Delirium in Critically Ill Patients

Refeeding hypophosphatemia is a common cause of delirium in critically ill patients: A retrospective study

BACKGROUND

The purpose was to explore the correlation between refeeding hypophosphatemia and delirium and analyze the related factors in critically ill patients.

METHODS

We conducted a retrospective review of critically ill patients admitted to Nanjing Drum Tower Hospital between September 2019 and March 2021. The patients were divided into delirium and nondelirium groups. Demographic data, underlying diseases, laboratory findings, comorbidities, nutritional intake and overall prognosis were collected and analyzed.

RESULTS

In total, 162 patients were included and divided into delirium (n=54) and nondelirium (n=108) groups. Serum phosphorus levels in the two groups decreased significantly in the first three days (P1, P2, P3) after nutrient intake compared with baseline before nutrient intake (Ppre). P1 and P2 were significantly lower in the delirium group compared to the nondelirium group. The maximum blood phosphorus reduction (Pmax) in the first three days after nutrient intake was significantly higher in the delirium group than in the nondelirium group. The time of Pmax in the delirium group was on the first day after nutrient intake. Multivariable logistic regression analysis identified starting route of nutrition and P1< 0.845 mmol/L as the independent predictors of delirium development in critically ill patients.

CONCLUSION

The incidence of delirium in critically ill patients is high and associated with refeeding hypophosphatemia. Delirium may occur with serum phosphorus levels less than 0.845 mmol/L on the first day.

The EyeControl-Med device, an alternative tool for communication in ventilated critically ill patients: A pilot study examining communication capabilities and delirium

INTRODUCTION

Communication with ventilated patients in the Intensive care unit (ICU) is challenging. This may lead to anxiety and frustration, potentially contributing to the development of delirium. Various technologies, such as eye-tracking devices, have been employed to facilitate communication with varying grades of success. The EyeControl-Med device is a novel technology that delivers audio content and allows patients to interact by eye movements and could potentially allow for better communication in this setting. The aim of this exploratory concept study was to assess communication capabilities and delirium incidence using the EyeControl-Med device in critically ill patients unable to generate speech.

MATERIAL AND METHODS

A single-arm pilot study of patients in a mixed ICU. Patients were approached for consent if they were invasively ventilated and/or tracheotomized, hence unable to generate speech, but had no severe cognitive or sensory impairment that could prevent proper usage. Patients underwent at least 3 sessions with the EyeControl-Med device administered by a speech-language pathologist. Communication and consciousness were assessed using the Loewenstein Communication Scale (LCS) tool during the first and last sessions. Delirium was assessed using a computerized CAM-ICU questionnaire.

RESULTS

15 patients were included, 40% of whom were diagnosed with COVID-19. All patients completed three to seven usage sessions. The mean LCS score improved by 19.3 points (p < 0.0001), with each of its five components showing significant improvements as well. The mean number of errors on the CAM-ICU questionnaire decreased from 6.5 to 2.5 (p = 0.0006), indicating a lower incidence of delirium. No adverse effects were observed.

CONCLUSION

The EyeControl-Med device may facilitate communication and reduce the manifestations and duration of delirium in ventilated critically ill patients. Controlled studies are required to establish this effect.

Dynamic Nomogram for Subsyndromal Delirium in Adult Intensive Care Unit: A Prospective Cohort Study

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.

Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) for the diagnosis of delirium in adults in critical care settings

BACKGROUND

Delirium is an underdiagnosed clinical syndrome typified by an acute alteration of mental state. It is an important problem in critical care and intensive care units (ICU) due to its high prevalence and its association with adverse outcomes. Delirium is a very distressing condition for patients, with a huge impact on their well-being. Diagnosis of delirium in the critical care setting is challenging. This is especially true for patients who are mechanically ventilated and are therefore unable to engage in a verbal interview. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is a tool specifically designed to assess for delirium in the context of ICU patients, including those on mechanical ventilation. CAM-ICU can be administered by non-specialists to give a dichotomous delirium present/absent result.

OBJECTIVES

To determine the diagnostic accuracy of the CAM-ICU for the diagnosis of delirium in adult patients in critical care units.

SEARCH METHODS

We searched MEDLINE (Ovid SP, 1946 to 8 July 2022), Embase (Ovid SP, 1982 to 8 July 2022), Web of Science Core Collection (ISI Web of Knowledge, 1945 to 8 July 2022), PsycINFO (Ovid SP, 1806 to 8 July 2022), and LILACS (BIREME, 1982 to 8 July 2022). We checked the reference lists of included studies and other resources for additional potentially relevant studies. We also searched the Health Technology Assessment database, the Cochrane Library, Aggressive Research Intelligence Facility database, WHO ICTRP, ClinicalTrials.gov, and websites of scientific associations to access any annual meetings and abstracts of conference proceedings in the field.

SELECTION CRITERIA

We included diagnostic studies enrolling adult ICU patients assessed using the CAM-ICU tool, regardless of language or publication status and reporting sufficient data on delirium diagnosis for the construction of 2 x 2 tables. Eligible studies evaluated the diagnostic performance of the CAM-ICU versus a clinical reference standard based on any iteration of the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria applied by a clinical expert.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected and collated study data. We assessed the methodological quality of studies using the QUADAS-2 tool. We used two univariate fixed-effect or random-effects models to determine summary estimates of sensitivity and specificity. We performed sensitivity analyses that excluded studies considered to be at high risk of bias and high concerns in applicability, due mainly to the target population included (e.g. patients with traumatic brain injury). We also investigated potential sources of heterogeneity, assessing the effect of reference standard diagnosis and proportion of patients ventilated.

MAIN RESULTS

We included 25 studies (2817 participants). The mean age of participants ranged from 48 to 69 years; 15 of the studies included critical care units admitting mixed populations (e.g. medical, trauma, surgery patients). The percentage of patients receiving mechanical ventilation ranged from 11.8% to 100%. The prevalence of delirium in the studies included ranged from 12.5% to 83.9%. Presence of delirium was determined by the application of DSM-IV criteria in 13 out of 25 included studies. We assessed 13 studies as at low risk of bias and low applicability concerns for all QUADAS-2 domains. The most common issue of concern was flow and timing of the tests, followed by patient selection. Overall, we estimated a pooled sensitivity of 0.78 (95% confidence interval (CI) 0.72 to 0.83) and a pooled specificity of 0.95 (95% CI 0.92 to 0.97). Sensitivity analysis restricted to studies at low risk of bias and without any applicability concerns (n = 13 studies) gave similar summary accuracy indices (sensitivity 0.80 (95% CI 0.72 to 0.86), specificity 0.95 (95% CI 0.93 to 0.97)). Subgroup analyses based on diagnostic assessment found summary estimates of sensitivity and specificity for studies using DSM-IV of 0.79 (95% CI 0.72 to 0.85) and 0.94 (95% CI 0.90 to 0.96). For studies that used DSM-5 criteria, summary estimates of sensitivity and specificity were 0.75 (95% CI 0.67 to 0.82) and 0.98 (95% CI 0.95 to 0.99). DSM criteria had no significant effect on sensitivity (P = 0.421), but the specificity for detection of delirium was higher when DSM-5 criteria were used (P = 0.024). The relative specificity comparing DSM-5 versus DSM-IV criteria was 1.05 (95% CI 1.02 to 1.08). Summary estimates of sensitivity and specificity for studies recruiting < 100% of patients with mechanical ventilation were 0.81 (95% CI 0.75 to 0.85) and 0.95 (95% CI 0.91 to 0.98). For studies that exclusively recruited patients with mechanical ventilation, summary estimates of sensitivity and specificity were 0.91 (95% CI 0.76 to 0.97) and 0.98 (95% CI 0.92 to 0.99). Although there was a suggestion of differential performance of CAM-ICU in ventilated patients, the differences were not significant in sensitivity (P = 0.316) or in specificity (P = 0.493).

AUTHORS' CONCLUSIONS

The CAM-ICU tool may have a role in the early identification of delirium, in adult patients hospitalized in intensive care units, including those on mechanical ventilation, when non-specialized, properly trained clinical personnel apply the CAM-ICU. The test is most useful for exclusion of delirium. The test may miss a proportion of patients with incident delirium, therefore in situations where detection of all delirium cases is desirable, it may be best to repeat the test or combine CAM-ICU with another assessment. Future studies should compare different screening tests proposed for bedside assessment of delirium, as this approach will reveal which tool yields superior accuracy. In addition, future studies should consider and report the flow and timing of the tests and clearly report key characteristics related to patient selection. Finally, future research should focus on the impact of CAM-ICU screening on patient outcomes.

The impact of rounds with a psychiatry team in the intensive care unit: A prospective observational pilot study evaluating the effects on delirium incidence and outcomes

BACKGROUND

Delirium in the intensive care unit (ICU) is a common but serious condition that has been associated with in-hospital mortality and post-discharge psychological dysfunction. The aim of this before and after study is to determine the effect of a multidisciplinary care model entailing daily ICU rounds with a psychiatrist on the incidence of delirium and clinical outcomes.

OBJECTIVE

To assess the impact of a proactive psychiatry consultation model in the surgical ICU on the incidence and duration of delirium.

METHODS

This was a prospective, single institution, observational controlled cohort pilot study of adult patients admitted to a surgical ICU. A control group that received standard of care (SOC) with daily delirium prevention care bundles in the pre-intervention period was compared to an intervention group, which had a psychiatrist participate in daily ICU rounds (post-intervention period). The primary outcome was delirium incidence. The secondary outcomes were: delirium duration, ventilator days, hospital and ICU length of stay, and in-hospital mortality.

RESULTS

A total of 104 patients were enrolled and equally split between SOC and intervention groups; 95 contributed to analysis. The overall incidence of ICU delirium was 19%. SOC and intervention groups had similar rates of delirium (21% vs 18%, p = 0.72). None of the secondary outcomes statistically significantly differed between the two groups.

CONCLUSION

Delirium in ICU patients is a potentially preventable condition with serious sequelae. There was no difference in delirium incidence or duration between patients receiving SOC or patients who had multidisciplinary rounds with a psychiatrist.

Dexmedetomidine for the prevention of delirium in adults admitted to the intensive care unit or post-operative care unit: A systematic review of randomised clinical trials with meta-analysis and Trial Sequential Analysis

OBJECTIVES

To assess any benefit or harm, we conducted a systematic review of randomised clinical trials (RCTs) allocating adults to dexmedetomidine versus placebo/no intervention for the prevention of delirium in intensive care or post-operative care units.

DATA SOURCES

We searched Medline, Embase, CENTRAL and other databases. The last search was 9 April 2022.

DATA EXTRACTION

Literature screening, data extraction and risk of bias volume 2 assessments were performed independently and in duplicate. Primary outcomes were occurrences of serious adverse events (SAEs), delirium and all-cause mortality. We used meta-analysis, Trial Sequential Analysis, and GRADE (Grading Recommendations Assessment, Development and Evaluation).

DATA SYNTHESIS

Eighty-one RCTs (15,745 patients) provided data for our primary outcomes. Results from trials at low risk of bias showed that dexmedetomidine may reduce the occurrence of the most frequently reported SAEs (relative risk [RR] 0.69; 95% CI 0.43-1.09), cumulated SAEs (RR 0.70; 95% CI 0.52-0.95) and the occurrence of delirium (RR 0.62; 95% CI 0.43-0.89). The certainty of evidence was very low for delirium. Mortality was very low in trials at low risk of bias (0.4% in the dexmedetomidine groups and 1.0% in the control groups) and meta-analysis did not provide conclusive evidence that dexmedetomidine may result in lower or higher all-cause mortality (RR 0.47; 95% CI 0.18-1.21). There was a lack of information from trial results at low risk of bias for all primary outcomes.

CONCLUSIONS

Trial results at low risk of bias showed that dexmedetomidine might reduce occurrences of SAEs and delirium, while no conclusive evidence was found for effects on all-cause mortality. The certainty of evidence ranged from very low for occurrence of delirium to low for the remaining outcomes.

Evaluation of the delirium preventive effect of dual orexin receptor antagonist (DORA) in critically ill adult patients requiring ventilation with tracheal intubation at an advanced emergency center: A single-center, retrospective, observational study

OBJECTIVE

ICU delirium reportedly contributes to increased mortality attributed to underlying diseases, long-term cognitive decline, and increased healthcare costs. Dual orexin receptor antagonists (DORAs), suvorexant and lemborexant, have been suggested for preventing ICU delirium. Although ventilator management is a risk factor for delirium, no study has examined the efficacy of suvorexant and lemborexant in preventing delirium in critically ill patients requiring ventilation. Thus, we retrospectively evaluated the efficacy of DORA in preventing delirium in critically ill adult patients requiring ventilatory management in the emergency room.

METHOD

This retrospective study included patients aged ≥18 years who were admitted to the emergency room and received ventilator support between January 2015 and April 2022. The HR (95% CI) for delirium development in patients taking DORA was estimated using a Cox proportional hazards model, which was adjusted for the patient background and concomitant medications. HRs were calculated for patients taking suvorexant and those taking lemborexant using a stratified analysis.

RESULTS

Of the 297 patients included in the study, 67 were in the DORA group; 50 were on suvorexant and 17 were on lemborexant. The DORA group had a lower incidence of delirium than the control group (p < 0.0001). The risk of delirium was lower in the DORA group compared the control group (HR, 0.22; 95% CI 0.12-0.40).The risk of developing delirium was lower with suvorexant (HR 0.22; 95% CI 0.11-0.41) and lemborexant (HR 0.25; 95% CI 0.08-0.81).

CONCLUSION

DORA is a promising drug that could have the potential to prevent delirium, and its efficacy in preventing delirium should be tested in randomized controlled trials in the future.

Improving Nurses Knowledge and Practices of Delirium Assessment at Mbarara Regional Referral Hospital: A Quasi Experimental Study

BACKGROUND

Despite the recommendations for delirium assessment in clinical settings, it stills remain a serious clinical problem associated with prolonged mechanical ventilation, stress on the patient and family, and mortality. There is paucity of data regarding delirium assessment and prevention in developing world. The Confusion Assessment Method for Intensive Care Unit (CAM-ICU) was developed to aid in the assessment of delirium. There is no documented assessment of delirium and prevention in Uganda. This study evaluated the effect of an educational intervention on nurses' knowledge and practices of delirium assessment using the CAM-ICU tool.

METHODS

We used a quasi-experimental and recruited a convenience sample of 29 nurses from ICU and ER. The assessment before and after the interventions was conducted using a self-completed questionnaire from October 2020 to January 2021. The interventions were delivered through face-to-face presentations, demonstrations, watching videos, and hands on practice. Data were entered into excel, cleaned and exported to Stata version 14. Median and interquartile ranges were used for continuous variables, and frequencies and percentages for categorical variables. The mean knowledge score was calculated before and after the intervention. A paired t-test was used to compare Pre- and Post-test knowledge and practice scores at P <0.05.

RESULTS

Majority (62%) were female, 48% were Diploma holders, median age was 30 (IQR = 28-32) years and median years of experience 3.5 (IQR = 3-4). The Mean knowledge scores was 10.7 (SD = 2.36) pretest and 19 (0.94) posttest. The mean practice score was 2 (SD = 0.83) pretest and 6 (0.35) posttest. There were significant differences in mean knowledge and practice scores before and after intervention mean of (t (28) =17.32, p < 0.001) and (t (28) = 25.04, p<0.001), respectively.

CONCLUSION

Educational intervention Improved nurses' knowledge and practice of delirium assessment. Continuous nursing education could improve nurses' knowledge of delirium assessment and thus quality of patient care.

Delirium in the intensive care unit and its importance in the post-operative context: A review

The burden of delirium in the intensive care setting is a global priority. Delirium affects up to 80% of patients in intensive care units; an episode of delirium is often distressing to patients and their families, and delirium in patients within, or outside of, the intensive care unit (ICU) setting is associated with poor outcomes. In the short term, such poor outcomes include longer stay in intensive care, longer hospital stay, increased risk of other hospital-acquired complications, and increased risk of hospital mortality. Longer term sequelae include cognitive impairment and functional dependency. While medical category of admission may be a risk factor for poor outcomes in critical care populations, outcomes for surgical ICU admissions are also poor, with dependency at hospital discharge exceeding 30% and increased risk of in-hospital mortality, particularly in vulnerable groups, with high-risk procedures, and resource-scarce settings. A practical approach to delirium prevention and management in the ICU setting is likely to require a multi-faceted approach. Given the good evidence for the prevention of delirium among older post-operative outside of the intensive care setting, simple non-pharmacological interventions should be effective among older adults post-operatively who are cared for in the intensive care setting. In response to this, the future ICU environment will have a range of organizational and distinct environmental characteristics that are directly targeted at preventing delirium.

A nurse-led intervention to reduce the incidence and duration of delirium among adults admitted to intensive care: A stepped-wedge cluster randomised trial

BACKGROUND

Delirium is an acute change in behaviour, characterised by a fluctuating course, inattention, and disorganised thinking. For critically ill adults in the intensive care, the incidence of delirium has been reported to be at least 30% and is associated with both short-term and long-term complications, longer hospital stay, increased risk of mortality, and long-term cognitive problems.

AIM

The objective of this study was to determine the effectiveness of a nurse-led delirium-prevention protocol in reducing the incidence and duration of delirium among adults admitted to intensive care.

METHODS

A hybrid stepped-wedge cluster randomised controlled trial was conducted to assess the effectiveness of the implementation and dissemination of the nurse-led intervention to reduce the incidence and duration of delirium among adults admitted to the four adults intensive care units in the southwest of Sydney, Australia.

RESULTS

Between May 2019 and February 2020, over a 10-month period, 2618 admissions, among 2566 patients, were included in the study. After an initial 3-month baseline period, each month there was a random crossover to the nurse-led intervention in one of the four intensive care units, and by the 7th month of the trial, all units were exposed to the intervention for at least 3 months. The incidence of acute delirium was observed to be 10.7% (95% confidence interval [CI] = 9.1-12.4%), compared to 14.1% (95% CI = 12.2-16.2%) during the preintervention (baseline) period (adjusted rate ratio [adjRR] = 0.78, 95% CI = 0.57-1.08, p = 0.134). The average delirium-free-days for these preintervention and postintervention periods were 4.1 days (95% CI = 3.9-4.3) and 4.4 days (95% CI = 4.2-4.5), respectively (adjusted difference = 0.24 days [95% CI = -0.12 to 0.60], p = 0.199).

CONCLUSION

Following the introduction of a nurse-led, nonpharmacological intervention to reduce the burden of delirium, among adults admitted to intensive care, we observed no statistically significant decrease in the incidence of delirium or the duration of delirium.

The effect of delirium information training given to intensive care nurses on patient care: quasi-experimental study

Background

Training programs aiming to improve delirium diagnosis and management skills increase nurses' care efficiency and improve patients' health outcomes. This study was conducted to examine the effect of delirium information training on patient care by intensive care nurses.

Methods

In the research, one group pretest-posttest quasi-experimental design was used. The study sample consisted of 30 nurses working in four intensive care units of a university hospital between November 05, 2018, and February 15, 2019. The Personal Information Form, the Checklist for the Care of the Patient in Delirium, and the Confusion Assessment Scale for the Intensive Care Unit were used to collect the data. Intensive care nurses were provided with information training supported by a training booklet in two sessions of 40 min each.

Results

In the study, according to the Checklist for the Care of the Patient in Delirium, while the pre-test point average of the nurses was 6.17 ± 2.29, the post-test point average had increased to 11.17 ± 1.51 (p < 0.001). After the training, it was determined that there was a significant increase in the percentage of nurses who stated that they evaluated and detected whether their patients had pain, hallucinations, and delusions (p < 0.001). As a result, it has been determined that providing delirium information training to intensive care nurses positively affects the care of patients with delirium. In addition, it has been determined that with the Confusion Assessment Scale for Intensive Care Unit, nurses can provide the care they need to patients at risk in terms of delirium by identifying delirium.

Development of a delirium predictive model for adult trauma patients in an emergency and critical care center: a retrospective study

Background

Delirium has been shown to prolong the length of intensive care unit stay, hospitalization, and duration of ventilatory control, in addition to increasing the use of sedatives and increasing the medical costs. Although there have been a number of reports referring to risk factors for the development of delirium, no model has been developed to predict delirium in trauma patients at the time of admission. This study aimed to create a scoring system that predicts delirium in trauma patients.

Methods

In this single-center, retrospective, observational study, trauma patients aged 18 years and older requiring hospitalization more than 48 hours were included and divided into the development and validation cohorts. Univariate analysis was performed in the development cohort to identify factors significantly associated with prediction of delirium. The final scoring system for predicting delirium was developed using multivariate analysis and internal validation was performed.

Results

Of the 308 patients in the development cohort, 91 developed delirium. Clinical Frailty Score, fibrin/fibrinogen degradation products, low body mass index, lactate level, and Glasgow Coma Scale score were independently associated with the development of delirium. We developed a scoring system using these factors and calculated the delirium predictive score, which had an area under the curve of 0.85. In the validation cohort, 46 of 206 patients developed delirium. The area under the curve for the validation cohort was 0.86, and the calibration plot analysis revealed the scoring system was well calibrated in the validation cohort.

Discussion

This scoring system for predicting delirium in trauma patients consists of only five risk factors. Delirium prediction at the time of admission may be useful in clinical practice.

Level of evidence

Prognostic and epidemiological, level III.

Development and Implementation of a Multicomponent Protocol to Promote Sleep and Reduce Delirium in a Medical Intensive Care Unit

BACKGROUND

Evidence suggests that poor sleep increases risk of delirium. Because delirium is associated with poor outcomes, institutions have developed protocols to improve sleep in critically ill patients.

OBJECTIVE

To assess the impact of implementing a multicomponent sleep protocol.

METHODS

In this prospective, preimplementation and postimplementation evaluation, adult patients admitted to the medical intensive care unit (ICU) over 42 days were included. Outcomes evaluated included median delirium-free days, median Richards-Campbell Sleep Questionnaire (RCSQ) score, median optimal sleep nights, duration of mechanical ventilation (MV), ICU and hospital length of stay (LOS), and in-hospital mortality.

RESULTS

The preimplementation group included 78 patients and postimplementation group, 84 patients. There was no difference in median delirium-free days (1 day [interquartile range, IQR, = 0-2.5] vs 1 day [IQR = 0-2]; P = 0.48), median RCSQ score (59.4 [IQR = 43.2-71.6] vs 61.2 [IQR = 49.9-75.5]; P = 0.20), median optimal sleep nights (1 night [IQR = 0-2] vs 1 night [IQR = 0-2]; P = 0.95), and in-hospital mortality (16.7% vs 17.9%, P = 1.00). Duration of MV (8 days [IQR = 4-10] vs 4 days [IQR = 2-7]; P = 0.03) and hospital LOS (13 days [IQR = 7-22.3] vs 8 days [IQR = 6-17]; P = 0.05) were shorter in the postimplementation group, but both were similar between groups after adjusting for age and severity of illness.

CONCLUSIONS AND RELEVANCE

This report demonstrates that implementation of a multicomponent sleep protocol in everyday ICU care is feasible, but limitations exist when evaluating impact on measurable outcomes. Additional evaluations are needed to identify the most meaningful interventions and best practices for quantifying impact on patient outcomes.

Anxiety and depressive symptoms among COVID-19 patients admitted to three isolation facilities in Bangladesh

The COVID-19 pandemic can impose a profound impact on the mental health of hospitalised patients infected with SARS-CoV-2. However, there have been no studies that explored the psychological distress of the COVID-19 inpatients in Bangladesh. Therefore, this study aimed to assess the prevalence of anxiety and depressive symptoms and explore the associated factors among inpatients with COVID-19. A cross-sectional study was conducted among 138 COVID-19 patients admitted to three isolation facilities in Dhaka, Bangladesh, from September to October 2020. Participants' sociodemographic and clinical data were obtained. Mental health symptoms were evaluated with the Hospital Anxiety and Depression Scale (HADS). Descriptive statistics, bivariate and multivariate logistic regression models were performed to analyse the data. The prevalence of anxiety and depressive symptoms were 57.2% (95% CI: 48.2-65.2) and 52.2% (95% CI: 43.8-62.7), respectively. Presence of comorbidity (aOR: 5.64, 95% CI: 2.21-14.35) and having ≥3 COVID-19 physical symptoms (aOR: 6.90, 95% CI: 2.71-17.56) were associated with anxiety symptoms. Besides, presence of comorbidity (aOR: 2.73, 95% CI: 1.07-6.99), having ≥3 COVID-19 physical symptoms (aOR: 4.46, 95% CI: 1.78-11.20) and patient with ≤93% oxygen saturation (aOR: 2.33, 95% CI: 1.01-5.36) were associated with depressive symptoms. Considerable numbers of COVID-19 patients in Bangladesh experienced psychological distress during hospitalisation, requiring more attention and timely mental health interventions.

Development and validation of a predictive score for ICU delirium in critically ill patients

Background

The incidence of delirium in intensive care unit (ICU) patients is high and associated with a poor prognosis. We validated the risk factors of delirium to identify relevant early and predictive clinical indicators and developed an optimized model.

Methods

In the derivation cohort, 223 patients were assigned to two groups (with or without delirium) based on the CAM-ICU results. Multivariate logistic regression analysis was conducted to identify independent risk predictors, and the accuracy of the predictors was then validated in a prospective cohort of 81 patients.

Results

A total of 304 patients were included: 223 in the derivation group and 81 in the validation group, 64(21.1%)developed delirium. The model consisted of six predictors assessed at ICU admission: history of hypertension (RR = 4.367; P = 0.020), hypoxaemia (RR = 3.382; P = 0.018), use of benzodiazepines (RR = 5.503; P = 0.013), deep sedation (RR = 3.339; P = 0.048), sepsis (RR = 3.480; P = 0.018) and mechanical ventilation (RR = 3.547; P = 0.037). The mathematical model predicted ICU delirium with an accuracy of 0.862 (P < 0.001) in the derivation cohort and 0.739 (P < 0.001) in the validation cohort. No significant difference was found between the predicted and observed cases of ICU delirium in the validation cohort (P > 0.05).

Conclusions

Patients’ risk of delirium can be predicted at admission using the early prediction score, allowing the implementation of early preventive interventions aimed to reduce the incidence and severity of ICU delirium.

The prevalence of depression, anxiety, and sleep disturbances in COVID-19 patients: a meta-analysis

Evidence from previous coronavirus outbreaks has shown that infected patients are at risk for developing psychiatric and mental health disorders, such as depression, anxiety, and sleep disturbances. To construct a comprehensive picture of the mental health status in COVID-19 patients, we conducted a systematic review and random-effects meta-analysis to assess the prevalence of depression, anxiety, and sleep disturbances in this population. We searched MEDLINE, EMBASE, PubMed, Web of Science, CINAHL, Wanfang Data, Wangfang Med Online, CNKI, and CQVIP for relevant articles, and we included 31 studies (n = 5153) in our analyses. We found that the pooled prevalence of depression was 45% (95% CI: 37-54%, I2  = 96%), the pooled prevalence of anxiety was 47% (95% CI: 37-57%, I2  = 97%), and the pooled prevalence of sleeping disturbances was 34% (95% CI: 19-50%, I2  = 98%). We did not find any significant differences in the prevalence estimates between different genders; however, the depression and anxiety prevalence estimates varied based on different screening tools. More observational studies assessing the mental wellness of COVID-19 outpatients and COVID-19 patients from countries other than China are needed to further examine the psychological implications of COVID-19 infections.

Depression predicts long-term cognitive impairment in survivors of critical illness

INTRODUCTION

Intensive care unit (ICU) survivorship is associated with long-term cognitive impairment (LTCI). Our work has found post-ICU depression in up to 30% and posttraumatic stress disorder (PTSD) in up to 10% of ICU survivors. We hypothesized that post-ICU depression and PTSD are independently associated with LTCI in ICU survivors.

METHODS

This is a five-center nested prospective cohort of critically ill patients admitted to medical and surgical ICUs who underwent neuropsychological assessments at 3 and 12 months posthospital discharge. Our primary outcome was global cognition using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) and Trail Making Test, Part B, a test of executive functioning, at 3- and 12-month follow-up. Our independent variables were Beck Depression Inventory II and the PTSD Checklist-Specific Version measured at 3 and 12 months. We performed multivariable linear regression models controlling for covariates such as age, years of education, preexisting cognitive impairment, comorbidities, ventilator days, hypoxemia episodes, and days of delirium or coma.

RESULTS

Of 1,047 patients in the combined cohort, 679 were alive and available for follow-up at 3 months. A total of 590 (87%) ICU survivors completed at least one 3-month assessment, and of the 554 who survived to 12 months, 519 (94%) completed both a 3- and 12-month assessment with a median age of 61 years (52-70 years) and mean daily Sequential Organ Failure Assessment score of 6 (4-8), 520 (88%) were mechanically ventilated, and 420 (71%) were with delirium. Of these, 113 (19%) had PTSD and 187 (32%) had depression at 3 months with similar rates at 12 months. Depression at 3 months was associated with lower 3-month RBANS (coefficient, -2.25; -3.10 to -1.39) and lower Trails B scores at both 3 months (odds ratio, 0.69; 0.56-0.85) and 12 months (odds ratio, 0.66; 0.52-0.84). Posttraumatic stress disorder at 3 months had no association with RBANS or Trails B scores at 3 or 12 months.

CONCLUSION

Early post-ICU depression, but not PTSD, is independently associated with coexisting LTCI, even when controlling for past ICU delirium. Treatment for early depression represents a novel intervention area for LTCI prevention in ICU survivors.

LEVEL OF EVIDENCE

Prognostic/epidemiological, level III.

Platelet-to-lymphocyte ratio as a predictive index for delirium in critically ill patients: A retrospective observational study

Delirium is a neuropsychiatric syndrome commonly encountered in critically ill patients, and systemic inflammation has been strongly implicated to underlie its pathophysiology. This study aimed to investigate the predictive value of the platelet-to-lymphocyte ratio (PLR) for delirium in the intensive care unit (ICU).In this retrospective observational study, we analyzed the clinical and laboratory data of 319 ICU patients from October 2016 to December 2017. Using the Locally Weighted Scatterplot Smoothing technique, a PLR knot was detected at a value of approximately 100. Logistic regression was used to investigate the association between the PLR and delirium.Of the 319 patients included in this study, 29 (9.1%) were diagnosed with delirium. In the delirium group, the duration of mechanical ventilation was significantly longer than that in the no-delirium group (40.2 ± 65.5 vs. 19.9 ± 26.5 hours, respectively; P < .001). A multiple logistic regression analysis showed that PLR > 100 (odds ratio [OR]: 1.003, 95% confidence interval [CI]: 1.001-1.005), age (OR: 2.76, 95% CI: 1.110-6.861), and the ratio of arterial oxygen partial pressure to the inspired oxygen fraction (OR: 0.996, 95% CI: 0.992-0.999) were independent predictors of delirium.In our study, a high PLR value on ICU admission was associated with a higher incidence of delirium. Owing to easy calculability, the PLR could be a useful delirium predictive index in ICUs, thereby enabling early interventions to be implemented.

Effects of electroencephalography and regional cerebral oxygen saturation monitoring on perioperative neurocognitive disorders: a systematic review and meta-analysis

BACKGROUND

Perioperative neurocognitive disorders (PND) is a common postoperative complication including postoperative delirium (POD), postoperative cognitive decline (POCD) or delayed neurocognitive recovery. It is still controversial whether the use of intraoperative cerebral function monitoring can decrease the incidence of PND. The purpose of this study was to evaluate the effects of different cerebral function monitoring (electroencephalography (EEG) and regional cerebral oxygen saturation (rSO2) monitoring) on PND based on the data from randomized controlled trials (RCTs).

METHODS

The electronic databases of Ovid MEDLINE, PubMed, EMBASE, Cochrane Library database were systematically searched using the indicated keywords from their inception to April 2020. The odds ratio (OR) or mean difference (MD) with 95% confidence interval (CI) were employed to analyze the data. Heterogeneity across analyzed studies was assessed with chi-square test and I2 test.

RESULTS

Twenty two RCTs with 6356 patients were included in the final analysis. Data from 12 studies including 4976 patients were analyzed to assess the association between the EEG-guided anesthesia and PND. The results showed that EEG-guided anesthesia could reduce the incidence of POD in patients undergoing non-cardiac surgery (OR: 0.73; 95% CI: 0.57-0.95; P = 0.02), but had no effect on patients undergoing cardiac surgery (OR: 0.44; 95% CI: 0.05-3.54; P = 0.44). The use of intraoperative EEG monitoring reduced the incidence of POCD up to 3 months after the surgery (OR: 0.69; 95% CI: 0.49-0.96; P = 0.03), but the incidence of early POCD remained unaffected (OR: 0.61; 95% CI: 0.35-1.07; P = 0.09). The remaining 10 studies compared the effect of rSO2 monitoring to routine care in a total of 1380 participants on the incidence of PND. The results indicated that intraoperative monitoring of rSO2 could reduce the incidence of POCD (OR 0.53, 95% CI 0.39-0.73; P < 0.0001), whereas no significant difference was found regarding the incidence of POD (OR: 0.74; 95% CI: 0.48-1.14; P = 0.17).

CONCLUSIONS

The findings in the present study indicated that intraoperative use of EEG or/and rSO2 monitor could decrease the risk of PND.

TRIAL REGISTRATION

PROSPREO registration number: CRD42019130512 .

Validation of PREdiction of DELIRium in ICu patients (PRE-DELIRIC) among patients in intensive care units: A retrospective cohort study

BACKGROUND

An intensive care unit (ICU) delirium prediction tool, PREdiction of DELIRium in ICu patients (PRE-DELIRIC), has been developed and calibrated in a multinational project. However, there is a lack of evidence regarding the predictive ability of the PRE-DELIRIC among Chinese ICU patients.

AIM

To evaluate the predictive validity (discrimination and calibration) of PRE-DELIRIC.

DESIGN

This is a retrospective cohort study.

METHODS

A retrospective cohort study was conducted. Consecutive participants (a) admitted to the ICU for ≥24 hours, (b) aged ≥18 years, and (c) admitted to the ICU for the first time were included. Ten predictors (age, APACHE-II, urgent and admission category, urea level, metabolic acidosis, infection, coma, sedation, and morphine use) assessed within 24 hours upon ICU admission were assessed. Delirium was assessed using the Confusion Assessment Method for ICU. Outcomes included ICU length of stay and mortality. Discrimination and calibration were determined by the areas under the receiver operating characteristic curve (AUROC), box plot, and calibration plot.

RESULTS

A total of 375 ICU patients were included, with 44.0% of patients being delirious. Delirium was significantly associated with age, PRE-DELIRIC score, ICU length of stay, and mortality. The AUROC was 0.81 (95% confidence interval, 0.77-0.86). The optimal cut-off point identified by max Youden index was 49%. The calibration plot of pooled data demonstrated a calibration slope of 0.894 and an intercept of -0.178.

CONCLUSIONS

The PRE-DELIRIC has high predictive value and is suggested to be adopted in ICUs for early initiation of preventive interventions against delirium among high-risk patients.

RELEVANCE TO CLINICAL PRACTICE

Clinicians can adopt the PRE-DELIRIC among ICU patients to screen patients at high risk of developing delirium. Early initiative interventions could be implemented to reduce the negative impacts of ICU delirium.

Effect of early cognitive interventions on delirium in critically ill patients: a systematic review

PURPOSE

A systematic review of the literature was conducted to determine the effects of early cognitive interventions on delirium outcomes in critically ill patients.

SOURCE

Search strategies were developed for MEDLINE, EMBASE, Joanna Briggs Institute, Cochrane, Scopus, and CINAHL databases. Eligible studies described the application of early cognitive interventions for delirium prevention or treatment within any intensive care setting. Study designs included randomized-controlled trials, quasi-experimental trials, and pre/post interventional trials. Two reviewers independently extracted data and assessed risk of bias using Cochrane methodology.

PRINCIPAL FINDINGS

Four hundred and four citations were found. Seven full-text articles were included in the final review. Six of the included studies had an overall serious, high, or critical risk of bias. After application of cognitive intervention protocols, a significant reduction in delirium incidence, duration, occurrence, and development was found in four studies. Feasibility of cognitive interventions was measured in three studies. Cognitive stimulation techniques were described in the majority of studies.

CONCLUSION

The study of early cognitive interventions in critically ill patients was identified in a small number of studies with limited sample sizes. An overall high risk of bias and variability within protocols limit the utility of the findings for widespread practice implications. This review may help to promote future large, multi-centre trials studying the addition of cognitive interventions to current delirium prevention practices. The need for robust data is essential to support the implementation of early cognitive interventions protocols.

[Path Analysis for Delirium on Patient Prognosis in Intensive Care Units]

PURPOSE

This study was conducted to investigate relationship between delirium, risk factors on delirium, and patient prognosis based on Donabedian's structure-process-outcome model.

METHODS

This study utilized a path analysis design. We extracted data from the electronic medical records containing delirium screening data. Each five hundred data in a delirium and a non-delirium group were randomly selected from electronic medical records of medical and surgical intensive care patients. Data were analyzed using SPSS 20 and AMOS 24.

RESULTS

In the final model, admission via emergency department (B=.06, p=.019), age over 65 years (B=.11, p=.001), unconsciousness (B=.18, p=.001), dependent activities (B=.12, p=.001), abnormal vital signs (B=.12, p=.001), pressure ulcer risk (B=.12, p=.001), enteral nutrition (B=.12, p=.001), and use of restraint (B=.30, p=.001) directly affecting delirium accounted for 56.0% of delirium cases. Delirium had a direct effect on hospital mortality (B=.06, p=.038), hospital length of stay (B=5.06, p=.010), and discharge to another facility (not home) (B=.12, p=.001), also risk factors on delirium indirectly affected patient prognosis through delirium.

CONCLUSION

The use of interventions to reduce delirium may improve patient prognosis. To improve the dependency activities and risk of pressure ulcers that directly affect delirium, early ambulation is encouraged, and treatment and nursing interventions to remove the ventilator and drainage tube quickly must be provided to minimize the application of restraint. Further, delirium can be prevented and patient prognosis improved through continuous intervention to stimulate cognitive awareness and monitoring of the onset of delirium. This study also discussed the effects of delirium intervention on the prognosis of patients with delirium and future research in this area.

Delirium in intensive care: A stepped-wedge cluster randomised controlled trial for a nurse-led intervention to reduce the incidence and duration of delirium among adults admitted to the intensive care unit (protocol)

BACKGROUND

Delirium is an acute disorder of attention and cognition with the highest rates among adults receiving intensive care. An acute episode of delirium is associated with morbidity and mortality, as well as a significant psychological sequela. Importantly, an increasing body of evidence supports the benefit of nonpharmacological, nurse-led interventions to reduce the incidence and duration of delirium among adults cared for in the intensive care unit (ICU).

OBJECTIVES

This study will evaluate the impact of a nursing-led delirium prevention protocol that is aimed at reducing the incidence and duration of delirium among adults admitted to the ICU. The delirium prevention nursing protocol specifically targets risk factors for delirium.

STUDY PLAN

A stepped-wedge cluster randomised controlled trial approach will be used to assess the effectiveness of the nurse-led intervention, in four adult ICUs across the South Western Sydney Local Health District (SWS-LHD), over a 12-month period. The primary outcomes of interest are (i) the incidence of delirium before and after the implementation of the nurse-led intervention and (ii) the number of delirium-free days during an ICU stay, before and after the implementation of the nurse-led intervention.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR): (ACTRN12618000411246p).

Psychometric properties of the intensive care delirium screening checklist when used by bedside nurses in clinical practice: a prospective descriptive study

Background

The Intensive Care Delirium Screening Checklist (ICDSC) demonstrates good psychometric characteristics in research settings. However, evidence about these characteristics in pragmatic ICU settings is inconsistent. This study evaluated psychometric properties and user-friendliness of the ICDSC when administered by ICU nurses in daily practice.

Methods

This prospective study included 77 patients from a surgical intensive care unit. To examine the psychometric characteristics, the scores on the ICDSC (performed by bedside nurses) were compared with the scores on the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) (performed by researchers as gold standard). The user-friendliness was evaluated by 34 ICU nurses with a 20-item questionnaire.

Results

The ICDSC had an area under the curve of 0.843. It showed a good diagnostic accuracy with a sensitivity of 81.0%, a specificity of 87.7%, and a 53.1% positive and 96.4% negative predictive value. The overall Cronbach’s alpha coefficient for all ICDSC scores was high (0.839). Overall, ICU nurses experienced the ICDSC as easy-to-use. The scale was usable in most surgical ICU patients. Yet, some nurses (11.8%) had problems to score the items ‘inappropriate speech’ and ‘symptom fluctuation’ in intubated patients.

Conclusions

The ICDSC is a valid and user-friendly tool for delirium screening in daily ICU nursing practice. Yet, some problems were reported in intubated patients. Therefore, validation studies with specific focus on intubated patients are needed.

Predisposing and Precipitating Factors Associated With Postoperative Delirium in Patients Undergoing Cardiac Surgery at a Veterans Affairs Medical Center: A Pilot Retrospective Analysis

OBJECTIVE

Patients treated at Veterans Affairs (VA) medical centers are in poorer health, experience more medical and psychiatric conditions, and make greater use of medical resources than do patients in the general population. In the present pilot study, the authors examined their recent experience at a VA medical center to determine the incidence and risk factors associated with the development of postoperative delirium in VA patients after cardiac surgery and hypothesized that the risk factors for postoperative delirium after cardiac surgery are different between VA and non-VA patients.

DESIGN

Retrospective cohort study.

SETTING

Clement J. Zablocki Veterans Affairs Medical Center.

PARTICIPANTS

The study comprised 250 consecutive patients undergoing cardiac surgery from July 2014 to March 2016.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Demographics, coexisting diseases, and medications were obtained from the VA electronic medical record. The European System for Cardiac Operative Evaluation II mortality risk index was calculated for each patient. The type and duration of the procedure and the duration of bypass were recorded. Intraoperative crystalloid, colloid, cell saver, and blood product volumes were compiled. Progress notes and International Classification of Diseases, Tenth Revision, Clinical Modification codes were searched for documentation of postoperative delirium. Thirty-eight patients (15.2%) developed postoperative delirium. Stepwise logistic regression analysis demonstrated that the European System for Cardiac Operative Evaluation II mortality risk index (odds ratio [OR] 1.036, 95% confidence interval [CI] [1.003-1.070]; p = 0.0344), congestive heart failure (OR 2.223 [95% CI 1.046-4.722]; p = 0.0377), pre-existing cognitive impairment (OR 5.147 [95% CI 1.994-13.28]; p = 0.0007), and the presence of a neuropsychiatric disorder (OR 2.015 [95% CI 1.004-4.043]; p = 0.0487) were predisposing factors associated with higher odds of postoperative delirium. The duration of surgery; transfusion of blood products (including packed red blood cells, fresh frozen plasma, and platelets); the durations of mechanical ventilation and conscious sedation (using either propofol or dexmedetomidine); and the length of intensive care unit stay were precipitating factors associated with higher odds of postoperative delirium.

CONCLUSIONS

The results demonstrate that congestive heart failure, pre-existing cognitive impairment, and the presence of a neuropsychiatric disorder are predisposing risk factors for postoperative delirium after cardiac surgery in VA patients, whereas the duration of surgery, transfusion of blood products, durations of mechanical ventilation and conscious sedation, and length of intensive care unit stay are precipitating factors for postoperative delirium. These findings in VA patients generally are similar to those observed in the civilian population despite the differences between these cohorts.

Impact of Vitamin C and Thiamine Administration on Delirium-Free Days in Patients with Septic Shock

Sepsis is a common cause of delirium in the intensive care unit (ICU). Recently, vitamin C and thiamine administration has been gaining interest as a potential adjunct therapy for sepsis. We investigated the impact of early vitamin C and thiamine administration on ICU delirium-free days among critically ill patients in septic shock. We performed a single-center, retrospective study of patients who visited the emergency department (ED) from January 2017 to July 2018. We categorized patients into a treatment (received vitamin C and thiamine) and control group. We compared delirium-free days within 14 days after ICU admission using propensity score matching. Of 435 patients with septic shock, we assigned 89 propensity score-matched pairs to the treatment and control groups. The median delirium-free days did not differ between treatment (11, interquartile range [IQR] 5–14 days) and control (12, IQR 6–14 days) groups (p = 0.894). Secondary outcomes were not different between the two groups, including delirium incidence and 28-day mortality. These findings were consistent after subgroup analysis for patients who met the sepsis-3 definition of septic shock. Vitamin C and thiamine administration showed no association with ICU delirium-free days among patients in septic shock.

COVID-19: What do we need to know about ICU delirium during the SARS-CoV-2 pandemic?

In March 2020, the World Health Organisation announced the COVID-19 pandemic caused by the SARS-CoV-2 virus. As well as respiratory failure, the SARS-CoV-2 may cause central nervous system (CNS) involvement, including delirium occurring in critically ill patients (ICU delirium). Due attention must be paid to this subject in the face of the COVID-19 pandemic. Delirium, the detection of which takes less than two minutes, is frequently underestimated during daily routine ICU care, but it may be a prodromal symptom of infection or hypoxia associated with severe respiratory failure. During the COVID-19 pandemic, systematic delirium monitoring using validated tests (CAM-ICU or ICDSC) may be sacrificed. This is likely to be due to the fact that the main emphasis is placed on organisational issues, i.e. the lack of ventilators, setting priorities for limited mechanical ventilation options, and a shortage of personal protective equipment. Early identification of patients with delirium is critical in patients with COVID-19 because the occurrence of delirium may be an early symptom of worsening respiratory failure or of infectious spread to the CNS mediated by potential neuroinvasive mechanisms of the coronavirus. The purpose of this review is to identify problems related to the development of delirium during the COVID-19 epidemic, which are presented in three areas: i) factors contributing to delirium in COVID-19, ii) potential pathophysiological factors of delirium in COVID-19, and iii) long-term consequences of delirium in COVID-19. This article discusses how healthcare workers can reduce the burden of delirium by identifying potential risk factors and difficulties during challenges associated with SARS-CoV-2 infection.

A Quality Improvement Project to Increase Adherence to a Pain, Agitation, and Delirium Protocol in the Intensive Care Unit

BACKGROUND

In recent years, the incidence of delirium has grown to epidemic proportions in the intensive care setting with up to 80% of mechanically ventilated patients being affected. This can lead to adverse patient outcomes such as increased lengths of hospital stay, increased mortality rates, and increased long-term cognitive impairment.

OBJECTIVES

The objective of this project is to determine whether a quality improvement project can increase adherence to an existing pain, agitation, and delirium (PAD) protocol for enhanced patient outcomes.

METHODS

Chart audits were conducted to determine baseline compliance, use of the PAD protocol was measured, and the type of medications administered to each mechanically ventilated patient was assessed. Using the Knowledge-to-Action framework, a multidisciplinary, multidimensional educational module was then developed and implemented that included an online tutorial, point-of-care reminders, written materials, and verbal coaching. A 3-month postimplementation chart audit was conducted to determine whether increased protocol competence was achieved.

RESULTS

Protocol use unexpectedly decreased from 74% to 41% (P < .01);however, compliance with medication recommendations did increase despite the decrease in use. Intravenous opioid use increased from 12% to 40% (P ≤ .001), whereas sedative propofol infusions decreased from 82% to 35% (P ≤ .001).

CONCLUSIONS

The implementation of a multidimensional, multidisciplinary project was successful in increasing compliance to the clinical practice guidelines for the management of PAD in adult intensive care unit patients, despite a decrease in protocol use. This unanticipated decrease in protocol use indicates the need for additional research in this area. Future recommendations also include a review of the existing PAD protocol to determine whether revisions could be made to better suit the needs of the staff while also improving patient outcomes in the arena of delirium experienced during critical care stays.

Effect of Suvorexant on Nocturnal Delirium in Elderly Patients with Alzheimer's Disease: A Case-series Study

Suvorexant, an orexin receptor antagonist used for insomnia, has been shown to have a preventive effect on delirium in a randomized placebo-controlled trial. However, its effectiveness in the management of nocturnal delirium has not yet been determined. Here we report four cases in which elderly patients with moderate to severe Alzheimer’s disease who developed nocturnal delirium were treated with suvorexant. In case 1, 15 mg suvorexant was initiated to manage nocturnal delirium refractory to antipsychotics, antidepressants, and a Japanese herbal medicine, resulting in immediate sleep improvement. However, treatment discontinuation led to recurrence of symptoms, which were reversed by recommencing suvorexant. In case 2, as antipsychotics used for the treatment of nocturnal delirium were ineffective, 15 mg suvorexant was administered. The patient achieved rapid improvement in sleep. In case 3, the use of atypical antipsychotics for the treatment of nocturnal delirium was contraindicated, as the patient had diabetes. Therefore, 15 mg suvorexant was administered following good outcomes in cases 1 and 2, resulting in immediate sleep improvement. Finally, in case 4, 15 mg suvorexant was used as an initial medication for nocturnal delirium, and the patient showed sleep improvement immediately. Elevated orexin levels in the cerebrospinal fluid are reportedly linked to sleep deterioration in patients with moderate to severe Alzheimer’s disease. The immediate and reproducible action and effectiveness of suvorexant observed in our patients suggest that enhanced cerebral orexin activity might be associated with sleep-wake cycle disturbances due to delirium in elderly patients with Alzheimer’s disease.

How to manage fever in brain-injured patients

Fever represents a frequent and dangerous secondary insult for the injured brain and is often associated with worsened neurological outcomes. The identification of fever in the Neuro-Intensive Care Unit requires careful monitoring and rapid and effective treatment. The main objective of this article was to provide practical information regarding temperature monitoring, triggers for intervention and fever management in brain injured patients.

Dexmedetomidine for the prevention of delirium in critically ill patients - A protocol for a systematic review

BACKGROUND

Delirium is a common complication in critically ill patients and carries an increased risk of mortality and morbidity. Dexmedetomidine can potentially prevent delirium by diminishing predisposing factors. The evidence regarding the use of dexmedetomidine in preventing delirium is conflicting. This protocol aims to identify the beneficial and harmful effects of dexmedetomidine in the prevention of delirium.

METHODS

This protocol uses the recommendations of the Cochrane Collaboration, the Preferred Report Items of Systematic Reviews with Meta-Analysis Protocols, and the eight-step assessment procedure suggested by Jakobsen and colleagues. We wish to assess in critically ill patients, if dexmedetomidine versus placebo can reduce the incidence of delirium and improve clinical outcomes. We will include all randomised trials assessing the use of dexmedetomidine in the prevention of delirium. To identify trials, we will search the Cochrane Central Register of Controlled Trials, Medical Literature Analysis and Retrieval System Online, Excerpta Medica database, Latin American and Caribbean Health Sciences Literature, Science Citation Index Expanded on Web of Science, Chinese Biomedical Literature Database, China National Knowledge Infrastructure, Chinese Science Journal Database, and BIOSIS. Two authors will screen the literature and extract data. We will use the Cochrane risk of bias tool to evaluate trials. Extracted data will be analysed using Review Manager 5 and Trial Sequential Analysis. We will create a "Summary of Findings"-table in which we will present our primary and secondary outcomes. We will assess the quality of evidence using GRADE.

DISCUSSION

This systematic review can potentially aid clinicians in decision-making and benefit the many critically ill patients at risk of delirium.

Dexmedetomidine for the management of delirium in critically ill patients-A protocol for a systematic review

BACKGROUND

Delirium is a common complication in critically ill patients and carries an increased risk of mortality and morbidity. Dexmedetomidine can potentially treat delirium by diminishing predisposing factors. The evidence regarding the use of dexmedetomidine in the management of delirium is conflicting. This protocol aims to identify the beneficial and harmful effects of dexmedetomidine in the management of delirium.

METHODS

This protocol uses the recommendations of the Cochrane Collaboration, the Preferred Report Items of Systematic reviews with Meta-Analysis Protocols, and the eight-step assessment procedure suggested by Jakobsen and colleagues. We wish to assess in critically ill patients with delirium, if dexmedetomidine vs placebo is effective in managing delirium and improving clinical outcomes. We will include all relevant randomised clinical trials assessing the use of dexmedetomidine in treating delirium. To identify trials, we will search the Cochrane Central Register of Controlled Trials, Medical Literature Analysis and Retrieval System Online, Excerpta Medica database, Latin American and Caribbean Health Sciences Literature, Science Citation Index Expanded on Web of Science, Chinese Biomedical Literature Database, China National Knowledge Infrastructure, Chinese Science Journal Database, and BIOSIS. Two authors will screen the literature and extract data. The Cochrane risk of bias tool will be used to evaluate included trials. Extracted data will be analysed using Review Manager 5 and Trial Sequential Analysis. We will create a 'Summary of Findings'-table in which we will present our primary and secondary outcomes. We will assess the quality of evidence using GRADE assessment.

DISCUSSION

This systematic review can potentially aid clinicians in decision making and benefit the many critically ill patients developing delirium.

Pediatric Delirium in the Cardiac Intensive Care Unit: Identification and Intervention

Delirium is characterized by transient behavioral manifestations of acute brain disturbances. Delirium in the intensive care unit has been well researched and documented in the adult population. Pediatric delirium research has lagged, but recent developments in screening tools have shed light on the prevalence of delirium among children. The overall prevalence of delirium in the pediatric intensive care unit is 25%. A recent study showed a prevalence of 49% in the pediatric cardiac intensive care unit; this higher prevalence may be due to factors related to critical illness and the postoperative environment. This article is intended to increase awareness of delirium in the pediatric cardiac intensive care unit and give nurses the tools to identify it and intervene when necessary. A definition of delirium is provided, and its prevalence, risk factors, and current knowledge are reviewed. Available screening tools and environmental and pharmacological interventions are explored.

Assessment of delirium using the PRE-DELIRIC model in an intensive care unit in Argentina

OBJECTIVE

To describe the incidence of and risk factors for delirium in the intensive care unit of a tertiary care teaching hospital in Argentina and to conduct the first non-European study exploring the performance of the PREdiction of DELIRium in ICu patients (PRE-DELIRIC) model.

METHODS

Prospective observational study in a 20-bed intensive care unit of a tertiary care teaching hospital in Buenos Aires, Argentina. The PRE-DELIRIC model was applied to 178 consecutive patients within 24 hours of admission to the intensive care unit; delirium was assessed with the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU).

RESULTS

The mean age was 64.3 ± 17.9 years. The median time of stay in the intensive care unit was 6 (range, 2 - 56) days. Of the total number of patients, 49/178 (27.5%) developed delirium, defined as a positive CAM-ICU assessment, during their stay in the intensive care unit. Patients in the delirium group were significantly older and had a significantly higher Acute Physiological and Chronic Health Evaluation II (APACHE II) score. The mortality rate in the intensive care unit was 14.6%; no significant difference was observed between the two groups. Predictive factors for the development of delirium were increased age, prolonged intensive care unit stay, and opioid use. The area under the curve for the PRE-DELIRIC model was 0.83 (95%CI; 0.77 - 0.90).

CONCLUSIONS

The observed incidence of delirium highlights the importance of this problem in the intensive care unit setting. In this first study conducted outside Europe, PRE-DELIRIC accurately predicted the development of delirium.

Mesures de prévention non pharmacologiques du delirium de réanimation

Le delirium est défini par un changement brutal ou rapidement progressif de l’état mental ou une modification de l’humeur associés à une baisse des capacités de concentration, à une désorganisation de la pensée, à une confusion et à une altération du niveau de conscience. L’incidence du delirium en réanimation est variable d’environ 4 à 83 %, selon les études. Cela est probablement lié à la variété des outils de mesure employés, au niveau d’entraînement des professionnels de santé établissant ces scores, à la profondeur de la sédation et aux différences de populations étudiées. Son étiologie semble être multifactorielle. Il a été montré que la survenue du delirium a un fort impact sur le pronostic vital et fonctionnel des patients en réanimation, car son incidence est associée à une augmentation de la mortalité hospitalière précoce et tardive, et le déclin cognitif qui lui est associé peut persister à distance du séjour en réanimation. Il est important de souligner que la prise en charge dans les soins critiques est très hétérogène. Néanmoins, de nouvelles données de la littérature apportent des éléments concrets sur la prise charge de ce syndrome et fournissent un guide utile à la pratique paramédicale dans la prévention et le dépistage de ce trouble cognitif. L’objectif de ce travail est d’apporter une synthèse autour de la littérature disponible dans ce domaine, mettant en lumière le rôle clé de la profession paramédicale dans ce contexte afin d’identifier des éléments diagnostiques et thérapeutiques susceptibles de modifier pertinemment les pratiques soignantes.

Psychiatric Morbidity After Critical Illness

Critical illness survivors frequently have substantial psychiatric morbidity, including posttraumatic stress, depression, and anxiety symptoms. Prior psychiatric illness is a potent predictor of postcritical illness psychiatric morbidity. Early emotional distress and memories of frightening psychotic and nightmarish intensive care unit (ICU) experiences are risk factors for longer term psychiatric morbidity. ICU diaries may be effective in decreasing psychiatric morbidity after critical illness, though these and other interventions deserve further study.

Cognitive stimulation and occupational therapy for delirium prevention

Delirium is a relevant condition in critically ill patients with long-term impacts on mortality, cognitive and functional status and quality of life. Despite the progress in its diagnosis, prevention and management during the last years, its impact persists being relevant, so new preventive and therapeutic strategies need to be explored. Among non-pharmacologic preventive strategies, recent reports suggest a role for occupational therapy through a series of interventions that may impact the development of delirium. The aim of this review is to evaluate the studies evaluating the role of occupational therapy in the prevention of delirium in critically ill patient populations, and suggests perspectives to future research in this area.

The ABCDE Bundle: A Survey of Nurses Knowledge and Attitudes in the Intensive Care Units of a National Teaching Hospital in Italy

BACKGROUND

The ABCDE (Awakening and Breathing coordination of daily sedation and ventilator removal trials; Choice of sedative or analgesic exposure; Delirium monitoring and management; and Early mobility and exercise) bundle is a multidisciplinary set of evidence-based practices for improving patient outcomes in the intensive care unit. Nurses are critical to all the bundle's requirements. Therefore, understanding their knowledge, attitudes, and perception of the different bundle's components might help for an easier implementation into everyday clinical practice.

OBJECTIVE

The aim of this study was to assess nurses' knowledge, utility, and perception of the ABCDE bundle.

METHODS

An anonymous questionnaire with closed-end questions was administered to the nurses working at the intensive care unit (ICU) of a nationwide teaching hospital.

RESULTS

Only the 41.6% of the respondents declared to be aware of the bundle; however, the majority of them (67%) agreed with its potential capability of improving patients' outcomes after reviewing a document as they completed a survey. In addition, 71% of responders judged the Sedation Awakening Trial and the Spontaneous Breathing Trial easy to understand, and 80% found the Richmond Agitation-Sedation Scale and the Confusion Assessment Method for the ICU useful to asses and monitor delirium. However, 48% reported that they did not currently use them. Fifty-one percent of respondents reported that they were not aware of or had used the Exercise/Mobility Safety Screen. Fifty-three respondents reported that multidisciplinary rounds were not performed at their ICU but judged them as a positive activity. Only 34% of the respondents considered the ABCDE bundle applicable at their own ICU.

DISCUSSION

A substantial need for educational improvement and cultural change is needed. The results of this study may help other facilities to identify contextual and professionals-related factors possibly hindering the bundle's implementation.

Cardiothoracic Critical Care

High-value CCC is rapidly evolving to meet the demands of increased patient acuity and to incorporate advances in technology. The high-performing CCC system and culture should aim to learn quickly and continuously improve. CCC demands a proactive, interactive, precise, an expert team, and continuity.

The early diagnosis and management of mixed delirium in a patient placed on ECMO and with difficult sedation: A case report

Delirium represents a serious problem that impacts the physical and cognitive prognosis of patients admitted to intensive care units and requires prompt diagnosis and management. This article describes the case and progress of a patient placed on Extracorporeal Membrane Oxygenation with difficult sedation criteria and an early diagnosis of mixed delirium. During the case report, we reflect on the pharmacological and non-pharmacological strategies employed to cope with delirium paying special attention to the non-use of physical restraint measures in order to preserve vital support devices (endotracheal tube or Extracorporeal Membrane Oxygenation cannula). The multimodal and multidisciplinary approach, focused on nursing interventions, strict Pain/Agitation/Delirium monitoring and pharmacological measures, as well as the implementation of measures according to the eCASH (early Comfort using Analgesia, minimal Sedatives and maximal Human Care) concept, were effective, resulting in a relatively short admission considering the severity of the patient's condition and the associated complications. Early independent ambulation was achieved prior to transfer to a hospitalisation unit.

Altered mental status predicts mortality in cardiogenic shock – results from the CardShock study

Background:

Altered mental status is among the signs of hypoperfusion in cardiogenic shock, the most severe form of acute heart failure. The aim of this study was to investigate the prevalence of altered mental status, to identify factors associating with it, and to assess the prognostic significance of altered mental status in cardiogenic shock.

Methods:

Mental status was assessed at presentation of shock in 215 adult cardiogenic shock patients in a multinational, prospective, observational study. Clinical picture, biochemical variables, and short-term mortality were compared between patients presenting with altered and normal mental status.

Results:

Altered mental status was detected in 147 (68%) patients, whereas 68 (32%) patients had normal mental status. Patients with altered mental status were older (68 vs. 64 years, p=0.04) and more likely to have an acute coronary syndrome than those with normal mental status (85% vs. 74%, p=0.04). Altered mental status was associated with lower systolic blood pressure (76 vs. 80 mmHg, p=0.03) and lower arterial pH (7.27 vs. 7.35, p<0.001) as well as higher levels of blood lactate (3.4 vs. 2.3 mmol/l, p<0.001) and blood glucose (11.4 vs. 9.0 mmol/l, p=0.01). Low arterial pH (adjusted odds ratio 1.6 (1.1–2.2), p=0.02) was the only factor independently associated with altered mental status. Ninety-day mortality was significantly higher (51% vs. 22%, p<0.001) among patients with altered mental status.

Conclusions:

Altered mental status is a common clinical sign of systemic hypoperfusion in cardiogenic shock and is associated with poor outcome. It is also associated with several biochemical findings that reflect inadequate tissue perfusion, of which low arterial pH is independently associated with altered mental status.