Delirium in the critically ill patient

ICU Delirium in Cardiac Patients

Delirium is a prevalent complication in critically ill medical and surgical cardiac patients. It is associated with increased morbidity and mortality, prolonged hospitalizations, cognitive impairments, functional decline, and hospital costs. The incidence of delirium in cardiac patients varies based on the criteria used for the diagnosis, the population studied, and the type of surgery (cardiac or not cardiac). Delirium experienced when cardiac patients are in the intensive care unit (ICU) is likely preventable in most cases. While there are many protocols for recognizing and managing ICU delirium in medical and surgical cardiac patients, there is no homogeneity, nor are there established clinical guidelines. This review provides a comprehensive overview of delirium in cardiac patients and highlights its presentation, course, risk factors, pathophysiology, and management. We define cardiac ICU patients as both medical and postoperative surgical patients with cardiac disease in the ICU. We also highlight current controversies and future considerations of innovative therapies and nonpharmacological and pharmacological management interventions. Clinicians caring for critically ill patients with cardiac disease must understand the complex syndrome of ICU delirium and recognize the impact of delirium in predicting long-term outcomes for ICU patients.

Postoperative Delirium after Dexmedetomidine versus Propofol Sedation in Healthy Older Adults Undergoing Orthopedic Lower Limb Surgery with Spinal Anesthesia: A Randomized Controlled Trial

BACKGROUND

Delirium is a critical postoperative complication in older patients. Based on the hypothesis that intraoperative dexmedetomidine sedation would lower postoperative delirium than propofol sedation would, the authors compared the incidence of postoperative delirium in older adults, using the mentioned sedatives.

METHODS

This double-blinded, randomized controlled study included 748 patients, aged 65 yr or older, who were scheduled for elective lower extremity orthopedic surgery, between June 2017 and October 2021. Patients were randomized equally into two groups in a 1:1 ratio according to the intraoperative sedative used (dexmedetomidine vs. propofol). The postoperative delirium incidence was considered the primary outcome measure; it was determined using the confusion assessment method, on the first three postoperative days. The mean arterial pressure and heart rate were evaluated as secondary outcomes.

RESULTS

The authors enrolled 732 patients in the intention-to-treat analyses. The delirium incidence was lower in the dexmedetomidine group than in the propofol group (11 [3.0%] vs. 24 [6.6%]; odds ratio, 0.42; 95% CI, 0.201 to 0.86; P = 0.036). During sedation, the mean arterial pressure (median [interquartile range] mmHg) was higher in the dexmedetomidine group (77 [71 to 84]) than in the propofol group (74 [69 to 79]; P < 0.001); however, it significantly fell lower (74 [68 to 80]) than that of the propofol group (80 [74 to 87]) in the postanesthesia care unit (P < 0.001). Lower heart rates (beats/min) were recorded with the use of dexmedetomidine than with propofol, both during sedation (60 [55 to 66] vs. 63 [58 to 70]) and in the postanesthesia care unit (64 [58 to 72] vs. 68 [62-77]; P < 0.001).

CONCLUSIONS

Dexmedetomidine showed a lower incidence of postoperative delirium than propofol in healthy older adults undergoing lower extremity orthopedic surgery.

EDITOR’S PERSPECTIVE

Validation of an automated delirium prediction model (DElirium MOdel (DEMO)): an observational study

OBJECTIVES

Delirium is an underdiagnosed, severe and costly disorder, and 30%-40% of cases can be prevented. A fully automated model to predict delirium (DEMO) in older people has been developed, and the objective of this study is to validate the model in a hospital setting.

SETTING

Secondary care, one hospital with two locations.

DESIGN

Observational study.

PARTICIPANTS

The study included 450 randomly selected patients over 60 years of age admitted to Zuyderland Medical Centre. Patients who presented with delirium on admission were excluded.

PRIMARY OUTCOME MEASURES

Development of delirium through chart review.

RESULTS

A total of 383 patients were included in this study. The analysis was performed for delirium within 1, 3 and 5 days after a DEMO score was obtained. Sensitivity was 87.1% (95% CI 0.756 to 0.939), 84.2% (95% CI 0.732 to 0.915) and 82.7% (95% CI 0.734 to 0.893) for 1, 3 and 5 days, respectively, after obtaining the DEMO score. Specificity was 77.9% (95% CI 0.729 to 0.882), 81.5% (95% CI 0.766 to 0.856) and 84.5% (95% CI 0.797 to 0.884) for 1, 3 and 5 days, respectively, after obtaining the DEMO score.

CONCLUSION

DEMO is a satisfactory prediction model but needs further prospective validation with in-person delirium confirmation. In the future, DEMO will be applied in clinical practice so that physicians will be aware of when a patient is at an increased risk of developing delirium, which will facilitate earlier recognition and diagnosis, and thus will allow the implementation of prevention measures.

Postoperative delirium in elderly citizens and current practice

Postoperative delirium (POD) represents an acute brain dysfunction in the postsurgical period. Perioperative physicians caring for the older adults are familiar with the care of dysfunction of organs such as lungs, heart, liver, or kidney in the perioperative setting, but they are less familiar with management of brain dysfunction. As early detection and prompt treatment of inciting factors are utmost important to prevent or minimize the deleterious outcomes of delirium. The purpose of this review is to prepare perioperative physicians with a set of current clinical practice recommendations to provide optimal perioperative care of older adults, with a special focus on specific perioperative interventions that have been shown to prevent POD. On literature search in EMBASE, CINAHL, and PUBMED between January 2000 and September 2015 using search words delirium, POD, acute postoperative confusion, and brain dysfunction resulted in 9710 articles. Among them, 73 articles were chosen for review, in addition, National Institute for Health and Clinical Excellence guidelines, American Geriatric Society guidelines, hospital elderly life program-confusion assessment method training manual, New York geriatric nursing protocols, World Health Organization's International Classification of Diseases, 10th Revision classification of mental disorders, Food and Drug Administration requests boxed warnings on older class of antipsychotic drugs 2008 and delirium in Miller's text book of anesthesia were reviewed and relevant information presented in this article.

Reduction of self-perceived discomforts in critically ill patients in French intensive care units: study protocol for a cluster-randomized controlled trial

BACKGROUND

It is now well documented that critically ill patients are exposed to stressful conditions and experience discomforts from multiple sources. Improved identification of the discomforts of patients in intensive care units (ICUs) may have implications for managing their care, including consideration of ethical issues, and may assist clinicians in choosing the most appropriate interventions. The primary objective of this study was to assess the effectiveness of a multicomponent program of discomfort reduction in critically ill patients. The secondary objectives were to assess the sustainability of the impact of the program and the potential seasonality effect.

METHODS/DESIGN

We conducted a multicenter, cluster-randomized, controlled, single (patient)-blind study involving 34 French adult ICUs. The experimental intervention was a 6-month period during which the multicomponent program was implemented in the ICU and included the following steps: identification of discomforts, immediate feedback to the healthcare team, and implementation of targeted interventions. The control intervention was a 6-month period during which any program was implemented. The primary endpoint was the monthly overall score of self-reported discomfort from the French questionnaire on discomforts in ICU patients (IPREA). The secondary endpoints were the scores of the discomfort items of IPREA. The sample size was 660 individuals to obtain 80% power to detect a 25% difference in the overall discomfort score of IPREA between the two groups (design effect: 2.9).

DISCUSSION

The results of this cluster-randomized controlled study are expected to confirm that a multicomponent program of discomfort reduction may be a new strategy in the management of care for critically ill patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02442934, registered 11 May 2015.

Delirium screening anchored in child development: The Cornell Assessment for Pediatric Delirium

OBJECTIVE

The recently validated Cornell Assessment for Pediatric Delirium (CAPD) is a new rapid bedside nursing screen for delirium in hospitalized children of all ages. The present manuscript provides a "developmental anchor points" reference chart, which helps ground clinicians' assessment of CAPD symptom domains in a developmental understanding of the presentation of delirium.

METHOD

During the development of this CAPD screening tool, it became clear that clinicians need specific guidance and training to help them draw on their expertise in child development and pediatrics to improve the interpretative reliability of the tool and its accuracy in diagnosing delirium. The developmental anchor points chart was formulated and reviewed by a multidisciplinary panel of experts to evaluate content validity and include consideration of sick behaviors within a hospital setting.

RESULTS

The CAPD developmental anchor points for the key ages of newborn, 4 weeks, 6 weeks, 8 weeks, 28 weeks, 1 year, and 2 years served as the basis for training bedside nurses in scoring the CAPD for the validation trial and as a multifaceted bedside reference chart to be implemented within a clinical setting. In the current paper, we discuss the lessons learned during implementation, with particular emphasis on the importance of collaboration with the bedside nurse, the challenges of establishing a developmental baseline, and further questions about delirium diagnosis in children.

SIGNIFICANCE OF RESULTS

The CAPD with developmental anchor points provides a validated, structured, and developmentally informed approach to screening and assessment of delirium in children. With minimal training on the use of the tool, bedside nurses and other pediatric practitioners can reliably identify children at risk for delirium.

Perioperative delirium and its relationship to dementia

A number of serious clinical cognitive syndromes occur following surgery and anesthesia. Postoperative delirium is a behavioral syndrome that occurs in the perioperative period. It is diagnosed through observation and characterized by a fluctuating loss of orientation and confusion. A distinct syndrome that requires formalized neurocognitive testing is frequently referred to as postoperative cognitive dysfunction (POCD). There are serious concerns as to whether either postoperative delirium or postoperative cognitive dysfunction leads to dementia. These concerns are reviewed in this article.

Adverse drug events associated with the use of analgesics, sedatives, and antipsychotics in the intensive care unit

As critically ill patients frequently receive analgesics, sedatives, and antipsychotics to optimize patient comfort and facilitate mechanical ventilation, adverse events associated with the use of these agents can affect all organ systems and result in substantial morbidity and mortality. Although many of these adverse effects are common pharmacologic manifestations of the agent, and therefore frequently reversible, others are idiosyncratic and thus unexpected. The critically ill are more susceptible to adverse drug events than nonintensive care unit patients due to the high doses and long periods for which each of these agents are often administered, the frequent use of intravenous formulations that contain adjuvants that may lead to toxicity in some instances, and the high prevalence of end-organ dysfunction that affects the pharmacokinetic and pharmacodynamic response to therapy. This paper will review the most common and serious adverse drug events reported to occur with the use of sedatives, analgesics, and antipsychotics in the intensive care unit; highlight the pharmacokinetic, pharmacodynamic, and pharmacogenetic factors that can influence analgesic, sedative, and antipsychotic response and safety in the critically ill; and identify strategies that can be used to minimize toxicity with these agents.

Delirium in elderly adults: diagnosis, prevention and treatment

Delirium is a common and serious acute neuropsychiatric syndrome with core features of inattention and global cognitive dysfunction. The etiologies of delirium are diverse and multifactorial and often reflect the pathophysiological consequences of an acute medical illness, medical complication or drug intoxication. Delirium can have a widely variable presentation, and is often missed and underdiagnosed as a result. At present, the diagnosis of delirium is clinically based and depends on the presence or absence of certain features. Management strategies for delirium are focused on prevention and symptom management. This article reviews current clinical practice in delirium in elderly individuals, including the diagnosis, treatment, outcomes and economic impact of this syndrome. Areas of future research are also discussed.

Delirium in elderly adults: diagnosis, prevention and treatment

Delirium is a common and serious acute neuropsychiatric syndrome with core features of inattention and global cognitive dysfunction. The etiologies of delirium are diverse and multifactorial and often reflect the pathophysiological consequences of an acute medical illness, medical complication or drug intoxication. Delirium can have a widely variable presentation, and is often missed and underdiagnosed as a result. At present, the diagnosis of delirium is clinically based and depends on the presence or absence of certain features. Management strategies for delirium are focused on prevention and symptom management. This article reviews current clinical practice in delirium in elderly individuals, including the diagnosis, treatment, outcomes and economic impact of this syndrome. Areas of future research are also discussed.