Incidence, prevalence, risk factor and outcome of delirium in intensive care unit: a study from India

Impact of Dexmedetomidine on Hemodynamics, Plasma Catecholamine Levels, and Delirium Incidence Among Intubated Patients in the ICU--A Randomized Controlled Trial

Objective

To investigate the impact of various sedative medications on hemodynamics and plasma levels of epinephrine (E) and norepinephrine (NE) in mechanically ventilated patients postoperatively in the intensive care unit (ICU).

Methods

Ninety-seven patients admitted to the ICU undergoing postoperative mechanical ventilation with tracheal intubation and continuous analgesic sedation following general anesthesia were randomly assigned to either the observation group (dexmedetomidine) (n = 49) or the control group (propofol) (n = 48) in this randomized controlled trial. Upon transfer to the ICU, vital signs (heart rate [HR], respiratory rate [RR], mean arterial pressure [MAP]) were recorded prior to the initiation of the sedation treatment (T0), at one-hour post sedation (T1) and two hours following tracheal extubation (T2), plasma levels of epinephrine (E) and norepinephrine (NE) were measured at these time points. The incidence of delirium was recorded in both groups.

Results

MAP between the two groups at both T0 and T1 At T2 plasma NE and HR were found to be lower in the observation group compared to the control group (P < 0.001). Among the patients receiving antihypertensive medication in the ICU, NE levels were significantly lower in the observation group compared to the control group (P = 0.019) Among the patients not receiving antihypertensive medication, both NE (P < 0.001) and MAP (P = 0.001) levels were lower in the observation group compared to the control group. The incidence of delirium in the observation group (dexmedetomidine) was not significantly different from that in the control group (propofol).

Conclusion

With dexmedetomidine sedation, blood pressure fluctuated less, plasma catecholamine levels were lower, and sympathetic inhibition was stronger in patients before and after extubation. However, it did not significantly reduce the incidence of postoperative delirium.

The Validity and Applicability of the Revised Delirium Rating Scale (DRS-R98) for Delirium Severity Assessment in a Critical Care Setting

BACKGROUND

Delirium is a neuropsychiatric syndrome common in critical illness. Worsening delirium severity is associated with poorer clinical outcomes, yet its assessment remains under-reported with most severity assessment tools not validated for critical care. The DRS-R98 is a widely applied and validated tool. The aim of this project is to report the validation and utility of the DRS-R98 in critical illness.

METHODS

This prospective, cohort study was conducted in adults with delirium admitted to a critical care unit and predicted to stay for ≥ 24 h. We excluded patients with severe neurological or communication barriers that would have interfered with the DRS-R98 assessment. Patients were screened using a delirium detection algorithm and the Confusion Assessment Method for the Intensive Care Unit. Eligible patient informations were collected and reported to qualified assessor/s before visiting clinical areas, confirming delirium presence and undertaking DRS- R98 assessments. To assess the tool's construct validity, an intensivist completed the Clinical Global Impression-Scale (CGI-S). To calculate the inter-rater reliability (IRR) a subset of patients were simultaneously evaluated by two assessors.

RESULTS

We assessed 22 patients, 73% were male, with a median age of 65 years (IQR14). The DRS -R98 mean (SD) severity score was 24 (+/-7.7), total scale was 29 (+/18.0), and CGI-S 3.5 (+/11.5). Assessment duration was 90 min (+/-55) and 15 min (+/-5) for record data extraction and clinical assessment respectively. The CGI-S significantly correlated with DRS-R98 severity (r = 0.626) and total (r = 0.628) scales. The DRS-R98 Cronbach's alpha was 0.896 for severity scale and 0.886 for total scale. The inter-rater reliability (IRR) was assessed in six patients and reported an inter-correlation coefficient of 0.505 (p = 0.124) and 0.565 (p = 0.93) for the severity and total scale respectively.

CONCLUSIONS

In critical care, the Delirium Rating Scale R98 had good construct validity, excellent internal consistency, and moderate inter-rater reliability.

Point prevalence and clinical profile of patients with delirium admitted in internal medicine department at tertiary care centre in eastern Nepal: a descriptive cross-sectional study

Introduction

Delirium, marked by acute disturbances in consciousness and cognition, remains underdiagnosed despite its significant impact on morbidity and mortality. This study investigates the point prevalence and clinical profile of delirium in patients at an eastern Nepal tertiary care centre.

Methods

A 1-month descriptive cross-sectional study involved 152 Internal Medicine Department patients at BPKIHS, Dharan. Data, collected through face-to-face interviews and the Confusion Assessment Method (CAM), analyzed demographic details, clinical history, and laboratory findings. Ethical clearance and informed consent were obtained.

Results

Among 152 participants, 13.2% exhibited delirium, with notable risk factors identified. Elderly patients (≥65 years) and those with nasogastric tubes faced higher risks. Significant associations were found with cardiovascular diseases (P=0.002), central nervous system diseases (P=0.015), and alcoholism (P=0.003). Laboratory findings revealed correlations with elevated creatinine, hyperuremia, and abnormal aspartate aminotransferase levels. The study emphasizes key contributors to delirium, providing valuable insights for clinicians in identifying, preventing, and managing delirium in a hospital setting.

Conclusions

This study provides critical insights into delirium prevalence and profiles in Eastern Nepal. Identified risk factors underscore the importance of routine screenings and targeted interventions for at-risk populations. Study limitations, including sample size and single-centre focus, call for further research to validate findings and enhance our understanding of delirium's management across diverse healthcare settings. Overall, the study informs clinical practices and prompts broader exploration of delirium in healthcare contexts.

The effects of a sensory stimulation intervention for preventing delirium in a surgical intensive care unit: A randomized controlled trial

BACKGROUND

Despite extensive efforts and advances in developing and fostering evidence-based delirium prevention interventions, the incidence of delirium remains high in hospitalized patients. Evidence suggests that sensory stimulation is a core component in interventions to prevent delirium among critically ill patients. However, its impact on the occurrence and outcomes of delirium is poorly understood.

AIM

To evaluate the effects of a sensory stimulation intervention on preventing delirium in a surgical intensive care unit (ICU).

STUDY DESIGN

A prospective, assessor-blind, parallel-group randomized controlled trial. Adult patients were recruited from a surgical ICU of one tertiary hospital in Guangzhou, China. Participants in the intervention group received a daily 30-min auditory and visual stimulation session for a week, taking into consideration the participants' predefined condition and intervention protocol. The primary outcomes were delirium incidence and delirium-free days, and the secondary outcomes were delirium duration, severity and the first occurrence of delirium. Demographic and clinical data were collected at recruitment, and delirium was assessed three times a day for seven consecutive days using Confusion Assessment-ICU.

RESULTS

One hundred and fifty-two participants were randomly assigned to intervention or control groups. For primary outcomes, there were fewer patients with delirium in the intervention group than in the control group (10 vs. 19, risk ratio = 0.53), although statistical significance was not reached. The result showed that there were longer delirium-free days among participants in the intervention group than in the control group (3.66 vs. 2.84, p = .019). For secondary outcomes, the intervention could significantly reduce delirium duration (1.70 ± 0.82 vs. 4.53 ± 2.74 days, p = .004) and delirium severity (3.70 ± 1.25 vs. 5.68 ± 1.57, p = .002). The Kaplan-Meier curve showed the intervention group had a significantly delayed first occurrence of delirium compared with the control group (p = .043).

CONCLUSIONS

The study did not provide significant evidence to support that sensory stimulation could reduce the incidence of delirium, but significant difference on delirium-free days.

RELEVANCE TO CLINICAL PRACTICE

This study provides evidence-based practice for clinical healthcare providers to adopt the sensory stimulation protocol to prevent delirium, significantly reducing delirium duration and severity.

Incidence of Delirium in Critically Ill Patients With and Without COVID-19

BACKGROUND

It is known that patients with COVID-19 are at high risk of developing delirium. The aim of the study was to compare the incidence of delirium between critically ill patients with and without a diagnosis of COVID-19.

METHODS

This is a retrospective study conducted in a southern Brazilian hospital from March 2020 to January 2021. Patients were divided into two groups: the COVID-19 group consisted of patients with a diagnosis of COVID-19 confirmed by reverse transcription-polymerase chain reaction (RT-PCR) or serological tests who were admitted to specific ICUs. The non-COVID-19 group consisted of patients with other surgical and medical diagnoses who were admitted to non-COVID ICUs. All patients were evaluated daily using the Intensive Care Delirium Screening Checklist (ICDSC). The two cohorts were compared in terms of the diagnosis of delirium.

RESULTS

Of the 649 patients who remained more than 48 h in the ICU, 523 were eligible for the study (COVID-19 group: 292, non-COVID-19 group: 231). There were 119 (22.7%) patients who had at least one episode of delirium, including 96 (32.9%) in the COVID-19 group and 23 (10.0%) in the non-COVID-19 group (odds ratio [OR] 4.42; 95% confidence interval [CI], 2.69 to 7.26; p < 0.001). Among patients mechanically ventilated for two days or more, the incidence of delirium did not differ between groups (COVID-19: 89/211, 42.1% vs non-COVID-19: 19/47, 40.4%; p  =  0.82). Logistic regression showed that the duration of mechanical ventilation was the only independent factor associated with delirium (p  =  0.001).

CONCLUSION

COVID-19 can be associated with a higher incidence of delirium among critically ill patients, but there was no difference in this incidence between groups when mechanical ventilation lasted two days or more.

S100B as a predictor of delirium in critically ill obstetric patients: A nested case-control study

Background

Delirium is a neuropsychiatric illness that lasts for a short period of time. The incidence of delirium in the intensive care unit (ICU) varies from 20% to 80%.

Methods

A nested case-control study was carried out in the obstetric ICU. Individuals were divided into three groups: critically ill obstetric women who had delirium on admission (Group A), women who developed delirium within follow-up of 7 days (Group B), and women who did not develop delirium after follow-up of 7 days (Group C). The APACHE II score was used to assess critical illness severity. The Richmond Agitation-Sedation Scale was used to assess the alertness or sedation level of patients, and the Confusion Assessment Method (ICU scale) was used to assess the presence of delirium. S100B was measured by human S100B calcium-binding protein B ELISA kit (Elabscience Biotechnology, Houston, USA).

Results

Severe preeclampsia and antepartum eclampsia were significantly associated with delirium. S100B levels in Group B were found to be significantly higher than those in Group C. S100B levels were higher in patients with >2 morbidities in comparison to patients with two morbidities. At a cutoff value of >169.25 pg/ml, S100B had a sensitivity of 74% and a specificity of 87.2% to discriminate cases of delirium from nondelirium.

Conclusion

The rise in S100B levels was approximately three times greater in those who developed delirium as compared to those who did not. It is a more specific predictor of delirium.

Factors Affecting Delirium in ICU Patients

This study examined delirium severity using a delirium screening tool and analyzed the predictors, including pain, acuity, level of consciousness, fall risk, and pain score, to increase understanding of delirium and present foundational data for developing nursing interventions for delirium prevention. This was a retrospective study of 165 patients admitted to three intensive care units (ICUs). the Nursing Delirium Screening Scale (Nu-DESC) was used as a research tool to screen for delirium and measure the degree of delirium. The incidence of delirium in patients was 53.3%, and the average delirium score in the delirium group was 2.40 ± 0.56. Nu-DESC scores were significantly correlated with ICU days, ventilator days, restraint applications, the number of catheters inserted, sedative medication use, the Simplified Acute Physiology Score (SAPS III), the Morse Fall Scale (MFS), the Glasgow Coma Scale (GCS) scores, pain scores, and blood urea nitrogen (BUN). Stepwise multiple linear regression showed that the number of restraint applications, GCS score, ICU days, and BUN levels were factors influencing delirium. Based on the findings, ICU nurses should use delirium screening tools to ensure accurate delirium screening and work to reduce the incidence and degree of delirium by observing factors affecting delirium in patients.

Correlation of C-reactive Protein with Delirium in Obstetrics Intensive Care Unit: A Tertiary Center Experience

Background

Delirium is a neuropsychiatric illness. It affects critically ill patients on ventilator and increases mortality. The aim of this study was to evaluate the association of C-reactive protein (CRP) level with delirium in critically obstetrics women and its role in prediction of delirium.

Materials and methods

Arospective observational study was conducted in the intensive care unit (ICU), and the duration of study was one year. Total 145 subjects were recruited, 33 patients were excluded, and 112 subjects were studied. For study, group A (n = 36) includes critically ill obstetric women who had delirium on admission; group B (n = 37) includes critically ill obstetric women who developed delirium within 7 days; and group C (n = 39) that includes critically ill obstetric women who did not develop delirium after follow-up of 7 days was served as control. Disease severity was assessed by using acute physiologic assessment and chronic health evaluation (APACHE) II score, and Richmond Agitation-Sedation Scale (RASS) was used to assess awakeness. In awake patients (RASS of ≥3), delirium was assessed by the use of confusion assessment method for ICU tools. C-reactive protein measured by particle enhanced turbidimetric immunoassay-two point kinetic method.

Results

The mean ages of group A, B, and C were 26.44 ± 4.72, 27.46 ± 4.97, and 28.26 ± 5.67 years, respectively. C-reactive protein levels on the day of delirium development (group B) were found to be significantly higher than day 1 CRP levels of groups A and C. The mean Global Attentiveness Rating (GAR) was significantly lower in groups A and B as compared to that in group C (p < 0.001). On evaluating the correlation of CRP with GAR, it was found to be inverse and mild in strength for the correlation between CRP and GAR (r = -0.403, p < 0.001). At a cut-off value of >181 mg/L, CRP had sensitivity of 93.2% and specificity of 69.2%. The positive predictive value was 85% and the negative predictive value was 84.4% that differentiate delirium from non-delirium.

Conclusion

C-reactive protein is a useful tool for screening and prediction of delirium in critically ill obstetric patients.

How to cite this article

Shyam R, Patel ML, Solanki M, Sachan R, Ali W. Correlation of C-reactive Protein with Delirium in Obstetrics Intensive Care Unit: A Tertiary Center Experience. Indian J Crit Care Med 2023;27(5):315-321.

Postoperative Hyperuricemia-A Risk Factor in Elective Cardiosurgical Patients

Hyperuricemia is a well-known cardiovascular risk factor. The aim of our study was to investigate the connection between postoperative hyperuricemia and poor outcomes after elective cardiac surgery compared to patients without postoperative hyperuricemia. In this retrospective study, a total of 227 patients after elective cardiac surgery were divided into two groups: 42 patients with postoperative hyperuricemia (mean age 65.14 ± 8.9 years) and a second group of 185 patients without it (mean age 62.67 ± 7.45 years). The time spent on mechanical ventilation (hours) and in the intensive care unit (days) were taken as the primary outcome measures while the secondary measure comprised postoperative complications. The preoperative patient characteristics were similar. Most of the patients were men. The EuroSCORE value of assessing the risk was not different between the groups nor the comorbidities. Among the most common comorbidities was hypertension, seen in 66% of all patients (69% in patients with postoperative hyperuricemia and 63.7% in those without it). A group of patients with postoperative hyperuricemia had a prolonged time of treatment in the intensive care unit (p = 0.03), as well as a prolonged duration of mechanical ventilation (p < 0.01) and a significantly higher incidence of the following postoperative complications: circulatory instability and/or low cardiac output syndrome (LCOS) (χ2 = 4486, p < 0.01), renal failure and/or continuous venovenous hemodiafiltration (CVVHDF's) (χ2 = 10,241, p < 0.001), and mortality (χ2 = 5.22, p < 0.01). Compared to patients without postoperative hyperuricemia, elective cardiac patients with postoperative hyperuricemia have prolonged postoperative treatment in intensive care units, extended durations of mechanically assisted ventilation, and a higher incidence of postoperative circulatory instability, renal failure, and death.

Incidence, Subtypes, Risk factors, and Outcome of Delirium: A Prospective Observational Study from Indian Intensive Care Unit

Background

Delirium is a common, under-recognized, and often fatal condition in critically ill patients, characterized by acute disorder of attention and cognition. The global prevalence varies with a negative impact on outcomes. A paucity of Indian studies exists that have systematically assessed delirium.

Objective

A prospective observational study designed to determine the incidence, subtypes, risk factors, complications, and outcome of delirium in Indian intensive care units (ICUs).

Patients and methods

Among 1198 adult patients screened during the study period (December 2019-September 2021), 936 patients were included. The confusion assessment method score (CAM-ICU) and Richmond agitation sedation scale (RASS) were used, with additional confirmation of delirium by the psychiatrist/neurophysician. Risk factors and related complications were compared with a control group.

Results

Delirium occurred in 22.11% of critically ill patients. The hypoactive subtype was the most common (44.9%). The risk factors recognized were higher age, increased acute physiology and chronic health evaluation (APACHE-II) score, hyperuricemia, raised creatinine, hypoalbuminemia, hyperbilirubinemia, alcoholism, and smoking. Precipitating factors included patients admitted on noncubicle beds, proximity to the nursing station, requiring ventilation, as well as the use of sedatives, steroids, anticonvulsants, and vasopressors. Complications observed in the delirium group were unintentional removal of catheters (35.7%), aspiration (19.8%), need for reintubation (10.6%), decubitus ulcer formation (18.4%), and high mortality (21.3% vs 5%).

Conclusion

Delirium is common in Indian ICUs with a potential effect on length of stay and mortality. Identification of incidence, subtype, and risk factors is the first step toward prevention of this important cognitive dysfunction in the ICU.

How to cite this article

Tiwari AM, Zirpe KG, Khan AZ, Gurav SK, Deshmukh AM, Suryawanshi PB, et al. Incidence, Subtypes, Risk factors, and Outcome of Delirium: A Prospective Observational Study from Indian Intensive Care Unit. Indian J Crit Care Med 2023;27(2):111-118.

Risk Factors for Delirium Superimposed on Dementia in Elderly Patients in Comprehensive Ward

OBJECTIVE

To investigate the incidence of delirium and its related risk factors in patients with senile dementia during hospitalization.

METHODS

A retrospective analysis of clinical data of 157 patients over 65 with cognitive impairment who were hospitalized in the comprehensive ward from October 2019 to February 2023 was conducted. Patients were assigned into delirium and non-delirium groups according to whether they exhibited delirium during hospitalization. General information about the patients and Visual Analogue Scale (VAS) score, blood C-reactive protein level, and blood superoxide dismutase (SOD) level were recorded. Univariate analysis was used to identify potential risk factors for delirium, and factors with statistical significance were subjected to multivariate logistic regression analysis. A prediction line chart for delirium in elderly dementia patients was constructed using R 4.03 software, and the model was validated.

RESULTS

Among the 157 patients with senile dementia, 42 patients exhibited delirium and 115 patients exhibited non-delirium. Multivariate logistic regression analysis showed that diabetes, cerebrovascular disease, VAS score ≥4 points, use of sedative drugs, and blood SOD <129 U/mL were independent risk factors for delirium during hospitalization in elderly dementia patients. A prediction nomogram was plotted based on the five risk factors, and receiver operating characteristic curve analysis presented an area under the curve of .875 (95% CI: .816-.934). The nomogram model was internally validated by the Bootstrap method, and the calibration curve showed good agreement between predicted and actual results. Hosmer-Lemeshow test demonstrated that the model had a good fit and high predictive ability.

CONCLUSION

Diabetes, cerebrovascular disease, VAS ≥4 points, use of sedative drugs, and blood SOD <129 U/mL were independent risk factors for delirium in patients with senile dementia during hospitalization. The nomogram model had good accuracy and clinical application value for predicting delirium in this study.

Incidence, characteristics and risk factors of delirium in the intensive care unit: An observational study

AIMS AND OBJECTIVE

To investigate the incidence, characteristics and risk factors of delirium in the ICU.

BACKGROUND

Identifying the risk factors of delirium is important for early detection and to prevent adverse consequences.

DESIGN

An observational cohort study conducted according to STROBE Guidelines.

METHOD

The study was conducted with patients who stayed in ICU ≥24 h and were older than 18 years. Patients were assessed twice daily using the RASS and CAM-ICU until either discharge or death. Cumulative incidence was calculated. Demographic/clinical characteristics, length of stay and mortality were compared between patients with and without delirium. A logistic regression model was used to investigate risk factors.

RESULTS

The incidence of delirium was 31.8% and hypoactive type was the most frequent (41.5%). The median onset of delirium was 3 days (IQR = 2) with a mean duration of 5.27 ± 2.32 days. Patients with delirium were significantly older, had higher APACHE-II, SOFA and CPOT scores, higher blood urea levels, higher requirements for mechanical ventilation, sedation and physical restraints, longer stays in the ICU and higher mortality than those without delirium. The logistic regression analysis results revealed that a CPOT score ≥3 points (OR = 4.70, 95% CI: 1.05-20.93; p = .042), physical restraint (OR = 10.40, 95% CI: 2.75-39.27; p = .001) and ICU stay ≥7 days (OR = 7.26, 95% CI: 1.60-32.84; p = .010) were independent risk factors of delirium.

CONCLUSIONS

In this study, the incidence of delirium was high and associated with several factors. It is critical that delirium is considered by all members of the healthcare team, especially nurses, and that protocols are established for improvements.

RELEVANCE TO THE CLINICAL PRACTICE

Based on the results of this study, delirium could be decreased by preventing the presence of pain, prudent use of physical restraints and shortening the ICU stay.

Prognostic significance of delirium subtypes in critically ill medical and surgical patients: a secondary analysis of a prospective multicenter study

BACKGROUND

The prognostic implication of delirium subtypes in critically ill medical and surgical patients is scarcely investigated. The objective was to determine how delirium subtypes are associated with hospital mortality and other clinical outcomes.

METHODS

We performed a secondary analysis on data from a prospective multicenter study aimed at implementation of delirium-oriented measures, conducted between 2012 and 2015 in The Netherlands. We included adults (≥ 18 years) admitted to the medical or surgical intensive care unit (ICU). Exclusion criteria were neurological admission diagnosis, persistent coma or ICU readmissions. Delirium was assessed using the Confusion Assessment Method-ICU or Intensive Care Delirium Screening Checklist, and delirium subtypes (hypoactive, hyperactive, or mixed) were classified using the Richmond Agitation-Sedation Scale. The main outcome was hospital mortality. Secondary outcomes were ICU mortality, ICU length of stay, coma, mechanical ventilation, and use of antipsychotics, sedatives, benzodiazepines and opioids.

RESULTS

Delirium occurred in 381 (24.4%) of 1564 patients (52.5% hypoactive, 39.1% mixed, 7.3% hyperactive). After case-mix adjustment, patients with mixed delirium had higher hospital mortality than non-delirious patients (OR 3.09, 95%CI 1.79-5.33, p = 0.001), whereas hypoactive patients did not (OR 1.34, 95%CI 0.71-2.55, p = 0.37). Similar results were found for ICU mortality. Compared to non-delirious patients, both subtypes had longer ICU stay, more coma, increased mechanical ventilation frequency and duration, and received more antipsychotics, sedatives, benzodiazepines and opioids. Except for coma and benzodiazepine use, the most unfavourable outcomes were observed in patients with mixed delirium.

CONCLUSIONS

Patients with mixed delirium had the most unfavourable outcomes, including higher mortality, compared with no delirium. These differences argue for distinguishing delirium subtypes in clinical practice and future research. Trial registration ClinicalTrials.gov NCT01952899.

Incidence, Associated Factors, and Outcome of Delirium among Patients Admitted to ICUs in Oman

Background

The incidence of delirium is high up to 46.3% among patients admitted to ICU. Delirium is linked to negative patient outcomes like increased duration of mechanical ventilation use, prolonged ICU stay, increased mortality rate, and healthcare costs. Despite the importance of delirium and its consequences that are significant, there is a scarcity of studies which explored delirium in Oman.

Objectives

This study was conducted to assess the incidence of delirium, the association between the selected predisposing factors and precipitating factors with delirium, determine the predicators of delirium, and evaluate its impacts on ICU mortality and ICU length of stay among ICU patients in Oman.

Methods

A multicenter prospective observational design was used. A total of 153 patients were assessed two-times a day by bedside ICU nurses through the Intensive Care Delirium Screening Checklist (ICDSC).

Results

The results revealed that the delirium incidence was 26.1%. Regression analysis showed that sepsis, metabolic acidosis, nasogastric tube use, and APACHE II score were independent predictors for delirium among ICU patients in Oman and delirium had significant impacts on ICU length of stay and mortality rate.

Conclusion

Delirium is common among ICU patients and it is associated with negative consequences. Multidisciplinary prevention strategies should be implemented to identify and treat the modifiable risk factors.

Development of a Delirium Risk Predication Model among ICU Patients in Oman

Background

Delirium is a common disorder among patients admitted to intensive care units. Identification of the predicators of delirium is very important to improve the patient's quality of life.

Methods

This study was conducted in a prospective observational design to build a predictive model for delirium among ICU patients in Oman. A sample of 153 adult ICU patients from two main hospitals participated in the study. The Intensive Care Delirium Screening Checklist (ICDSC) was used to assess the participants for delirium twice daily.

Result

The results showed that the incidence of delirium was 26.1%. Multiple logistic regression analysis showed that sepsis (odds ratio (OR) = 9.77; 95% confidence interval (CI) = 1.91–49.92; P < 0.006), metabolic acidosis (odds ratio (OR) = 3.45; 95% confidence interval [CI] = 1.18–10.09; P=0.024), nasogastric tube use (odds ratio (OR) 9.74; 95% confidence interval (CI) = 3.48–27.30; P ≤ 0.001), and APACHEII score (OR = 1.22; 95% CI = 1.09–1.37; P ≤ 0.001) were predictors of delirium among ICU patients in Oman (R²=0.519, adjusted R²=0.519, P ≤ 0.001).

Conclusion

To prevent delirium in Omani hospitals, it is necessary to work on correcting those predictors and identifying other factors that had effects on delirium development. Designing of a prediction model may help on early delirium detection and implementation of preventative measures.

The Preventive Effect of Transcutaneous Electrical Acupoint Stimulation on Postoperative Delirium in Elderly Patients with Time Factors: A Randomized Trial

Objectives: There is currently no exact and effective treatment for postoperative delirium (POD). The purpose of this study was to observe the effect of transcutaneous electrical acupoint stimulation (TEAS) before surgery and during surgery in elderly patients with POD. Materials and Methods: A total of 90 patients were randomly divided into three groups: a preoperative TEAS group (group E1), an intraoperative TEAS group (group E2), and a control group (group C). In group E1, TEAS was applied at the Shenting, Baihui, bilateral Neiguan, and Hegu points for 30 min 1 day before surgery and before the induction of anesthesia. In group E2, TEAS was applied during surgery. In group C, electrodes were applied to the points just cited, but no electric stimulation was administered. The incidence of delirium was assessed within 5 days after surgery, and the plasma concentration of propofol at bispectral index (BIS) = 50 was recorded. Blood samples were collected to measure neuron-specific enolation (NSE), tumor necrosis factor-α (TNF-α), and interleukin (IL)-1β 1 day before surgery and 1 and 5 days after surgery. Results: The incidence of delirium in group E1 was decreased in comparison with group C and group E1 (both p < 0.05). The propofol plasma concentration at BIS = 50 in group E1 was also decreased in comparison with group C and group E2 (both p < 0.05). Compared with group C, the concentrations of NSE, TNF-α, and IL-1β in plasma were decreased in group E1 and group E2 1 and 5 days after surgery (both p < 0.05), and the concentrations of NSE and IL-1β in plasma in group E1 were decreased 1 and 5 days after surgery in comparison with group E2. Conclusion: The TEAS can reduce the dosage of propofol required during surgery and the occurrence of delirium after surgery. Its mechanism may be related to inhibiting inflammation response and alleviating brain injury. Compared with intraoperative application, the effect of preconditioning with TEAS before surgery is better. Trial Registration: ChiCTR-INR-17012501. Date of registration: August 29, 2017.

Incidence, predictors and health outcomes of delirium in very old hospitalized patients: a prospective cohort study

Background

Delirium is a common complication that leads to poor health outcomes in older patients undergoing treatment. Due to severe consequences, early recognition of high-risk patients and risk factors for delirium are crucial in the prompt initiation of prevention measures. However, research in medically hospitalized patients aged ≥80 years remains limited. This study aimed to determine the incidence, predictors and health outcomes of delirium in very old (aged ≥80 years) hospitalized patients in China.

Methods

A prospective study was conducted in individuals aged ≥80 years admitted to geriatric departments. Potential risk factors were assessed within 24 h after hospital admission. Screening for delirium was performed on admission and every 48 h thereafter for 14 days and assessed if acute mental status changes were observed. During hospitalization, health outcomes were recorded daily.

Results

Incident delirium occurred in 109 of 637 very old hospitalized patients (17.1%). The independent predictors of delirium in hospitalized patients aged 80 and over were cognitive function impairment [OR 17.42, 95% CI:(7.47–40.64)], depression [OR 9.30, 95% CI: (4.59–18.84)], CCI ≥ 5 [OR 4.21, 95% CI: (1.48–12.01)], sleep deprivation [OR 3.89, 95% CI: (1.71–8.82)], infection [OR 3.33, 95% CI: (1.70–6.54)], polypharmacy (≥5 medications) [OR 2.85, 95% CI: (1.51–5.39)], constipation [OR 2.58, 95% CI: (1.33–5.02)], and emergency admission [OR 2.13, 95% CI: (1.02–4.45)]. Patients with delirium had significantly longer hospital stays(P < 0.001) and higher percentages of physical restraint use(P < 0.001) and falls (P = 0.001) than those without delirium,.

Conclusion

The incidence of delirium was high in hospitalized patients aged ≥80 years admitted to the geriatric department and was associated with prolonged hospital stay and higher rates of physical restraint use and falls. In this population, the most important independent risk factors for incident delirium were cognitive function impairment and depression. Health care professionals should recognize and initiate interventions for delirium early in geriatric patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02932-9.

Predictive Value of Preoperative Profiling of Serum Metabolites for Emergence Agitation After General Anesthesia in Adult Patients

Background: Emergence agitation (EA) in adult patients under general anesthesia leads to increased postoperative complications and heavy medical burden. Unfortunately, its pathogenesis has not been clarified until now. The purpose of the present study was to explore the relationship between preoperative serum metabolites and EA. Methods: We used an untargeted metabolic analysis method to investigate the different metabolomes in the serum of EA patients and non-EA patients undergoing elective surgical procedures after the induction of general anesthesia. A Richmond Agitation-Sedation Scale score ≥ +2 was diagnosed as EA during postoperative emergence. Non-EA patients were matched with EA patients according to general characteristics. Preoperative serum samples of the two groups were collected to investigate the association between serum metabolites and EA development. Results: The serum samples of 16 EA patients with 34 matched non-EA patients were obtained for metabolic analysis. After screening and alignment with databases, 31 altered metabolites were detected between the two groups. These metabolites were mainly involved in the metabolism of lipids, purines, and amino acids. Analyses of receiver-operating characteristic curves showed that the preoperative alterations of choline, cytidine, glycerophosphocholine, L-phenylalanine, oleamide, and inosine may be associated with adult EA. Conclusion: Multiple metabolic abnormalities (including those for lipids, purines, and amino acids) and other pathological processes (e.g., neurotransmitter imbalance and oxidative stress) may contribute to EA. Several altered metabolites in serum before surgery may have predictive value for EA diagnosis. This study might afford new metabolic clues for the understanding of EA pathogenesis.

Factors associated with the decision to prescribe and administer antipsychotics for older people with delirium: a qualitative descriptive study

OBJECTIVES

To explore factors associated with decision-making of nurses and doctors in prescribing and administering as required antipsychotic medications to older people with delirium.

DESIGN

Qualitative descriptive.

SETTING

Two acute care hospital organisations in Melbourne, Australia.

PARTICIPANTS

Nurses and doctors were invited to participate. Semi-structured focus groups and individual interviews were conducted between May 2019 and March 2020. Interviews were audio-recorded and transcribed verbatim. Data were analysed using thematic analysis.

RESULTS

Participants were 42 health professionals; n=25 nurses and n=17 doctors. Themes relating to decisions to use antipsychotic medication were: safety; a last resort; nursing workload; a dilemma to medicate; and anticipating worsening behaviours. Nurses and doctors described experiencing pressures when trying to manage hyperactive behaviours. Safety was a major concern leading to the decision to use antipsychotics. Antipsychotics were often used as chemical restraints to 'sedate' a patient with delirium because nurses 'can't do their job'. Results also indicated that nurses had influence over doctors' decisions despite nurses being unaware of this influence. Health professionals' descriptions are illustrated in a decision-making flowchart that identifies how nurses and doctors navigated decisions regarding prescription and administration of antipsychotic medications.

CONCLUSIONS

The decision to prescribe and administer antipsychotic medications for people with delirium is complex as nurses and doctors must navigate multiple factors before making the decision. Collaborative support and multidisciplinary teamwork are required by both nurses and doctors to optimally care for people with delirium. Decision-making support for nurses and doctors may also help to navigate the multiple factors that influence the decision to prescribe antipsychotics.

Delirium and Associated Length of Stay and Costs in Critically Ill Patients

Purpose

Delirium frequently affects critically ill patients in the intensive care unit (ICU). The purpose of this study is to evaluate the impact of delirium on ICU and hospital length of stay (LOS) and perform a cost analysis.

Materials and Methods

Prospective studies and randomized controlled trials of patients in the ICU with delirium published between January 1, 2015, and December 31, 2020, were evaluated. Outcome variables including ICU and hospital LOS were obtained, and ICU and hospital costs were derived from the respective LOS.

Results

Forty-one studies met inclusion criteria. The mean difference of ICU LOS between patients with and without delirium was significant at 4.77 days (p < 0.001); for hospital LOS, this was significant at 6.67 days (p < 0.001). Cost data were extractable for 27 studies in which both ICU and hospital LOS were available. The mean difference of ICU costs between patients with and without delirium was significant at $3,921 (p < 0.001); for hospital costs, the mean difference was $5,936 (p < 0.001).

Conclusion

ICU and hospital LOS and associated costs were significantly higher for patients with delirium, compared to those without delirium. Further research is necessary to elucidate other determinants of increased costs and cost-reducing strategies for critically ill patients with delirium. This can provide insight into the required resources for the prevention of delirium, which may contribute to decreasing healthcare expenditure while optimizing the quality of care.

Delirium Research in India: A Systematic Review

Delirium is the most common psychiatric diagnoses encountered in patients with various medical-surgical illnesses, in all the treatment set-ups, with relatively higher incidence and prevalence in the intensive care units. As delirium is encountered in multiple specialties, it is important to understand the research on this diagnosis. This study aims to assess the research output involving patients of delirium from India. A comprehensive search was undertaken using Medline (PubMed) and other databases. Search words included were “delirium,” “delirious,” “delirium tremens” AND “India.” No filters were used. Internet and hand searches yielded 305 articles. Out of these articles, 151 had the terms “delirium,” “delirious,” “delirium tremens” in the title and these were included for the review. Additionally, 14 articles were included for the review, although these did not have these terms in the title, but delirium was one of the major outcome parameters in these studies. Majority of the papers were original articles ( n = 81), and these were followed by, case reports ( n = 58), review articles ( n = 10), letter to the editor (not as case reports but as a communication; n = 13), editorials ( n = 2) and one clinical practice guideline. Most of the original papers have either focused on epidemiology (incidence, prevalence, outcome, etc.), symptom profile, with occasional studies focusing on effectiveness of various pharmacological interventions. There is a dearth of research in the field of delirium from India. There is a lack of studies on biomarkers, evaluation of nonpharmacological interventions, and evaluation of prevention strategies. It is the need of the hour to carry out more studies to further our understanding of delirium in the Indian context.

Systematic review of cognitive impairment and brain insult after mechanical ventilation

We conducted a systematic review following the PRISMA protocol primarily to identify publications that assessed any links between mechanical ventilation (MV) and either cognitive impairment or brain insult, independent of underlying medical conditions. Secondary objectives were to identify possible gaps in the literature that can be used to inform future studies and move toward a better understanding of this complex problem. The preclinical literature suggests that MV is associated with neuroinflammation, cognitive impairment, and brain insult, reporting higher neuroinflammatory markers, greater evidence of brain injury markers, and lower cognitive scores in subjects that were ventilated longer, compared to those ventilated less, and to never-ventilated subjects. The clinical literature suggests an association between MV and delirium, and that delirium in mechanically ventilated patients may be associated with greater likelihood of long-term cognitive impairment; our systematic review found no clinical study that demonstrated a causal link between MV, cognitive dysfunction, and brain insult. More studies should be designed to investigate ventilation-induced brain injury pathways as well as any causative linkage between MV, cognitive impairment, and brain insult.

Delirium Triage Screen/Brief Confusion Assessment Method in Adult Orthopaedic and Hematological Patients: A Validation Study

Delirium in the hospitalized orthopaedic patient is associated with numerous negative outcomes. Assessing for the presence of delirium using an accurate and reliable tool is essential. However, the number of validated screening tools is limited. The purpose of this study was to validate and test the reliability of the Delirium Triage Screening and brief Confusion Assessment Method (DTS/bCAM) to screen for delirium in non-intensive care (ICU) orthopaedic and hematological patients. This was a prospective, observational study. Seventy-six delirium assessments were completed on 19 orthopaedic patients and 10 hematological patients. The clinical nurse performed the DTS/bCAM during every 12-hour shift. Within 2 hours of this assessment, a research investigator performed both the DTS/bCAM and the Confusion Assessment Method (CAM). Each patient had a maximum of three assessments by a research investigator. Interrater reliability for the clinical nurse and the researcher was measured through comparison of positive and negative DTS/bCAM results. Validity was measured by comparing the matched DTS/bCAM and CAM results, both performed by the researcher. The DTS/bCAM and CAM results had 100% agreement. Two patients (7%) screened positive for delirium. Sensitivity of the DTS/bCAM was 100% (95% CI [15.8-100]) and specificity was 100% (95% CI [95.1, 100]). There was 86% agreement (43/50) between the clinical nurse and the researcher for the DTS/bCAM. In adult orthopaedic and hematological patients not receiving intensive care, the DTS/bCAM may be a valid, reliable, and rapid screening tool for delirium.

Delirium

Delirium, a syndrome characterized by an acute change in attention, awareness and cognition, is caused by a medical condition that cannot be better explained by a pre-existing neurocognitive disorder. Multiple predisposing factors (for example, pre-existing cognitive impairment) and precipitating factors (for example, urinary tract infection) for delirium have been described, with most patients having both types. Because multiple factors are implicated in the aetiology of delirium, there are likely several neurobiological processes that contribute to delirium pathogenesis, including neuroinflammation, brain vascular dysfunction, altered brain metabolism, neurotransmitter imbalance and impaired neuronal network connectivity. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) is the most commonly used diagnostic system upon which a reference standard diagnosis is made, although many other delirium screening tools have been developed given the impracticality of using the DSM-5 in many settings. Pharmacological treatments for delirium (such as antipsychotic drugs) are not effective, reflecting substantial gaps in our understanding of its pathophysiology. Currently, the best management strategies are multidomain interventions that focus on treating precipitating conditions, medication review, managing distress, mitigating complications and maintaining engagement to environmental issues. The effective implementation of delirium detection, treatment and prevention strategies remains a major challenge for health-care organizations globally.

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.

Association between increased neutrophil-to-lymphocyte ratio and postoperative delirium in elderly patients with total hip arthroplasty for hip fracture

BACKGROUND

Delirium is a common complication in elderly patients with total hip arthroplasty (THA) for hip fracture. The mechanism of postoperative delirium (POD) is associated with the neuroinflammatory process. The aim of this study was to the incidence and perioperative risk factors of POD and investigate whether NLR could serve as a potential marker for POD in elderly patients with THA for hip fracture.

METHODS

This was a multicenter prospective study, we included elderly patients with THA for hip fracture under general anesthesia. Receiver operating characteristic (ROC) curve was performed to identify the optimal cut point of NLR for POD. The relationship between NLR and POD was analyzed by multivariable analysis.

RESULTS

Seven hundred eighty patients (mean age 73.33 ± 7.66) were eligible for inclusion in the study. 23.33% (182/780) of patients had POD. ROC curve analysis showed that the optimal cut point of NLR for POD was NLR ≥ 3.5. Compared with no POD, higher NLR, older age, diabetes, and higher neutrophil count were more likely in patients with POD(P < 0.05). Multivariate logistic regression analysis showed that NLR ≥ 3.50 [adjusted odds ratio(aOR), 3.93; confidence interval (CI), 2.47-6.25; P < 0.001)], older age (aOR, 1.04; 95%CI, 1.02-1.07; P = 0.001), diabetes (aOR, 1.58; 95% CI, 1.06-2.36; P = 0.025),higher neutrophil count (aOR, 1.25; 95%CI, 1.15-1.35; P < 0.001) were associated with increased risk of POD.

CONCLUSIONS

Older age, diabetes, higher neutrophil count, and NLR ≥ 3.5 were independent risk factors for POD, and NLR can be used as a potential marker for prediction of delirium in elderly patients with THA for hip fracture.

The association of delirium severity with patient and health system outcomes in hospitalised patients: a systematic review

BACKGROUND

delirium is an acute state of confusion that affects >20% of hospitalised patients. Recent literature indicates that more severe delirium may lead to worse patient outcomes and health system outcomes, such as increased mortality, cognitive impairment and length of stay (LOS).

METHODS

using systematic review methodology, we summarised associations between delirium severity and patient or health system outcomes in hospitalised adults. We searched MEDLINE, EMBASE, PsycINFO, CINAHL and Scopus databases with no restrictions, from inception to 25 October 2018. We included original observational research conducted in hospitalised adults that reported on associations between delirium severity and patient or health system outcomes. Quality of included articles was assessed using the Newcastle-Ottawa Scale. The level of evidence was quantified based on the consistency of findings and quality of studies reporting on each outcome.

RESULTS

we included 20 articles evaluating associations that reported: mortality (n = 11), cognitive ability (n = 3), functional ability (n = 3), patient distress (n = 1), quality of life (n = 1), hospital LOS (n = 4), intensive care unit (ICU) LOS (n = 2) and discharge home (n = 2). There was strong-level evidence that delirium severity was associated with increased ICU LOS and a lower proportion of patients discharged home. There was inconclusive evidence for associations between delirium severity and mortality, hospital LOS, functional ability, cognitive ability, patient distress and quality of life.

CONCLUSION

delirium severity is associated with increased ICU LOS and a lower proportion of patients discharged home. Delirium severity may be a useful adjunct to existing delirium screening to determine the burden to health care system resources.

[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.

Risk factors and outcomes among delirium subtypes in adult ICUs: A systematic review

PURPOSE

Use systematic review methodology to summarize risk factors and outcomes for each delirium subtype (hypoactive, hyperactive and mixed) in an adult ICU population.

MATERIALS AND METHODS

We searched the MEDLINE, Embase, CINAHL, SCOPUS, Web of Science and PsycINFO databases from database inception until August 13, 2018, with no restrictions.

RESULTS

Of 9635 abstracts, 20 studies were included. Older age was not associated with any delirium subtype in 4/7 (57%) studies. Sex was not associated with any delirium subtype in 4/4 (100%) studies. Mortality was consistently associated with hypoactive delirium in 4/7 (57%) studies. The evidence supporting the association of APACHE-II score, mechanical ventilation, length of stay, duration of delirium and removal of tubes were inconsistent across studies.

CONCLUSIONS

Although included studies reported on many subtype-specific risk factors and outcomes, heterogeneity in reporting and methodological quality limited the generalizability of the results and the evidence for many subtype-specific risk factors or outcomes is inconsistent across studies. Standardized methodology and the creation of a universal template for collecting data in ICU delirium studies are essential moving forward; helping to identify subtype-specific risk factors or outcomes and strengthen the association of potential risk factors or outcomes.

Neurocognitive and Quality-of-life Outcomes Following Intensive Care Admission: A Prospective 6-month Follow-up Study

Background

Post-intensive care survivors have decreased quality-of-life scores and prolonged cognitive dysfunction due to baseline factors and events related to intensive care unit admission, which remain largely unrecognized.

Materials and methods

A prospective observational cohort study to assess the quality of life and occurrence of cognitive dysfunction, 3 and 6 months following discharge from the intensive care unit, was carried out. We enrolled 136 adults presenting to the intensive care unit with no prior cognitive dysfunction or depression and followed up and assessed them with repeatable battery for the assessment of neuropsychological status (RBANS) and quality of life with short Form-36 (SF-36) health survey.

Results

The incidence and prevalence of cognitive dysfunction was 100% at 3 and 6 months, respectively, as assessed by RBANS with a global cognition scores at 3 and 6 months of 71 (IQR 68.5–73) and 74 (IQR 72–86), respectively. Higher Charlson's comorbidity score, increased severity of illness, longer duration of mechanical ventilation, pain, delirium, coma, and hospital stay were associated with statistically significant lower scores at 3 months. The median SF-36 mental component score (MCS) and physical component score (PCS) at 3 months were 38.4 and 32.5 and at 6 months were 38.2 and 32.6, respectively. Poor score was associated significantly with advancing age, poor functional parameters at baseline as evidenced by clinical frailty, poor baseline Katz ADL scores, increased severity of illness, longer duration of mechanical ventilation, occurrence and duration of delirium, coma, pain, and usage of sedatives with or without analgesics.

Conclusion and clinical significance

Patients discharged from the intensive care unit are at high risk for persistent cognitive impairment and poor quality of life score. Poor baseline patient characteristics and events occurring in ICU are associated with worse cognition and quality of life scores. There is an urgent need to prevent, diagnose, and manage these patients by optimizing intensive care practices.

How to cite this article

Balasubramanian V, Suri JC, Ish P, Gupta N, Behera D, Gupta P, et al. Neurocognitive and Quality-of-life Outcomes Following Intensive Care Admission: A Prospective 6-month Follow-up Study. Indian J Crit Care Med 2020;24(10):932–937.

Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

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.

Delirium in the intensive care setting dependent on the Richmond Agitation and Sedation Scale (RASS): Inattention and visuo-spatial impairment as potential screening domains

OBJECTIVE

In the intensive care setting, delirium is a common occurrence; however, the impact of the level of alertness has never been evaluated. Therefore, this study aimed to assess the delirium characteristics in the drowsy, as well as the alert and calm patient.

METHOD

In this prospective cohort study, 225 intensive care patients with Richmond Agitation and Sedation Scale (RASS) scores of -1 - drowsy and 0 - alert and calm were evaluated with the Delirium Rating Scale-Revised-1998 (DRS-R-98) and the Diagnostic and Statistical Manual 4th edition text revision (DSM-IV-TR)-determined diagnosis of delirium.

RESULTS

In total, 85 drowsy and 140 alert and calm patients were included. Crucial items for the correct identification of delirium were sleep-wake cycle disturbances, language abnormalities, thought process alterations, psychomotor retardation, disorientation, inattention, short- and long-term memory, as well as visuo-spatial impairment, and the temporal onset. Conversely, perceptual disturbances, delusions, affective lability, psychomotor agitation, or fluctuations were items, which identified delirium less correctly. Further, the severities of inattentiveness and visuo-spatial impairment were indicative of delirium in both alert- or calmness and drowsiness.

SIGNIFICANCE OF RESULTS

The impairment in the cognitive domain, psychomotor retardation, and sleep-wake cycle disturbances correctly identified delirium irrespective of the level alertness. Further, inattentiveness and - to a lesser degree - visuo-spatial impairment could represent a specific marker for delirium in the intensive care setting meriting further evaluation.

Risk factors for delirium: are therapeutic interventions part of it?

Background: Delirium is associated with increased morbidity and mortality in critically ill patients. Research on risk factors for delirium allows clinicians to identify high-risk patients, which is the basis for early prevention and diagnosis. Besides the risk factors for delirium that are commonly studied, here we more focused on the less-studied therapeutic interventions for critically ill patients which are potentially modifiable. Materials and methods: A total of 320 non-comatose patients admitted to the ICU for more than 24 hrs during 9 months were eligible for the study. Delirium was screened once daily using the CAM-ICU. Demographics, admission clinical data, and daily interventions were collected. Results: Ninety-two patients (28.75%) experienced delirium at least once. Delirious patients were more likely to have longer duration of mechanical ventilation, ICU stay, and hospital stay. Most of the less-studied therapeutic interventions were linked to delirium in the univariate analysis, including gastric tube, artificial airway, deep intravenous catheter, arterial line, urinary catheter, use of vasoactive drugs, and sedative medication. After adjusting with age and ICU length of stay, mechanical ventilation (OR: 5.123; 95% CI: 2.501-10.494), Acute Physiology and Chronic Health Evaluation (APACHE) II score≥20 at admission (OR: 1.897; 95% CI: 1.045-3.441), and gastric tube (OR: 1.935, 95% CI: 1.012-3.698) were associated with increased risk of delirium in multivariate analysis. Conclusion: Delirium was associated with prolonged mechanical ventilation, ICU stay, and hospital stay. Multivariate risk factors were gastric tube, mechanical ventilation, and APACHE II score. Although being a preliminary study, this study suggests the necessity of earliest removal of tubes and catheters when no longer needed.

Quality of recovery in elderly patients with postoperative delirium

Background:

Our study aimed to evaluate quality of recovery in elderly patients with postoperative delirium (POD).

Subjects and Methods:

An observational prospective study was conducted. Patients aged >60 submitted to elective surgery and admitted to Post Anesthesia Care Unit (PACU) in a tertiary hospital from May to July 2017 were included. POD was evaluated with the Nursing Delirium Screening Scale (NuDESC). Quality of recovery-15 (QoR-15) was used before (T0) and 24 h (T24) after surgery to assess quality of recovery. Data collection include patient's characteristics, respiratory events at the PACU, and other perioperative variables. The Chi-square, Fisher's exact, or Mann–Whitney U-tests were used for comparisons.

Results:

Of a total of 235 patients, 12.3% developed POD at PACU. POD was more frequently in patients older than 80 years (P = 0.017), patients with neurological disease (P = 0.026), dementia (P = 0.026), peripheral vascular disease (P = 0.016), and diabetes mellitus (P = 0.037). At T0, there were no differences at median total QoR-15, whereas at T24, patients POD scored lower in 10 items (including “severe pain” with P = 0.001 and “nausea or vomiting” with P = 0.009) of QoR-15 and in total median lower scores (P = 0.001). POD patients stayed longer at PACU (P = 0.017) and they stayed longer at hospital (P = 0.002).

Conclusions:

POD patients were older and had more comorbidities. POD patients had lower QoR scores at T24 suggesting an adverse impact of delirium in postoperative quality of recovery. POD patients stayed for long in the PACU and at hospital.

Delirium in medical intensive care units: Incidence, subtypes, risk factors, and outcome

BACKGROUND

Delirium is a frequent yet underdiagnosed neuropsychiatric condition encountered in intensive care units (ICUs). Being both a preventable and potentially reversible process associated with significant morbidity and mortality, understanding risk factors that predispose and precipitate delirium in any given patient are critical in ICUs.

AIMS AND OBJECTIVES

The aim of this study is to evaluate the incidence, motor subtypes, risk factors, and clinical outcome of delirium in the medical ICU.

MATERIALS AND METHODS

We used a prospective study design on a cohort of consecutive medical ICU admissions of a tertiary care teaching hospital. The Confusion Assessment Method-ICU and Richmond Agitation Sedation Scale were used to diagnose and motor subtype delirium, respectively, along with a checklist to assess risk factors.

RESULTS

Of the 280 ICU admissions, 88 (31.4%) developed delirium. Hypoactive delirium was the most common motor subtype (55.7%). The detection rate of delirium was 12.5% (lowest for hypoactive delirium at 2.04%). Age, gender, and years of education did not significantly predict delirium (all P > 0.05). Tobacco use, chronic liver disease, and past episodes of delirium significantly predisposed, while mechanical ventilation, hypoxia, fever, raised levels of bilirubin and creatinine, and benzodiazepine administration significantly precipitated ICU delirium. Delirium was significantly associated with longer ICU stay (t = 4.23, P = 0.000) and 1-month postdischarge mortality (χ ² = 6.867, P = 0.009).

CONCLUSION

Detection of delirium is challenging, especially in ICU patients on mechanical ventilation and hypoactive delirium. Screening and monitoring for predisposing and precipitating risk factors can greatly improve the odds of detection and intervention as ICU delirium is associated with significant morbidity and mortality.

Screening for delirium with the Intensive Care Delirium Screening Checklist (ICDSC): Symptom profile and utility of individual items in the identification of delirium dependent on the level of sedation

OBJECTIVE

The importance of the proper identification of delirium, with its high incidence and adversities in the intensive care setting, has been widely recognized. One common screening instrument is the Intensive Care Delirium Screening Checklist (ICDSC); however, the symptom profile and key features of delirium dependent on the level of sedation have not yet been evaluated.

METHOD

In this prospective cohort study, the ICDSC was evaluated versus the Diagnostic and Statistical Manual, 4th edition, text revision, diagnosis of delirium set as standard with respect to the symptom profile, and correct identification of delirium. The aim of this study was to identify key features of delirium in the intensive care setting dependent on the Richmond Agitation and Sedation Scale levels of sedation: drowsiness versus alert and calmness.ResultThe 88 delirious patients of 225 were older, had more severe disease, and prolonged hospitalization. Irrespective of the level of sedation, delirium was correctly classified by items related to inattention, disorientation, psychomotor alterations, inappropriate speech or mood, and symptom fluctuation. In the drowsy patients, inattention reached substantial sensitivity and specificity, whereas psychomotor alterations and sleep-wake cycle disturbances were sensitive lacked specificity. The positive prediction was substantial across items, whereas the negative prediction was only moderate. In the alert and calm patient, the sensitivities were substantial for psychomotor alterations, sleep-wake cycle disturbances, and symptom fluctuations; however, these fluctuations were not specific. The positive prediction was moderate and the negative prediction substantial. Between the nondelirious drowsy and alert, the symptom profile was similar; however, drowsiness was associated with alterations in consciousness.Significance of resultsIn the clinical routine, irrespective of the level of sedation, delirium was characterized by the ICDSC items for inattention, disorientation, psychomotor alterations, inappropriate speech or mood and symptom fluctuation. Further, drowsiness caused altered levels of consciousness.

Evaluation of PRE-DELIRIC (PREdiction of DELIRium in ICu patients) delirium prediction model for the patients in the intensive care unit

Introduction

Delirium not only compromises patient care, but is also associated with poorer outcomes: increased duration of mechanical ventilation, higher mortality, and greater long-term cognitive dysfunction. The PRE-DELIRIC model is a tool used to calculate the risk of the development of delirium. The classification of the patients into groups by risk allows efficient initiation of preventive measures. The goal of this study was to validate the PRE-DELIRIC model using the CAM-ICU (The Confusion Assessment Method for the Intensive Care Unit) method for the diagnosis of delirium.

Materials and methods

Patients admitted to the University Hospital of Vilnius during February 2015 were enrolled. Every day, data were collected for APACHE-II and PRE-DELIRIC scores. Out of 167 patients, 38 (23%) were included and screened using the CAM-ICU method within 24 hours of admission to the ICU. We defined patients as having delirium when they had at least one positive CAM-ICU screening or haloperidol administration due to sedation. To validate the PRE-DELIRIC model, we calculated the area under receiver operating characteristic curve.

Results

The mean age of the patients was 69.2 ± 17.2 years, 19 (50%) were male, APACHE-II mean score 18.0 ± 7.4 points. Delirium was diagnosed in 22 (58%) of 38 patients. Data used for validation of the PRE-DELIRIC model resulted in an area under the curve of 0.713 (p < 0.05, 95% CI 0.539-0.887); sensitivity and specificity for the patients with 20% risk were, accordingly, 77.3% and 50%; 40% risk - 45.5% and 81.3%, 60% - 36.4%, and 87.5%.

Conclusions

The PRE-DELIRIC model predicted delirium in the patients within 24 hours of admission to the ICU. Preventive therapy could be efficiently targeted at high-risk patients if both of the methods are to be implemented.