January 2020 and June 2020. The effectiveness of the model was evaluated through discrimination and calibration. As a result, the prediction model contains seven risk factors (age, anesthesia method, score of mini-mental state examination, hypoxia, major hemorrhage, level of interleukin-6, and company of family members), which had an area under the receiver operating characteristics curve of 0.82 (95% confidence interval 0.76-0.88) and was stable after bootstrapping. The temporal validation resulted in an area under the curve of 0.80 (95% confidence interval 0.67-0.93). Our prediction model had excellent discrimination power in predicting postoperative delirium in elderly patients and could assist intensive care physicians with early prevention.
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Affiliation(s)
- Gang Wang
- Department of Critical Care Medicine, Tongji Hospital, Tongji University School of Medicine, Tongji University, Shanghai 200065, China
| | - Lei Zhang
- Department of Critical Care Medicine, Tongji Hospital, Tongji University School of Medicine, Tongji University, Shanghai 200065, China
| | - Ying Qi
- Department of Economic Management, Yingkou Institute of Technology, Yingkou 115014, Liaoning, China
| | - Guangjian Chen
- Department of Critical Care Medicine, Tongji Hospital, Tongji University School of Medicine, Tongji University, Shanghai 200065, China
| | - Juan Zhou
- Department of Critical Care Medicine, Tongji Hospital, Tongji University School of Medicine, Tongji University, Shanghai 200065, China
| | - Huihui Zhu
- Department of Critical Care Medicine, Tongji Hospital, Tongji University School of Medicine, Tongji University, Shanghai 200065, China
| | - Yingxin Hao
- Department of Critical Care Medicine, Tongji Hospital, Tongji University School of Medicine, Tongji University, Shanghai 200065, China
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Ince I, Chiu A, Sagir A, Chahar P, Lin J, Douglas A, Adi A, Fang J, Mao G, Turan A. Association of Pain With Atrial Fibrillation and Delirium After Cardiac Surgery: A DECADE Sub-Study. J Cardiothorac Vasc Anesth 2021; 35:3021-3026. [PMID: 34148803 DOI: 10.1053/j.jvca.2021.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 05/05/2021] [Accepted: 05/06/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The authors aimed to evaluate the effects of postoperative pain on the incidence of atrial fibrillation and delirium in patients having surgery with cardiopulmonary bypass (CPB). DESIGN Post hoc analysis of the (An investigator-initiated, multicentre, double-blind trial (ClinicalTrials NCT02004613) (DECADE)), a randomized, placebo-controlled trial. SETTING Tertiary, academic hospital. PARTICIPANTS Six hundred five adults from the DECADE enrolled at Cleveland Clinic Main Campus, who had had surgery with CPB. INTERVENTIONS Dexmedetomidine versus placebo started before surgical incision and postoperatively was maintained until 24 hours. MEASUREMENTS Primary outcomes were atrial fibrillation, diagnosed by clinicians in the intensive care unit (ICU), presence of delirium assessed with the Confusion Assessment Method for the ICU, data on pain scores, and opioid consumption, occurring between ICU admission and the earlier of postoperative day five or hospital discharge. RESULTS Postoperative pain levels were similar among patients with or without atrial fibrillation. Two hundred six (34%) patients had atrial fibrillation and ninety-two (15%) had delirium before hospital discharge within the first five postoperative days. The risk of atrial fibrillation was not significantly different between groups (hazard ratio: 1.09; 97.5% confidence interval [CI]: 0.99, 1.20, p = 0.039); there were no associations between postoperative pain and the risk of postoperative delirium (hazard ratio: 0.96; 97.5% CI: 0.84-1.11; p = 0.57). Postoperative opioid consumption was neither significantly associated with postoperative atrial fibrillation nor delirium. CONCLUSIONS Atrial fibrillation and delirium was not associated with pain after cardiac surgery. Opioid use was not associated with atrial fibrillation and delirium. Because both atrial fibrillation and delirium have a multifactorial nature, further studies should be focused on other plausible mechanisms.
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Affiliation(s)
- Ilker Ince
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH; Anesthesiology Clinical Research Office, Ataturk University, Erzurum, Turkey
| | - Andrew Chiu
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH
| | - Afrin Sagir
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH
| | - Praveen Chahar
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH; Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH
| | - Jia Lin
- Department of Cardiovascular Anesthesiology, Cleveland Clinic, Cleveland, OH
| | - Aaron Douglas
- Department of Cardiovascular Anesthesiology, Cleveland Clinic, Cleveland, OH
| | - Ahmad Adi
- Department of Cardiovascular Anesthesiology, Cleveland Clinic, Cleveland, OH
| | - Jonathan Fang
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH
| | - Guangmei Mao
- Department Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Alparslan Turan
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH; Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH.
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Pan CX, Thomson K, Costa BA, Morris J. Questioning Capacity in an Elderly Jamaican Man with Terminal Cancer Exhibiting Near-Death Awareness: A Case Report and Review of Literature. J Palliat Med 2021; 24:1413-1417. [PMID: 33970707 DOI: 10.1089/jpm.2020.0785] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Near-death awareness (NDA) refers to visions and dreams commonly experienced by terminally ill individuals within months to hours before death. Methods: A case report of a 68-year-old Jamaican male diagnosed with advanced cholangiocarcinoma, who experienced visions of his deceased mother during hospitalization. Results: This article discusses how to differentiate NDA from delirium, core components for determining decisional capacity, and how clinicians can use a cultural guide to optimize patient-centered care. Conclusion: Improved recognition of NDA may promote cultural humility/competency and help to differentiate NDA from an underlying medical/psychiatric condition. It may assist the clinician in understanding the significance of NDA and the comfort and meaning these experiences may hold for both the individual and their family.
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Affiliation(s)
- Cynthia X Pan
- Division of Geriatrics and Palliative Care Medicine, NewYork-Presbyterian Queens, Flushing, New York, USA
| | - Kelly Thomson
- Division of General Internal Medicine, NewYork-Presbyterian Queens, Flushing, New York, USA
| | - Bruno A Costa
- Department of Internal Medicine, Walter Cantidio University Hospital, Federal University of Ceará, Fortaleza, Ceará, Brazil
| | - Jane Morris
- Department of Internal Medicine, Walter Cantidio University Hospital, Federal University of Ceará, Fortaleza, Ceará, Brazil
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30
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Naef AC, Jeitziner MM, Gerber SM, Jenni-Moser B, Müri RM, Jakob SM, Nef T, Hänggi M. Virtual reality stimulation to reduce the incidence of delirium in critically ill patients: study protocol for a randomized clinical trial. Trials 2021; 22:174. [PMID: 33648572 PMCID: PMC7923502 DOI: 10.1186/s13063-021-05090-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 02/02/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Delirium has been long considered as a major contributor to cognitive impairments and increased mortality following a critical illness. Pharmacologic and non-pharmacologic strategies are used against delirium in the intensive care unit (ICU), despite these strategies remaining controversial. Previous studies have shown the feasibility of using virtual reality within the ICU setting, and we propose to use this technology to investigate the effect of immersive virtual reality stimulation on the incidence of delirium in the ICU. Moreover, we propose to use motion sensors to determine if patient movement patterns can lead to early prediction of delirium onset. METHODS This study is conducted as a randomized clinical trial. A total of 920 critically ill patients in the ICU will participate. The control group will receive standard ICU care, whereas the intervention group will, in addition to the standard ICU care, receive relaxing 360-degree immersive virtual reality content played inside a head-mounted display with noise-cancelling headphones, three times a day. The first 100 patients, regardless of their group, will additionally have their movement patterns recorded using wearable and ambient sensors. Follow-up measurements will take place 6 months after discharge from the ICU. DISCUSSION Delirium is widely present within the ICU setting but lacks validated prevention and treatment strategies. By providing patients with virtual reality stimulation presented inside a head-mounted display and noise-cancelling headphones, participants may be isolated from disturbances on an ICU. It is believed that by doing so, the incidence of delirium will be decrease among these patients. Moreover, identifying movement patterns associated with delirium would allow for early detection and intervention, which may further improve long-term negative outcomes associated with delirium during critical care. TRIAL REGISTRATION ClinicalTrials.gov NCT04498585 . Registered on August 3, 2020.
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Affiliation(s)
- Aileen C. Naef
- Gerontechnology and Rehabilitation Group, University of Bern, Bern, Switzerland
| | - Marie-Madlen Jeitziner
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stephan M. Gerber
- Gerontechnology and Rehabilitation Group, University of Bern, Bern, Switzerland
| | - Béatrice Jenni-Moser
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - René M. Müri
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stephan M. Jakob
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Tobias Nef
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- ARTORG Centre for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Matthias Hänggi
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Abstract
Illusions and hallucinations are commonly encountered in both daily life and clinical practice. In this chapter, we review definitions and possible underlying mechanisms of these phenomena and then review what is known about specific conditions that are associated with them, including ophthalmic causes, migraine, epilepsy, Parkinson's disease, and schizophrenia. We then discuss specific syndromes including the Charles Bonnet syndrome, visual snow syndrome, Alice in Wonderland syndrome, and peduncular hallucinosis. The scientific study of illusions and hallucinations has contributed significantly to our understanding of how eye and brain process vision and contribute to perception. Important concepts are the distinction between topologic and hodologic mechanisms underlying hallucinations and the involvement of attentional networks. This chapter examines the various ways in which pathological illusions and hallucinations might arise in relation to the phenomenology and known pathology of the various conditions associated with them.
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Affiliation(s)
- Clare L Fraser
- Department of Ophthalmology, Save Sight Institute, Faculty of Health and Medicine, University of Sydney, Sydney, Australia.
| | - Christian J Lueck
- Department of Neurology, Canberra Hospital, and Australian National University Medical School, Canberra, Australia
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Huang K, Lu J, Zhu Y, Cheng T, Du D, Qian X, Pan H, Wang X, Yang H, Lou S. Incidence and risk factors of delirium after percutaneous coronary intervention in individuals hospitalised for acute myocardial infarction: protocol for a systematic review and meta-analysis. BMJ Open 2020; 10:e044564. [PMID: 33380487 PMCID: PMC7780515 DOI: 10.1136/bmjopen-2020-044564] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Delirium in the postoperative period is a wide-reaching problem that affects important clinical outcomes. The incidence and risk factors of delirium in individuals with acute myocardial infarction (AMI) after primary percutaneous coronary intervention (PCI) has not been completely determined and no relevant systematic review and meta-analysis of incidence or risk factors exists. Hence, we aim to conduct a systematic review and meta-analysis to ascertain the incidence and risk factors of delirium among AMI patients undergoing PCI. METHODS AND ANALYSES We will undertake a comprehensive literature search among PubMed, EMBASE, Cochrane Library, PsycINFO, CINAHL and Google Scholar from their inception to the search date. Prospective cohort and cross-sectional studies that described the incidence or at least one risk factor of delirium will be eligible for inclusion. The primary outcome will be the incidence of postoperative delirium. The quality of included studies will be assessed using a risk of bias tool for prevalence studies and the Cochrane guidelines. Heterogeneity of the estimates across studies will be assessed. Incidence and risk factors associated with delirium will be extracted. Incidence data will be pooled. Each risk factor reported in the included studies will be recorded together with its statistical significance; narrative and meta-analytical approaches will be employed. The systematic review and meta-analysis will be presented according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. ETHICS AND DISSEMINATION This proposed systematic review and meta-analysis is based on published data, and thus there is no requirement for ethics approval. The study will provide an up to date and accurate incidence and risk factors of delirium after PCI among patients with AMI, which is necessary for future research in this area. The findings of this study will be disseminated through publication in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42020184388.
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Affiliation(s)
- Kaizhuang Huang
- Intensive Care Unit, The Fifth Affiliated Hospital, Sun Yat-Sen University, Zhuhai 519000, China
| | - Jiaying Lu
- Department of Gastroenterology, The Fifth Affiliated Hospital, Sun Yat-Sen University, Zhuhai 519000, China
| | - Yaoli Zhu
- Intensive Care Unit, The Fifth Affiliated Hospital, Sun Yat-Sen University, Zhuhai 519000, China
| | - Tao Cheng
- Intensive Care Unit, The Fifth Affiliated Hospital, Sun Yat-Sen University, Zhuhai 519000, China
| | - Dahao Du
- Intensive Care Unit, The Fifth Affiliated Hospital, Sun Yat-Sen University, Zhuhai 519000, China
| | - Xueqin Qian
- Intensive Care Unit, The Fifth Affiliated Hospital, Sun Yat-Sen University, Zhuhai 519000, China
| | - Haiyan Pan
- Intensive Care Unit, The Fifth Affiliated Hospital, Sun Yat-Sen University, Zhuhai 519000, China
| | - Xiaohua Wang
- Intensive Care Unit, The Fifth Affiliated Hospital, Sun Yat-Sen University, Zhuhai 519000, China
| | - Hong Yang
- Intensive Care Unit, The Fifth Affiliated Hospital, Sun Yat-Sen University, Zhuhai 519000, China
| | - Shaofei Lou
- Intensive Care Unit, The Fifth Affiliated Hospital, Sun Yat-Sen University, Zhuhai 519000, China
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Krewulak KD, Hiploylee C, Ely EW, Stelfox HT, Inouye SK, Fiest KM. Adaptation and Validation of a Chart-Based Delirium Detection Tool for the ICU (CHART-DEL-ICU). J Am Geriatr Soc 2020; 69:1027-1034. [PMID: 33348428 PMCID: PMC8049975 DOI: 10.1111/jgs.16987] [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: 07/20/2020] [Revised: 10/19/2020] [Accepted: 11/20/2020] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To adapt and validate a chart-based delirium detection tool for use in critically ill adults. DESIGN Validation study. SETTING Medical-surgical intensive care unit (ICU) in an academic hospital. MEASUREMENTS A chart-based delirium detection tool (CHART-DEL) was adapted for use in critically ill adults (CHART-DEL-ICU) and compared with prospective delirium assessments (i.e., clinical assessments (reference standard) by a research nurse trained by a neuropsychiatrist and routine delirium screening tools Confusion Assessment Method (CAM-ICU)) and (Intensive Care Delirium Screening Checklist (ICDSC)). The original CHART-DEL tool was adapted to include physician-reported ICDSC score (for probable delirium) and Richmond-Agitation Sedation Scale score (for altered level of consciousness and agitation). Two trained chart abstractors blinded to all delirium assessments manually abstracted delirium-related information from medical charts and electronic medical records and rated if delirium was present (four levels: uncertain, possible, probable, definite) or absent (no evidence). RESULTS Charts were manually abstracted for delirium-related information for 213 patients who were included in a prospective cohort study that included prospective delirium assessments. The CHART-DEL-ICU tool had excellent interrater reliability (kappa = 0.90). Compared to the reference standard, the sensitivity was 66.0% (95% CI = 59.3-72.3%) and specificity was 82.1% (95% CI = 78.0-85.7%), with a cut-point that included definite, probable, possible, and uncertain delirium. The AUC of the CHART-DEL-ICU alone is 74.1% (95% CI = 70.4-77.8%) compared with the addition of the CAM-ICU and ICDSC (CAM-ICU/CHART-DEL-ICU: 80.9% (95% CI = 77.8-83.9%), P = .01; ICDSC/CHART-DEL-ICU: 79.2% (95% CI = 75.9-82.6%), P = .03). CONCLUSION A chart-based delirium detection tool has improved diagnostic accuracy when combined with routine delirium screening tools (CAM-ICU and ICDSC), compared to a chart-based method on its own. This presents a potential for retrospective detection of delirium from medical charts for research or to augment routine delirium screening methods to find missed cases of delirium.
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Affiliation(s)
- Karla D Krewulak
- Department of Critical Care Medicine, Alberta Health Services & University of Calgary, Calgary, Alberta, Canada
| | - Carmen Hiploylee
- Department of Critical Care Medicine, Alberta Health Services & University of Calgary, Calgary, Alberta, Canada
| | - E W Ely
- Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center (VA GRECC), Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Henry T Stelfox
- Department of Critical Care Medicine, Alberta Health Services & University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences & O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Sharon K Inouye
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.,Aging Brain Center, Marcus Institute for Aging Research, Hebrew Senior Life, Boston, Massachusetts, USA
| | - Kirsten M Fiest
- Department of Critical Care Medicine, Alberta Health Services & University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences & O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada.,Department of Psychiatry & Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Abstract
Supplemental Digital Content is available in the text. Objective: Summarize performance and development of ICU delirium-prediction models published within the past 5 years. Data Sources: Systematic electronic searches were conducted in April 2019 using PubMed, Embase, Cochrane Central, Web of Science, and Cumulative Index to Nursing and Allied Health Literature to identify peer-reviewed studies. Study Selection: Eligible studies were published in English during the past 5 years that specifically addressed the development, validation, or recalibration of delirium-prediction models in adult ICU populations. Data Extraction: Screened citations were extracted independently by three investigators with a 42% overlap to verify consistency using the CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies. Data Synthesis: Eighteen studies featuring 23 distinct prediction models were included. Model performance varied greatly, as assessed by area under the receiver operating characteristic curve (0.62–0.94), specificity (0.50–0.97), and sensitivity (0.45–0.96). Most models used data collected from a single time point or window to predict the occurrence of delirium at any point during hospital or ICU admission, and lacked mechanisms for providing pragmatic, actionable predictions to clinicians. Conclusions: Although most ICU delirium-prediction models have relatively good performance, they have limited applicability to clinical practice. Most models were static, making predictions based on data collected at a single time-point, failing to account for fluctuating conditions during ICU admission. Further research is needed to create clinically relevant dynamic delirium-prediction models that can adapt to changes in individual patient physiology over time and deliver actionable predictions to clinicians.
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Henao-Castaño AM, Pachón Cetina LE, Monroy Rodríguez JD. Nursing Delirium Screening Scale, a Tool for Early Detection of Delirium: Integrative Review. AQUICHAN 2020. [DOI: 10.5294/aqui.2020.20.4.5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective: To analyze the context and use of the Nursing Delirium Screening Scale (Nu-DESC) for early detection of delirium in adult patients, compiling the available evidence.
Method: Searching for relevant articles on databases such as Cinahl, Medline, Ovid, Scopus, and Web of Science. Inclusion criteria: Articles written in English, Spanish, and Portuguese, published between January 2013 and October 2019. Search terms: “nursing delirium screen,” “inpatient delirium screening,” and “nursing assessment.” We identified 23 articles in which the Nu-DESC was used. Two reviewers independently assessed the articles using the CASPe (Critical Appraisal Skills Program in Spanish) tool.
Results: The Nu-DESC is employed in different contexts such as the adult intensive care unit (ICU), post-anesthetic care unit (PACU), palliative care unit, and hospitalization unit. It is more frequently used in the PACU with a more sensitive threshold (≥ 1); the test showed greater sensitivity of 54.5 % (95 % CI: 32.2–75.6) and specificity of 97.1 % (95 % CI: 95.3–98.4).
Conclusion: The Nu-DESC facilitates the recognition of delirium episodes by the nursing team, makes care quicker and individualized for each patient, avoiding immediate pharmacological interventions, and coordinate interdisciplinary actions for diagnosis, especially in post-anesthetic care units.
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Badjatia N, Sanchez S, Judd G, Hausladen R, Hering D, Motta M, Parikh G, Chang W, Morris N, Simard JM, Sorkin J, Wittenberg GF, Ryan AS. Neuromuscular Electrical Stimulation and High-Protein Supplementation After Subarachnoid Hemorrhage: A Single-Center Phase 2 Randomized Clinical Trial. Neurocrit Care 2020; 35:46-55. [PMID: 33150572 DOI: 10.1007/s12028-020-01138-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 10/15/2020] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Aneurysmal subarachnoid hemorrhage (SAH) survivors live with long-term residual physical and cognitive disability. We studied whether neuromuscular electrical stimulation (NMES) and high-protein supplementation (HPRO) in the first 2 weeks after SAH could preserve neuromotor and cognitive function as compared to standard of care (SOC) for nutrition and mobilization. METHODS SAH subjects with a Hunt Hess (HH) grade > 1,modified Fisher score > 1 and BMI < 40 kg/m2 were randomly assigned to SOC or NMES + HPRO. NMES was delivered to bilateral quadricep muscles daily during two 30-min sessions along with HPRO (goal:1.8 g/kg/day) between post-bleed day (PBD) 0 and 14. Primary endpoint was atrophy in the quadricep muscle as measured by the percentage difference in the cross-sectional area from baseline to PBD14 on CT scan. All subjects underwent serial assessments of physical (short performance physical battery, SPPB) cognitive (Montreal Cognitive Assessment Scale, MoCA) and global functional recovery (modified Rankin Scale, mRS) at PBD 14, 42, and 90. RESULTS Twenty-five patients (SOC = 13, NMES + HPRO = 12) enrolled between December 2017 and January 2019 with no between-group differences in baseline characteristics (58 years old, 68% women, 50% HH > 3). Median duration of interventions was 12 days (range 9-14) with completion of 98% of NMES sessions and 83% of goal HPRO, and no reported serious adverse events. There was no difference in caloric intake between groups, but HPRO + NMES group received more protein (1.5 ± 0.5 g/kg/d v 0.9 ± 0.4 g/kg/d, P < 0.01). Muscle atrophy was less in NMES + HPRO than the SOC group (6.5 ± 4.1% vs 12.5 ± 6.4%, P 0.01). Higher atrophy was correlated with lower daily protein intake (ρ = - 0.45, P = 0.03) and lower nitrogen balance (ρ = 0.47, P = 0.02); and worse 3 month SPPB (ρ = - 0.31, P = 0.1) and mRS (ρ = 0.4, P = 0.04). NMES + HPRO patients had a better median [25%,75] SPPB (12[10, 12] v. 9 [4, 12], P = 0.01) and mRS (1[0,2] v.2[1, 3], P = 0.04) than SOC at PBD 90. CONCLUSIONS NMES + HPRO appears to be feasible and safe acutely after SAH and may reduce acute quadriceps muscle wasting with a lasting benefit on recovery after SAH.
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Affiliation(s)
- Neeraj Badjatia
- Program in Trauma, University of Maryland School of Medicine, 22 S. Greene Street G7K19, Baltimore, MD, 21201, USA.
- Departments of Neurology, University of Maryland School of Medicine, Baltimore, USA.
| | - Stephanie Sanchez
- Departments of Neurology, University of Maryland School of Medicine, Baltimore, USA
| | - Gabriella Judd
- Department of Clinical Nutrition, University of Maryland Medical Center, Baltimore, USA
| | - Rachel Hausladen
- Advanced Practice Provider Program, Neurocritical Care Unit, University of Maryland Medical Center, Baltimore, USA
| | - David Hering
- Advanced Practice Provider Program, Neurocritical Care Unit, University of Maryland Medical Center, Baltimore, USA
| | - Melissa Motta
- Program in Trauma, University of Maryland School of Medicine, 22 S. Greene Street G7K19, Baltimore, MD, 21201, USA
- Departments of Neurology, University of Maryland School of Medicine, Baltimore, USA
| | - Gunjan Parikh
- Program in Trauma, University of Maryland School of Medicine, 22 S. Greene Street G7K19, Baltimore, MD, 21201, USA
- Departments of Neurology, University of Maryland School of Medicine, Baltimore, USA
| | - Wendy Chang
- Program in Trauma, University of Maryland School of Medicine, 22 S. Greene Street G7K19, Baltimore, MD, 21201, USA
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, USA
| | - Nicholas Morris
- Program in Trauma, University of Maryland School of Medicine, 22 S. Greene Street G7K19, Baltimore, MD, 21201, USA
- Departments of Neurology, University of Maryland School of Medicine, Baltimore, USA
| | - J Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, USA
| | - John Sorkin
- Department of Medicine, University of Maryland School of Medicine, Baltimore, USA
| | - George F Wittenberg
- Departments of Neurology, University of Maryland School of Medicine, Baltimore, USA
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Alice S Ryan
- Department of Medicine, University of Maryland School of Medicine, Baltimore, USA
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Hallucinations: diagnosis, neurobiology and clinical management. Int Clin Psychopharmacol 2020; 35:293-299. [PMID: 32324611 DOI: 10.1097/yic.0000000000000313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Hallucinations are important diagnostic symptoms in schizophrenia, but also occur in other medical and neuropsychiatric conditions. Not all patients with hallucinations are psychotic. There has been a surge of interest in the topic of hallucinations, as new research data have begun to reveal their neurobiology. Hallucinogenic molecules may also serve as new scaffolds for the development of new psychotropic drugs. We searched and reviewed recent literature, focusing on the refinement of clinical management, which was inspired by new data regarding the neurobiology of hallucination subtypes. We concluded that the successful management of hallucinations depends on accurate differential diagnosis to identify subtypes, which would then determine the most appropriate treatment.
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Wintermann GB, Weidner K, Strauss B, Rosendahl J. Single assessment of delirium severity during postacute intensive care of chronically critically ill patients and its associated factors: post hoc analysis of a prospective cohort study in Germany. BMJ Open 2020; 10:e035733. [PMID: 33033083 PMCID: PMC7545620 DOI: 10.1136/bmjopen-2019-035733] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVES To assess the delirium severity (DS), its risk factors and association with adverse patient outcomes in chronically critically ill (CCI) patients. DESIGN A prospective cohort study. SETTING A tertiary care hospital with postacute intensive care units (ICUs) in Germany. PARTICIPANTS N=267 CCI patients with critical illness polyneuropathy and/or critical illness myopathy, aged 18-75 years, who had undergone elective tracheotomy for weaning failure. INTERVENTIONS None. MEASURES Primary outcomes: DS was assessed using the Confusion Assessment Method for the Intensive Care Unit-7 delirium severity score, within 4 weeks (t1) after the transfer to a tertiary care hospital. In post hoc analyses, univariate linear regressions were employed, examining the relationship of DS with clinical, sociodemographic and psychological variables. Secondary outcomes: additionally, correlations of DS with fatigue (using the Multidimensional Fatigue Inventory-20), quality of life (using the Euro-Quality of Life) and institutionalisation/mortality at 3 (t2) and 6 (t3) months follow-up were computed. RESULTS Of the N=267 patients analysed, 9.4% showed severe or most severe delirium symptoms. 4.1% had a full-syndromal delirium. DS was significantly associated with the severity of illness (p=0.016, 95% CI -0.1 to -0.3), number of medical comorbidities (p<0.001, 95% CI .1 to .3) and sepsis (p<0.001, 95% CI .3 to 1.0). Patients with a higher DS at postacute ICU (t1), showed a higher mental fatigue at t2 (p=0.008, 95% CI .13 to .37) and an increased risk for institutionalisation/mortality (p=0.043, 95% CI 1.1 to 28.9/p=0.015, 95% CI 1.5 to 43.2). CONCLUSIONS Illness severity is positively associated with DS during postacute care in CCI patients. An adequate management of delirium is essential in order to mitigate functional and cognitive long-term sequelae following ICU. TRIAL REGISTRATION NUMBER DRKS00003386.
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Affiliation(s)
- Gloria-Beatrice Wintermann
- Department of Psychotherapy and Psychosomatic Medicine, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Sachsen, Germany
| | - Kerstin Weidner
- Department of Psychotherapy and Psychosomatic Medicine, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Sachsen, Germany
| | - Bernhard Strauss
- Institute of Psychosocial Medicine, Psychotherapy and Psychooncology, Jena University Hospital, Jena, Thüringen, Germany
| | - Jenny Rosendahl
- Institute of Psychosocial Medicine, Psychotherapy and Psychooncology, Jena University Hospital, Jena, Thüringen, Germany
- Center for Sepsis Control and Care, Jena University Hospital, Jena, Thüringen, Germany
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Schnitker L, Nović A, Arendts G, Carpenter CR, LoGiudice D, Caplan GA, Fick DM, Beattie E. Prevention of Delirium in Older Adults With Dementia: A Systematic Literature Review. J Gerontol Nurs 2020; 46:43-54. [PMID: 32852044 DOI: 10.3928/00989134-20200820-02] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 06/08/2020] [Indexed: 11/20/2022]
Abstract
Although dementia is the largest independent risk factor for delirium and leads to poor health outcomes, we know little about how to prevent delirium in persons with dementia (PWD). The purpose of the current systematic literature review was to identify interventions designed to prevent delirium in older PWD. Seven studies meeting inclusion criteria were extracted. Five studies were in the acute care setting and two were community settings. One study used a randomized controlled trial design. Five of the seven interventions comprised multiple components addressing delirium risk factors, including education. Two studies addressed delirium by administration of medication or vitamin supplementation. Using the GRADE framework for the evaluation of study quality, we scored three studies as moderate and four studies as low. Thus, high-quality research studies to guide how best to prevent delirium in PWD are lacking. Although more research is required, the current review suggests that multicomponent approaches addressing delirium risk factors should be considered by health care professionals when supporting older PWD. [Journal of Gerontological Nursing, 46(10), 43-54.].
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Acosta-Murillo NR. Delirio en niños críticamente enfermos. REVISTA DE LA FACULTAD DE MEDICINA 2020. [DOI: 10.15446/revfacmed.v68n4.77430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
El delirio en pacientes críticos es una condición médica que afecta tanto a adultos como a niños; en ambas poblaciones implica graves complicaciones como estancia hospitalaria prolongada, alto riesgo de muerte y deterioro cognitivo a largo plazo, así como mayores costos económicos en cuanto a la prestación de servicios de salud. La principal dificultad de esta condición en la población pediátrica es su adecuado reconocimiento, ya que puede presentarse en edades muy tempranas, incluso en niños lactantes, cuando sus signos y síntomas pueden confundirse o superponerse con otras patologías, tales como el síndrome de abstinencia. En consecuencia, en estos casos el uso de herramientas diagnósticas puede ser una labor compleja que implica múltiples dificultades.Antes de 2011 no había muchos estudios que abordaran la evaluación del delirio en niños. Sin embargo, ese mismo año se estableció la primera escala desarrollada específicamente para el monitoreo de pacientes en unidades de cuidado intensivo pediátrico, lo que llevó a un aumento significativos del número de casos de delirio en niños menores de 5 años críticamente enfermos; esta situación hizo que los pediatras se interesaran más en estudiar esta importante patología.La presente reflexión, basada en una revisión de la literatura, busca actualizar el amplio espectro fisiopatológico del delirio en niños críticamente enfermos y, de esta forma, mejorar su tamizaje, diagnóstico e intervenciones terapéuticas tempranas en todas las edades pediátricas, incluso en menores de 5 años.
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Deffland M, Spies C, Weiss B, Keller N, Jenny M, Kruppa J, Balzer F. Effects of pain, sedation and delirium monitoring on clinical and economic outcome: A retrospective study. PLoS One 2020; 15:e0234801. [PMID: 32877411 PMCID: PMC7467321 DOI: 10.1371/journal.pone.0234801] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 06/02/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Significant improvements in clinical outcome can be achieved by implementing effective strategies to optimise pain management, reduce sedative exposure, and prevent and treat delirium in ICU patients. One important strategy is the monitoring of pain, agitation and delirium (PAD bundle). We hypothesised that there is no sufficient financial benefit to implement a monitoring strategy in a Diagnosis Related Group (DRG)-based reimbursement system, therefore we expected better clinical and decreased economic outcome for monitored patients. METHODS This is a retrospective observational study using routinely collected data. We used univariate and multiple linear analysis, machine-learning analysis and a novel correlation statistic (maximal information coefficient) to explore the association between monitoring adherence and resulting clinical and economic outcome. For univariate analysis we split patients in an adherence achieved and an adherence non-achieved group. RESULTS In total 1,323 adult patients from two campuses of a German tertiary medical centre, who spent at least one day in the ICU between admission and discharge between 1. January 2016 and 31. December 2016. Adherence to PAD monitoring was associated with shorter hospital LoS (e.g. pain monitoring 13 vs. 10 days; p<0.001), ICU LoS, duration of mechanical ventilation shown by univariate analysis. Despite the improved clinical outcome, adherence to PAD elements was associated with a decreased case mix per day and profit per day shown by univariate analysis. Multiple linear analysis did not confirm these results. PAD monitoring is important for clinical as well as economic outcome and predicted case mix better than severity of illness shown by machine learning analysis. CONCLUSION Adherence to PAD bundles is also important for clinical as well as economic outcome. It is associated with improved clinical and worse economic outcome in comparison to non-adherence in univariate analysis but not confirmed by multiple linear analysis. TRIAL REGISTRATION clinicaltrials.gov NCT02265263, Registered 15 October 2014.
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Affiliation(s)
- Marc Deffland
- Department of Anaesthesiology and Intensive Care Medicine (CCM, CVK), Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Claudia Spies
- Department of Anaesthesiology and Intensive Care Medicine (CCM, CVK), Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
- * E-mail:
| | - Bjoern Weiss
- Department of Anaesthesiology and Intensive Care Medicine (CCM, CVK), Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Niklas Keller
- Department of Anaesthesiology and Intensive Care Medicine (CCM, CVK), Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Mirjam Jenny
- Science Communication Unit, Robert Koch Institute, Berlin, Germany
- Harding Center for Risk Literacy, Faculty of Health Sciences Brandenburg, University of Potsdam, Potsdam, Germany
- Center for Adaptive Rationality, Max Planck Institute for Human Development, Berlin, Germany
| | - Jochen Kruppa
- Institute of Biometry and Clinical Epidemiology, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | - Felix Balzer
- Department of Anaesthesiology and Intensive Care Medicine (CCM, CVK), Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
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Farasat S, Dorsch JJ, Pearce AK, Moore AA, Martin JL, Malhotra A, Kamdar BB. Sleep and Delirium in Older Adults. CURRENT SLEEP MEDICINE REPORTS 2020; 6:136-148. [PMID: 32837850 PMCID: PMC7382993 DOI: 10.1007/s40675-020-00174-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Purpose of Review Poor sleep and delirium are common in older patients but recognition and management are challenging, particularly in the intensive care unit (ICU) setting. The purpose of this review is to highlight current research on these conditions, their inter-relationship, modes of measurement, and current approaches to management. Recent Findings Sleep deprivation and delirium are closely linked, with shared clinical characteristics, risk factors, and neurochemical abnormalities. Acetylcholine and dopamine are important neurochemicals in the regulation of sleep and wakefulness and their dysregulation has been implicated in development of delirium. In the hospital setting, poor sleep and delirium are associated with adverse outcomes; non-pharmacological interventions are recommended, but tend to be resource intensive and hindered by a lack of reliable sleep measurement tools. Delirium is easier to identify, with validated tools available in both ICU and non-ICU settings; however, an optimal treatment approach remains unclear. Antipsychotics are used widely to prevent and treat delirium, although the efficacy data are equivocal. Bundled non-pharmacologic approaches represent a promising framework for prevention and management. Summary Poor sleep and delirium are common problems in older patients. While these phenomena appear linked, a causal relationship is not clearly established. At present, there are no established sleep-focused guidelines for preventing or treating delirium. Novel interventions are needed that address poor sleep and delirium, particularly in older adults.
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Affiliation(s)
- Sadaf Farasat
- Division of Geriatrics and Gerontology, University of California San Diego, 9350 Campus Point Drive, La Jolla, CA 92037 USA
| | - Jennifer J Dorsch
- Johns Hopkins Medicine, Baltimore, MD USA.,Johns Hopkins Medicine, Howard County General Hospital, 5755 Cedar Ln, Columbia, MD 21044 USA
| | - Alex K Pearce
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego School of Medicine, 9300 Campus Point Drive #7381, La Jolla, CA 92037-7381 USA
| | - Alison A Moore
- Division of Geriatrics and Gerontology, University of California San Diego, 9500 Gilman Drive, MC 0665, La Jolla, CA 92093-0665 USA
| | - Jennifer L Martin
- VA Greater Los Angeles Healthcare System, 16111 Plummer St. (11E), North Hills, CA 91343 USA.,David Geffen School of Medicine at the University of California, Los Angeles, CA USA
| | - Atul Malhotra
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego School of Medicine, 9300 Campus Point Drive #7381, La Jolla, CA 92037-7381 USA
| | - Biren B Kamdar
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego School of Medicine, 9300 Campus Point Drive #7381, La Jolla, CA 92037-7381 USA
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Orsucci D, Ienco EC, Nocita G, Napolitano A, Vista M. Neurological features of COVID-19 and their treatment: a review. Drugs Context 2020; 9:2020-5-1. [PMID: 32587625 PMCID: PMC7295105 DOI: 10.7573/dic.2020-5-1] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 05/29/2020] [Accepted: 05/29/2020] [Indexed: 12/13/2022] Open
Abstract
Severe acute respiratory syndrome-correlated new coronavirus (SARS-Cov-2) infection may result in neurological signs and symptoms through different mechanisms. Although direct infection of the central nervous system is uncertain or very rare and the para-infectious complications (e.g. inflammatory neuropathies) are rare, delirium and septic encephalopathy are common in severely ill patients. Smell dysfunction and headache are very common in mild cases, especially in younger people and females. Muscle pain is common in both mild and severe cases, and in the most compromised patients, it is accompanied by increased creatine kinase levels and by a likely true myopathic damage. Ischemic stroke has been reported as a possible complication of the hypercoagulability associated with severe SARS-Cov-2 infection, but further studies are needed. Most of the neurological manifestations may occur early in the illness. Therefore, during the pandemic period, neurologists need to be involved, alert, and prepared. Neurological practice will not be the same until a vaccine is available.
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Affiliation(s)
| | | | | | | | - Marco Vista
- Unit of Neurology, San Luca Hospital, Lucca, Italy
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Hollinger A, von Felten S, Sutter R, Huber J, Tran F, Reinhold S, Abdelhamid S, Todorov A, Gebhard CE, Cajochen C, Steiner LA, Siegemund M. Study protocol for a prospective randomised double-blind placebo-controlled clinical trial investigating a Better Outcome with Melatonin compared to Placebo Administered to normalize sleep-wake cycle and treat hypoactive ICU Delirium: the Basel BOMP-AID study. BMJ Open 2020; 10:e034873. [PMID: 32354780 PMCID: PMC7213885 DOI: 10.1136/bmjopen-2019-034873] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Delirium is frequently observed in the intensive care unit (ICU) population, in particular. Until today, there is no evidence for any reliable pharmacological intervention to treat delirium. The Basel BOMP-AID (Better Outcome with Melatonin compared to Placebo Administered to normalize sleep-wake cycle and treat hypoactive ICU Delirium) randomised trial targets improvement of hypoactive delirium therapy in critically ill patients and will be conducted as a counterpart to the Basel ProDex Study (Study Protocol, BMJ Open, July 2017) on hyperactive and mixed delirium. The aim of the BOMP-AID trial is to assess the superiority of melatonin to placebo for the treatment of hypoactive delirium in the ICU. The study hypothesis is based on the assumption that melatonin administered at night restores a normal circadian rhythm, and that restoration of a normal circadian rhythm will cure delirium. METHODS AND ANALYSIS The Basel BOMP-AID study is an investigator-initiated, single-centre, randomised controlled clinical trial for the treatment of hypoactive delirium with the once daily oral administration of melatonin 4 mg versus placebo in 190 critically ill patients. The primary outcome measure is delirium duration in 8-hour shifts. Secondary outcome measures include delirium-free days and death at 28 days after study inclusion, number of ventilator days, length of ICU and hospital stay, and sleep quality. Patients will be followed after 3 and 12 months for activities of daily living and mortality assessment. Sample size was calculated to demonstrate superiority of melatonin compared with placebo regarding the duration of delirium. Results will be presented using an intention-to-treat approach. ETHICS AND DISSEMINATION This study has been approved by the Ethics Committee of Northwestern and Central Switzerland and will be conducted in compliance with the protocol, the current version of the Declaration of Helsinki, the International Conference on Harmonisation (ICH) of technical requirements for registration of pharmaceuticals for human use; Good Clinical Practice (GCP) or ISO EN 14155 (as far as applicable), as well as all national legal and regulatory requirements. Study results will be presented in international conferences and published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT03438526. PROTOCOL VERSION Clinical Study Protocol Version 3, 10.03.2019.
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Affiliation(s)
- Alexa Hollinger
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland
| | - Stefanie von Felten
- Department of Clinical Research, Clinical Trial Unit, c/o University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Raoul Sutter
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland
- Department for Clinical Neurophysiology, Department of Neurology, University Hospital Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, BS, Switzerland
| | - Jan Huber
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland
| | - Fabian Tran
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland
| | - Simona Reinhold
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland
| | - Salim Abdelhamid
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland
| | - Atanas Todorov
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland
| | | | - Christian Cajochen
- Faculty of Medicine, University of Basel, Basel, BS, Switzerland
- Centre of Chronobiology, Psychiatric Hospital of the University of Basel, and Transfaculty Research Platform Molecular and Cognitive Neurosciences, University of Basel, Basel, Switzerland
| | - Luzius A Steiner
- Faculty of Medicine, University of Basel, Basel, BS, Switzerland
- Department for Anesthesia, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Martin Siegemund
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, BS, Switzerland
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Landolf KM, Rivosecchi RM, Goméz H, Sciortino CM, Murray HN, Padmanabhan RR, Sanchez PG, Harano T, Sappington PL. Comparison of Hydromorphone versus Fentanyl-based Sedation in Extracorporeal Membrane Oxygenation: A Propensity-Matched Analysis. Pharmacotherapy 2020; 40:389-397. [PMID: 32149413 DOI: 10.1002/phar.2385] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 02/02/2020] [Accepted: 02/15/2020] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Data comparing sedatives in patients receiving extracorporeal membrane oxygenation (ECMO) are sparse. However, it is known that the ECMO circuit alters the pharmacokinetic properties of medications via drug sequestration of lipophilic agents and increased volume of distribution. OBJECTIVES This study evaluated the difference in days alive without delirium or coma and the sedative requirements in patients receiving fentanyl versus hydromorphone in ECMO patients. METHODS This single-center retrospective observational study evaluated adults receiving ECMO for more than 48 hours and continuous infusion of either fentanyl or hydromorphone for at least 6 hours. Of 148 patients evaluated, 88 received fentanyl and 60 received hydromorphone continuous infusion sedation. Outcomes included delirium-free and coma-free (DFCF) days, narcotic use, and sedative use. MAIN RESULTS There was an increase in the number of DFCF days in the hydromorphone group at day 7 (p=0.07) and day 14 (p=0.08) and a significant reduction in daily fentanyl equivalent exposure. Propensity score matching yielded 54 matched pairs. An 11.1% increase was observed in the proportion of ECMO days alive without delirium or coma in the hydromorphone group at 7 days (53.2% vs 42.1%, p=0.006). Patients in the hydromorphone group received significantly fewer narcotics with a median of 555 µg (interquartile range [IQR] 287-905 µg) of fentanyl equivalents per day compared with 2291 µg (IQR 1053-4023 µg) in the fentanyl group (p<0.005). CONCLUSION The use of hydromorphone-based sedation in ECMO patients resulted in more days alive without delirium or coma while significantly reducing narcotic requirements.
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Affiliation(s)
| | - Ryan M Rivosecchi
- Department of Pharmacy, University of Pittsburgh Medical Center (UPMC) Presbyterian Hospital, Pittsburgh, Pennsylvania
| | - Hernando Goméz
- Department of Critical Care Medicine, University of Pittsburgh Medical Center (UPMC) Presbyterian Hospital, Pittsburgh, Pennsylvania
| | - Christopher M Sciortino
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center (UPMC) Presbyterian Hospital, Pittsburgh, Pennsylvania
| | - Holt N Murray
- Department of Critical Care Medicine, University of Pittsburgh Medical Center (UPMC) Presbyterian Hospital, Pittsburgh, Pennsylvania
| | - Rajagopala R Padmanabhan
- Department of Critical Care Medicine, University of Pittsburgh Medical Center (UPMC) Presbyterian Hospital, Pittsburgh, Pennsylvania
| | - Pablo G Sanchez
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center (UPMC) Presbyterian Hospital, Pittsburgh, Pennsylvania
| | - Takashi Harano
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center (UPMC) Presbyterian Hospital, Pittsburgh, Pennsylvania
| | - Penny L Sappington
- Department of Critical Care Medicine, University of Pittsburgh Medical Center (UPMC) Presbyterian Hospital, Pittsburgh, Pennsylvania
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Mutch WAC, El-Gabalawy R, Ryner L, Puig J, Essig M, Kilborn K, Fidler K, Graham MR. Brain BOLD MRI O 2 and CO 2 stress testing: implications for perioperative neurocognitive disorder following surgery. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:76. [PMID: 32131878 PMCID: PMC7057494 DOI: 10.1186/s13054-020-2800-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 02/18/2020] [Indexed: 12/17/2022]
Abstract
Background Mechanical ventilation to alter and improve respiratory gases is a fundamental feature of critical care and intraoperative anesthesia management. The range of inspired O2 and expired CO2 during patient management can significantly deviate from values in the healthy awake state. It has long been appreciated that hyperoxia can have deleterious effects on organs, especially the lung and retina. Recent work shows intraoperative end-tidal (ET) CO2 management influences the incidence of perioperative neurocognitive disorder (POND). The interaction of O2 and CO2 on cerebral blood flow (CBF) and oxygenation with alterations common in the critical care and operating room environments has not been well studied. Methods We examine the effects of controlled alterations in both ET O2 and CO2 on cerebral blood flow (CBF) in awake adults using blood oxygenation level-dependent (BOLD) and pseudo-continuous arterial spin labeling (pCASL) MRI. Twelve healthy adults had BOLD and CBF responses measured to alterations in ET CO2 and O2 in various combinations commonly observed during anesthesia. Results Dynamic alterations in regional BOLD and CBF were seen in all subjects with expected and inverse brain voxel responses to both stimuli. These effects were incremental and rapid (within seconds). The most dramatic effects were seen with combined hyperoxia and hypocapnia. Inverse responses increased with age suggesting greater risk. Conclusions Human CBF responds dramatically to alterations in ET gas tensions commonly seen during anesthesia and in critical care. Such alterations may contribute to delirium following surgery and under certain circumstances in the critical care environment. Trial registration ClincialTrials.gov NCT02126215 for some components of the study. First registered April 29, 2014.
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Affiliation(s)
- W Alan C Mutch
- Department of Anesthesiology, Perioperative and Pain Medicine, Max Rady College of Medicine, University of Manitoba, 2nd Floor, Harry Medovy House, 671 William Ave., Winnipeg, MB, R3E 0Z2, Canada. .,Canada North Concussion Network, .
| | - Renée El-Gabalawy
- Department of Anesthesiology, Perioperative and Pain Medicine, Max Rady College of Medicine, University of Manitoba, 2nd Floor, Harry Medovy House, 671 William Ave., Winnipeg, MB, R3E 0Z2, Canada.,Department of Clinical Health Psychology, University of Manitoba, Winnipeg, Canada
| | - Lawrence Ryner
- Canada North Concussion Network.,Department of Radiology, University of Manitoba, Winnipeg, Canada.,Department of Physics, University of Manitoba, Winnipeg, Canada
| | - Josep Puig
- Department of Radiology, University of Manitoba, Winnipeg, Canada
| | - Marco Essig
- Canada North Concussion Network.,Department of Radiology, University of Manitoba, Winnipeg, Canada
| | - Kayla Kilborn
- Department of Anesthesiology, Perioperative and Pain Medicine, Max Rady College of Medicine, University of Manitoba, 2nd Floor, Harry Medovy House, 671 William Ave., Winnipeg, MB, R3E 0Z2, Canada
| | - Kelsi Fidler
- Department of Anesthesiology, Perioperative and Pain Medicine, Max Rady College of Medicine, University of Manitoba, 2nd Floor, Harry Medovy House, 671 William Ave., Winnipeg, MB, R3E 0Z2, Canada
| | - M Ruth Graham
- Department of Anesthesiology, Perioperative and Pain Medicine, Max Rady College of Medicine, University of Manitoba, 2nd Floor, Harry Medovy House, 671 William Ave., Winnipeg, MB, R3E 0Z2, Canada.,Canada North Concussion Network
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Likhvantsev VV, Landoni G, Grebenchikov OA, Ovezov AM, Skripkin YV, Lembo R, Gaevskiy DI, Tereshina AA, Yavorovskiy AG. Perioperative Dexmedetomidine Supplement Decreases Delirium Incidence After Adult Cardiac Surgery: A Randomized, Double-Blind, Controlled Study. J Cardiothorac Vasc Anesth 2020; 35:449-457. [PMID: 32265083 DOI: 10.1053/j.jvca.2020.02.035] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 02/22/2020] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Conflicting data exist on the effect of dexmedetomidine on delirium. For the present study, a randomized trial was performed to investigate the effect of perioperative dexmedetomidine on the rate of postoperative delirium after cardiac surgery. DESIGN A randomized controlled trial. SETTING University hospital. PARTICIPANTS Patients (n = 169) undergoing elective cardiac surgery (coronary artery bypass graft surgery, valve surgery, or combined surgery) with cardiopulmonary bypass. INTERVENTIONS Patients received a sevoflurane-based general anesthesia and were randomly assigned 1:1 to receive a dexmedetomidine infusion that started in the operating room (0.7 μg/kg/h) and continued into the intensive care unit (0.4 μg/kg/h) or an equivolume infusion of placebo. MEASUREMENTS AND MAIN RESULTS A decrease in the rate of delirium in the dexmedetomidine group compared with the placebo group was demonstrated (6 of 84 [7.1%] v 16 of 85 [18.8%]; p = 0.02; odds ratio [OR] 0.33 [95% confidence interval {CI} 0.12-0.90]). Reduced intensive care unit and hospital lengths of stay also were observed (18 [18-22] hours v 22 [18-39] hours; p = 0.002 and 17 [7-20] days v 19 [8-21] days; p = 0.04, respectively). Mortality at 30 days was 2 (2.4%) in both groups. On multivariate analysis, only dexmedetomidine administration (OR 0.24 [95% CI 0.08-0.74]) and cardiopulmonary bypass time (OR 1.02 [95% CI 1.01-1.03] for increases of 1 min) were independent predictors of delirium development. CONCLUSIONS Dexmedetomidine administered during and after general anesthesia for cardiac surgery with cardiopulmonary bypass decreased the rate of postoperative delirium and intensive care unit and hospital lengths of stay.
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Affiliation(s)
- Valery V Likhvantsev
- Moscow Regional Research and Clinical Institute, Moscow, Russia; IM Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Giovanni Landoni
- Vita-Salute San Raffaele University, Milan, Italy; Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Oleg A Grebenchikov
- Moscow Regional Research and Clinical Institute, Moscow, Russia; VA Negovsky Research Institute of General Reanimatology, Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia
| | - Alexey M Ovezov
- Moscow Regional Research and Clinical Institute, Moscow, Russia
| | - Yuri V Skripkin
- Moscow Regional Research and Clinical Institute, Moscow, Russia
| | - Rosalba Lembo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | | | - Andrey G Yavorovskiy
- IM Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
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Belov YV, Medvedeva LA, Katunina EA, Zagorulko OI, Drakina OV, Oystrakh AS. [Differential diagnosis of neurological conditions in cardiac patients on the first day after cardiac, ascending aortic and aortic arch surgery and repair of internal carotid arteries]. Khirurgiia (Mosk) 2019:5-12. [PMID: 31825337 DOI: 10.17116/hirurgia20191215] [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] [Indexed: 01/27/2023]
Abstract
The review is devoted to analysis of current trends in interdisciplinary approach to the differential diagnosis of patients' conditions on the first day after cardiac, ascending aortic and aortic arch surgery and repair of internal carotid arteries (neurological disorders, delirium, cognitive dysfunction, psycho-emotional disorders, postoperative sedation). This approach is valuable to determine the prognosis and timely treatment. The basic concepts reflecting the discussion between neurologists, cardiovascular surgeons, anesthetists, radiation diagnostics specialists and rehabilitators are summarized. The authors concluded that timely and correct differential diagnosis of the states on the first postoperative day using current tests and interdisciplinary approach to the treatment of patients with postoperative impaired consciousness or neurological/psycho-emotional dysfunction can improve their quality of life and efficiency of medical care.
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Affiliation(s)
- Yu V Belov
- Petrovsky National Research Centre of Surgery, Moscow, Russia
| | - L A Medvedeva
- Petrovsky National Research Centre of Surgery, Moscow, Russia
| | - E A Katunina
- Department of Neurology, Neurosurgery and Medical Genetics of the Pirogov Russian National Research Medical University of the Ministry of Health of the Russia, Moscow, Russia
| | - O I Zagorulko
- Petrovsky National Research Centre of Surgery, Moscow, Russia
| | - O V Drakina
- Clinic of aortic and cardiovascular surgery of the Sechenov First Moscow State Medical University, Moscow, Russia
| | - A S Oystrakh
- Petrovsky National Research Centre of Surgery, Moscow, Russia
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Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Crit Care Med 2019; 46:e825-e873. [PMID: 30113379 DOI: 10.1097/ccm.0000000000003299] [Citation(s) in RCA: 1817] [Impact Index Per Article: 363.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To update and expand the 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU. DESIGN Thirty-two international experts, four methodologists, and four critical illness survivors met virtually at least monthly. All section groups gathered face-to-face at annual Society of Critical Care Medicine congresses; virtual connections included those unable to attend. A formal conflict of interest policy was developed a priori and enforced throughout the process. Teleconferences and electronic discussions among subgroups and whole panel were part of the guidelines' development. A general content review was completed face-to-face by all panel members in January 2017. METHODS Content experts, methodologists, and ICU survivors were represented in each of the five sections of the guidelines: Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption). Each section created Population, Intervention, Comparison, and Outcome, and nonactionable, descriptive questions based on perceived clinical relevance. The guideline group then voted their ranking, and patients prioritized their importance. For each Population, Intervention, Comparison, and Outcome question, sections searched the best available evidence, determined its quality, and formulated recommendations as "strong," "conditional," or "good" practice statements based on Grading of Recommendations Assessment, Development and Evaluation principles. In addition, evidence gaps and clinical caveats were explicitly identified. RESULTS The Pain, Agitation/Sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) panel issued 37 recommendations (three strong and 34 conditional), two good practice statements, and 32 ungraded, nonactionable statements. Three questions from the patient-centered prioritized question list remained without recommendation. CONCLUSIONS We found substantial agreement among a large, interdisciplinary cohort of international experts regarding evidence supporting recommendations, and the remaining literature gaps in the assessment, prevention, and treatment of Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) in critically ill adults. Highlighting this evidence and the research needs will improve Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) management and provide the foundation for improved outcomes and science in this vulnerable population.
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50
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Wang X, Feng K, Liu H, Liu Y, Ye M, Zhao G, Wang T. Regional cerebral oxygen saturation and postoperative delirium in endovascular surgery: a prospective cohort study. Trials 2019; 20:504. [PMID: 31412906 PMCID: PMC6694555 DOI: 10.1186/s13063-019-3586-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 07/16/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Delirium is an acute mental disorder and common postoperative complication. Monitoring regional cerebral oxygen saturation (rSO2) in endovascular therapeutic surgery may allow real-time monitoring of cerebral desaturation, avoiding profound cerebral dysfunction, and reducing the incidence of delirium. We sought to examine the incidence of delirium in patients undergoing endovascular surgery. METHODS This was a clinical cohort trial (registered with http://www.clinicaltrials.gov [NCT02356133]). We monitored the rSO2 of 43 patients undergoing general anesthesia and cerebral endovascular surgery. The occurrence of delirium after surgery was recorded with the Confusion Assessment Method (CAM). Multivariate logistic regression was performed to identify the main predictor of delirium. RESULTS rSO2 was significantly different between the delirium and no-delirium groups. The occurrence of delirium was 35% in our cohort, and higher rSO2 desaturation scores were significantly associated with profound delirium (higher CAM score; odds ratio = 1.002; P = 0.021). The maximum declines of systolic blood pressure were 24.86 (21.78-27.93) and 32.98 (28.78-37.19) in the no-delirium and delirium groups, respectively, which were significantly different (P = 0.002) but not closely associated with delirium in multivariate analysis (P = 0.512). Anesthesia, mechanical ventilation duration, and having two vascular risk factors differed significantly between groups but were poorly associated with delirium outcome. CONCLUSIONS Elevated rSO2 desaturation score was predictive of the occurrence of postoperative delirium following endovascular surgery. Monitoring rSO2 is invaluable for managing controlled hypotension during endovascular surgery and reducing postoperative delirium. TRIAL REGISTRATION ClinicalTrials.gov, NCT02356133 . Registered 1 February 2015. All statistical analysis results submitted August 4, 2018.
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Affiliation(s)
- Xiaohua Wang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China.,Institute of Geriatrics, Beijing, China.,National Clinical Research Center for Geriatric Disorders, Beijing, China
| | - Kunpeng Feng
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China.,Institute of Geriatrics, Beijing, China.,National Clinical Research Center for Geriatric Disorders, Beijing, China
| | - Haixia Liu
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China.,Institute of Geriatrics, Beijing, China.,National Clinical Research Center for Geriatric Disorders, Beijing, China
| | - Yanhui Liu
- Department of Cardiac surgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Ming Ye
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Guoguang Zhao
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China. .,Institute of Geriatrics, Beijing, China. .,National Clinical Research Center for Geriatric Disorders, Beijing, China. .,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China.
| | - Tianlong Wang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China. .,Institute of Geriatrics, Beijing, China. .,National Clinical Research Center for Geriatric Disorders, Beijing, China.
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