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Cortés-Beringola A, Vicent L, Martín-Asenjo R, Puerto E, Domínguez-Pérez L, Maruri R, Moreno G, Vidán MT, Bueno H. Diagnosis, prevention, and management of delirium in the intensive cardiac care unit. Am Heart J 2021; 232:164-176. [PMID: 33253676 DOI: 10.1016/j.ahj.2020.11.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 11/16/2020] [Indexed: 12/01/2022]
Abstract
Delirium is a frequent complication in patients admitted to intensive cardiac care units (ICCU) with potentially severe consequences including increased risks of mortality, cognitive impairment and dependence at discharge, and longer times on mechanical ventilation and hospital stay. Delirium has been widely documented and studied in general intensive care units and in patients after cardiac surgery, but it has barely been studied in acute nonsurgical cardiac patients. Moreover, delirium (especially in its hypoactive form) is commonly misdiagnosed. We propose a protocol for delirium prevention and management in ICCUs. A daily comprehensive assessment to improve detection should be done using validated scales (ie, confusion assessment method). Preventive measures are particularly relevance and constitute the basis of treatment as well, acting on reversible risk factors, including environmental interventions, such as quiet time, sleep promotion, family support, communication, and adequate treatment of pain and dyspnea. Pharmacological prophylaxis is not indicated with the exception of patients at risk of withdrawal syndrome but should only be used in patients with confirmed delirium. Dexmedetomidine is the drug of choice in patients with severe agitation, and those weaning from invasive mechanical ventilation. As the complexity of ICCUs increases, clinical scenarios posing challenges for the management of delirium become more frequent. Efforts should be done to improve the identification of patients at risk during admission in order to establish preventive interventions to avoid this complication. Patient-centered protocols will increase the awareness of the healthcare professionals for better prevention and earlier diagnosis and will positively impact on prognosis.
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Affiliation(s)
- Alejandro Cortés-Beringola
- Intensive Cardiac Care Unit, Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; Cardiology Department, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Lourdes Vicent
- Intensive Cardiac Care Unit, Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Roberto Martín-Asenjo
- Intensive Cardiac Care Unit, Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain
| | - Elena Puerto
- Intensive Cardiac Care Unit, Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain
| | - Laura Domínguez-Pérez
- Intensive Cardiac Care Unit, Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain
| | - Ramón Maruri
- Intensive Cardiac Care Unit, Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain
| | - Guillermo Moreno
- Intensive Cardiac Care Unit, Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - María T Vidán
- Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain; Department of Geriatric Medicine, Hospital General Universitario Gregorio Marañón, Madrid, Spain; CIBER de Fragilidad y Envejecimiento Saludable (CIBERFES), Madrid, Spain
| | - Héctor Bueno
- Intensive Cardiac Care Unit, Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain; Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.
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Abstract
PURPOSE OF REVIEW Postoperative delirium (POD) is one of the most severe complications after surgery.The consequences are dramatic: longer hospitalization, a doubling of mortality and almost all cases develop permanent, yet subtle, cognitive deficits specific to everyday life. Actually, no global guideline with standardized concepts of management exists. Advances in prevention, diagnosis and treatment can improve recognition and risk stratification of delirium and its consequences. RECENT FINDINGS Management of POD is a multiprofessional approach and consists of different parts: First, the detection of high-risk patients with a validated tool, preventive nonpharmacological concepts and an intraoperative anesthetic management plan that is individualized to the older patient (e.g. avoiding large swings in blood pressure, vigilance in maintaining normothermia, ensuring adequate analgesia and monitoring of anesthetic depth). In addition to preventive standards, treatment and diagnostic concepts must also be available, both pharmaceutical and nonpharmacological. SUMMARY Not every POD can be prevented. It is important to detect patients with high risk for POD and have standardized concepts of management. The most important predisposing risk factors are a higher age, preexisting cognitive deficits, multimorbidity and an associated prodelirious polypharmacy. In view of demographic change, the implementation of multidisciplinary approaches to pharmacological and nonpharmacological POD management is highly recommended.
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