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Miranda F, Gonzalez F, Plana MN, Zamora J, Quinn TJ, Seron P. Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) for the diagnosis of delirium in adults in critical care settings. Cochrane Database Syst Rev 2023; 11:CD013126. [PMID: 37987526 PMCID: PMC10661047 DOI: 10.1002/14651858.cd013126.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
BACKGROUND Delirium is an underdiagnosed clinical syndrome typified by an acute alteration of mental state. It is an important problem in critical care and intensive care units (ICU) due to its high prevalence and its association with adverse outcomes. Delirium is a very distressing condition for patients, with a huge impact on their well-being. Diagnosis of delirium in the critical care setting is challenging. This is especially true for patients who are mechanically ventilated and are therefore unable to engage in a verbal interview. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is a tool specifically designed to assess for delirium in the context of ICU patients, including those on mechanical ventilation. CAM-ICU can be administered by non-specialists to give a dichotomous delirium present/absent result. OBJECTIVES To determine the diagnostic accuracy of the CAM-ICU for the diagnosis of delirium in adult patients in critical care units. SEARCH METHODS We searched MEDLINE (Ovid SP, 1946 to 8 July 2022), Embase (Ovid SP, 1982 to 8 July 2022), Web of Science Core Collection (ISI Web of Knowledge, 1945 to 8 July 2022), PsycINFO (Ovid SP, 1806 to 8 July 2022), and LILACS (BIREME, 1982 to 8 July 2022). We checked the reference lists of included studies and other resources for additional potentially relevant studies. We also searched the Health Technology Assessment database, the Cochrane Library, Aggressive Research Intelligence Facility database, WHO ICTRP, ClinicalTrials.gov, and websites of scientific associations to access any annual meetings and abstracts of conference proceedings in the field. SELECTION CRITERIA We included diagnostic studies enrolling adult ICU patients assessed using the CAM-ICU tool, regardless of language or publication status and reporting sufficient data on delirium diagnosis for the construction of 2 x 2 tables. Eligible studies evaluated the diagnostic performance of the CAM-ICU versus a clinical reference standard based on any iteration of the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria applied by a clinical expert. DATA COLLECTION AND ANALYSIS Two review authors independently selected and collated study data. We assessed the methodological quality of studies using the QUADAS-2 tool. We used two univariate fixed-effect or random-effects models to determine summary estimates of sensitivity and specificity. We performed sensitivity analyses that excluded studies considered to be at high risk of bias and high concerns in applicability, due mainly to the target population included (e.g. patients with traumatic brain injury). We also investigated potential sources of heterogeneity, assessing the effect of reference standard diagnosis and proportion of patients ventilated. MAIN RESULTS We included 25 studies (2817 participants). The mean age of participants ranged from 48 to 69 years; 15 of the studies included critical care units admitting mixed populations (e.g. medical, trauma, surgery patients). The percentage of patients receiving mechanical ventilation ranged from 11.8% to 100%. The prevalence of delirium in the studies included ranged from 12.5% to 83.9%. Presence of delirium was determined by the application of DSM-IV criteria in 13 out of 25 included studies. We assessed 13 studies as at low risk of bias and low applicability concerns for all QUADAS-2 domains. The most common issue of concern was flow and timing of the tests, followed by patient selection. Overall, we estimated a pooled sensitivity of 0.78 (95% confidence interval (CI) 0.72 to 0.83) and a pooled specificity of 0.95 (95% CI 0.92 to 0.97). Sensitivity analysis restricted to studies at low risk of bias and without any applicability concerns (n = 13 studies) gave similar summary accuracy indices (sensitivity 0.80 (95% CI 0.72 to 0.86), specificity 0.95 (95% CI 0.93 to 0.97)). Subgroup analyses based on diagnostic assessment found summary estimates of sensitivity and specificity for studies using DSM-IV of 0.79 (95% CI 0.72 to 0.85) and 0.94 (95% CI 0.90 to 0.96). For studies that used DSM-5 criteria, summary estimates of sensitivity and specificity were 0.75 (95% CI 0.67 to 0.82) and 0.98 (95% CI 0.95 to 0.99). DSM criteria had no significant effect on sensitivity (P = 0.421), but the specificity for detection of delirium was higher when DSM-5 criteria were used (P = 0.024). The relative specificity comparing DSM-5 versus DSM-IV criteria was 1.05 (95% CI 1.02 to 1.08). Summary estimates of sensitivity and specificity for studies recruiting < 100% of patients with mechanical ventilation were 0.81 (95% CI 0.75 to 0.85) and 0.95 (95% CI 0.91 to 0.98). For studies that exclusively recruited patients with mechanical ventilation, summary estimates of sensitivity and specificity were 0.91 (95% CI 0.76 to 0.97) and 0.98 (95% CI 0.92 to 0.99). Although there was a suggestion of differential performance of CAM-ICU in ventilated patients, the differences were not significant in sensitivity (P = 0.316) or in specificity (P = 0.493). AUTHORS' CONCLUSIONS The CAM-ICU tool may have a role in the early identification of delirium, in adult patients hospitalized in intensive care units, including those on mechanical ventilation, when non-specialized, properly trained clinical personnel apply the CAM-ICU. The test is most useful for exclusion of delirium. The test may miss a proportion of patients with incident delirium, therefore in situations where detection of all delirium cases is desirable, it may be best to repeat the test or combine CAM-ICU with another assessment. Future studies should compare different screening tests proposed for bedside assessment of delirium, as this approach will reveal which tool yields superior accuracy. In addition, future studies should consider and report the flow and timing of the tests and clearly report key characteristics related to patient selection. Finally, future research should focus on the impact of CAM-ICU screening on patient outcomes.
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Affiliation(s)
- Fabian Miranda
- Department of Medicine, Universidad de Chile, Santiago, Chile
| | | | - Maria Nieves Plana
- Health Technology Assessment Unit, Hospital Universitario Ramón y Cajal (IRYCIS). CIBER Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Javier Zamora
- Clinical Biostatistics Unit, Hospital Universitario Ramón y Cajal (IRYCIS). CIBER Epidemiology and Public Health (CIBERESP), Madrid, Spain
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Terry J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Pamela Seron
- Facultad de Medicina, Departamento de Ciencias de la Rehabilitación & CIGES, Universidad de La Frontera, Temuco, Chile
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Moss SJ, Hee Lee C, Doig CJ, Whalen-Browne L, Stelfox HT, Fiest KM. Delirium diagnosis without a gold standard: Evaluating diagnostic accuracy of combined delirium assessment tools. PLoS One 2022; 17:e0267110. [PMID: 35436316 PMCID: PMC9015135 DOI: 10.1371/journal.pone.0267110] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 04/03/2022] [Indexed: 11/19/2022] Open
Abstract
Background Fluctuating course of delirium and complexities of ICU care mean delirium symptoms are hard to identify or commonly confused with other disorders. Delirium is difficult to diagnose, and clinicians and researchers may combine assessments from multiple tools. We evaluated diagnostic accuracy of different combinations of delirium assessments performed in each enrolled patient. Methods Data were obtained from a previously conducted cross-sectional study. Eligible adult patients who remained admitted to ICU for >24 hours with at least one family member present were consecutively enrolled as patient-family dyads. Clinical delirium assessments (Intensive Care Delirium Screening Checklist [ICSDC] and Confusion Assessment Method-ICU [CAM-ICU]) were completed twice daily by bedside nurse or trained research assistant, respectively. Family delirium assessments (Family Confusion Assessment Method and Sour Seven) were completed once daily by family members. We pooled all delirium assessment tools in a single two-class latent model and pairwise (i.e., combined, clinical or family assessments) Bayesian analyses. Results Seventy-three patient-family dyads were included. Among clinical delirium assessments, the ICDSC had lower sensitivity (0.72; 95% Bayesian Credible [BC] interval 0.54–0.92) and higher specificity (0.90; 95%BC, 0.82–0.97) using Bayesian analyses compared to pooled latent class analysis and CAM-ICU had higher sensitivity (0.90; 95%BC, 0.70–1.00) and higher specificity (0.94; 95%BC, 0.80–1.00). Among family delirium assessments, the Family Confusion Assessment Method had higher sensitivity (0.83; 95%BC, 0.71–0.92) and higher specificity (0.93; 95%BC, 0.84–0.98) using Bayesian analyses compared to pooled latent class analysis and the Sour Seven had higher specificity (0.85; 95%BC, 0.67–0.99) but lower sensitivity (0.64; 95%BC 0.47–0.82). Conclusions Results from delirium assessment tools are often combined owing to imperfect reference standards for delirium measurement. Pairwise Bayesian analyses that explicitly accounted for each tool’s (performed within same patient) prior sensitivity and specificity indicate that two combined clinical or two combined family delirium assessment tools have fair diagnostic accuracy.
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Affiliation(s)
- Stephana J. Moss
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
- O’Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Chel Hee Lee
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
- Alberta Health Services, Calgary, Alberta, Canada
| | - Christopher J. Doig
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
- O’Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
- Alberta Health Services, Calgary, Alberta, Canada
| | - Liam Whalen-Browne
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
| | - Henry T. Stelfox
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
- O’Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
- Alberta Health Services, Calgary, Alberta, Canada
| | - Kirsten M. Fiest
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
- O’Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Department of Psychiatry, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- * E-mail:
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Chen TJ, Traynor V, Wang AY, Shih CY, Tu MC, Chuang CH, Chiu HY, Chang HC(R. Comparative Effectiveness of Non-Pharmacological Interventions for Preventing Delirium in Critically Ill Adults: A Systematic Review and Network Meta-Analysis. Int J Nurs Stud 2022; 131:104239. [DOI: 10.1016/j.ijnurstu.2022.104239] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 03/10/2022] [Accepted: 03/22/2022] [Indexed: 11/16/2022]
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Arachchi TMJ, Pinto V. Understanding the Barriers in Delirium Care in an Intensive Care Unit: A Survey of Knowledge, Attitudes, and Current Practices among Medical Professionals Working in Intensive Care Units in Teaching Hospitals of Central Province, Sri Lanka. Indian J Crit Care Med 2022; 25:1413-1420. [PMID: 35027803 PMCID: PMC8693102 DOI: 10.5005/jp-journals-10071-24040] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Delirium is a common, underdiagnosed, and undertreated condition that increases morbidity and mortality in ICU patients which has an incidence up to 80%. Barriers that hinder optimum care of delirium include inadequate knowledge, poor attitudes, and low perceived importance of delirium care. Aim To assess attitudes, knowledge, and current practices related to delirium care among medical professionals working in intensive care units (ICUs) in all teaching hospitals in Central Province, Sri Lanka, as there are no Sri Lankan studies on this regard. Method A descriptive cross-sectional study was carried out among all medical professionals working in nine ICUs in all (n = 5) teaching hospitals in Central Province. Data were collected using a pretested self-administered questionnaire. Responses to questions were compared between postgraduate trainee medical officers (PG-MOs) and non-postgraduate-trainee medical officers (non-PG-MOs). Results Eighty-eight questionnaires were analyzed. More than 80% of PGs and non-PG-MOs regarded ICU delirium as significant problem that should be screened and prevented. Forty-one percent stated confidence in diagnosing delirium. However, more than 75% of non-PG-MOs failed to recognize features of hypoactive delirium. Only 30–50% subjects in incorporated preventive methods in usual practice and more than 60% non-PG-MOs had poor knowledge and experience on delirium screening. More than 80% of the participants did not routinely screen their patients. More than 90% non-PG-MOs (p <0.05) had no recent educational exposure. Conclusion A positive attitude toward the importance of management of delirium was observed. However, there is a discrepancy between the perceived importance and the current practice related to screening and prevention. Participants, especially non-PG-MOs, lacked knowledge on delirium screening, diagnosis, and identification of risk factors, probably related to a lack of educational exposure. How to cite this article Arachchi TMJ, Pinto V. Understanding the Barriers in Delirium Care in an Intensive Care Unit: A Survey of Knowledge, Attitudes, and Current Practices among Medical Professionals Working in Intensive Care Units in Teaching Hospitals of Central Province, Sri Lanka. Indian J Crit Care Med 2021;25(12):1413–1420.
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Affiliation(s)
- Tilani M Jayasinghe Arachchi
- Department of Anaesthesiology and Critical Care, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Vasanthi Pinto
- Department of Anaesthesiology and Critical Care, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
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Poulin TG, Krewulak KD, Rosgen BK, Stelfox HT, Fiest KM, Moss SJ. The impact of patient delirium in the intensive care unit: patterns of anxiety symptoms in family caregivers. BMC Health Serv Res 2021; 21:1202. [PMID: 34740349 PMCID: PMC8571897 DOI: 10.1186/s12913-021-07218-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 10/22/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of this study was to examine the association of patient delirium in the intensive care unit (ICU) with patterns of anxiety symptoms in family caregivers when delirium was determined by clinical assessment and family-administered delirium detection. METHODS In this cross-sectional study, consecutive adult patients anticipated to remain in the ICU for longer than 24 h were eligible for participation given at least one present family caregiver (e.g., spouse, friend) provided informed consent (to be enrolled as a dyad) and were eligible for delirium detection (i.e., Richmond Agitation-Sedation Scale score ≥ - 3). Generalized Anxiety Disorder-7 (GAD-7) was used to assess self-reported symptoms of anxiety. Clinical assessment (Confusion Assessment Method for ICU, CAM-ICU) and family-administered delirium detection (Sour Seven) were completed once daily for up to five days. RESULTS We included 147 family caregivers; the mean age was 54.3 years (standard deviation [SD] 14.3 years) and 74% (n = 129) were female. Fifty (34% [95% confidence interval [CI] 26.4-42.2]) caregivers experienced clinically significant symptoms of anxiety (median GAD-7 score 16.0 [interquartile range 6]). The most prevalent symptoms of anxiety were "Feeling nervous, anxious or on edge" (96.0% [95%CI 85.2-99.0]); "Not being able to stop or control worrying" (88.0% [95%CI 75.6-94.5]; "Worrying too much about different things" and "Feeling afraid as if something awful might happen" (84.0% [95%CI 71.0-91.8], for both). Family caregivers of critically ill adults with delirium were significantly more likely to report "Worrying too much about different things" more than half of the time (CAM-ICU, Odds Ratio [OR] 2.27 [95%CI 1.04-4.91]; Sour Seven, OR 2.28 [95%CI 1.00-5.23]). CONCLUSIONS Family caregivers of critically ill adults with delirium frequently experience clinically significant anxiety and are significantly more likely to report frequently worrying too much about different things. Future work is needed to develop mental health interventions for the diversity of anxiety symptoms experienced by family members of critically ill patients. TRIAL REGISTRATION This study is registered on ClinicalTrials.gov ( https://clinicaltrials.gov/ct2/show/NCT03379129 ).
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Affiliation(s)
- Therese G Poulin
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, T2N 1N4, Canada
| | - Karla D Krewulak
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, T2N 1N4, Canada
| | - Brianna K Rosgen
- Departments of Community Health Sciences and Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, T2N 1N4, Canada
| | - Henry T Stelfox
- Departments of Community Health Sciences and Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, T2N 1N4, Canada
| | - Kirsten M Fiest
- Departments of Critical Care Medicine, Community Health Sciences & Psychiatry, Cumming School of Medicine, University of Calgary, Calgary, AB, T2N 1N4, Canada.
| | - Stephana J Moss
- Departments of Community Health Sciences and Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, T2N 1N4, Canada
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Kim CM, van der Heide EM, van Rompay TJL, Verkerke GJ, Ludden GDS. Overview and Strategy Analysis of Technology-Based Nonpharmacological Interventions for In-Hospital Delirium Prevention and Reduction: Systematic Scoping Review. J Med Internet Res 2021; 23:e26079. [PMID: 34435955 PMCID: PMC8430840 DOI: 10.2196/26079] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 02/12/2021] [Accepted: 05/24/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Delirium prevention is crucial, especially in critically ill patients. Nonpharmacological multicomponent interventions for preventing delirium are increasingly recommended and technology-based interventions have been developed to support them. Despite the increasing number and diversity in technology-based interventions, there has been no systematic effort to create an overview of these interventions for in-hospital delirium prevention and reduction. OBJECTIVE This systematic scoping review was carried out to answer the following questions: (1) what are the technologies currently used in nonpharmacological technology-based interventions for preventing and reducing delirium? and (2) what are the strategies underlying these currently used technologies? METHODS A systematic search was conducted in Scopus and Embase between 2015 and 2020. A selection was made in line with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Studies were eligible if they contained any type of technology-based interventions and assessed delirium-/risk factor-related outcome measures in a hospital setting. Data extraction and quality assessment were performed using a predesigned data form. RESULTS A total of 31 studies were included and analyzed focusing on the types of technology and the strategies used in the interventions. Our review revealed 8 different technology types and 14 strategies that were categorized into the following 7 pathways: (1) restore circadian rhythm, (2) activate the body, (3) activate the mind, (4) induce relaxation, (5) provide a sense of security, (6) provide a sense of control, and (7) provide a sense of being connected. For all technology types, significant positive effects were found on either or both direct and indirect delirium outcomes. Several similarities were found across effective interventions: using a multicomponent approach or including components comforting the psychological needs of patients (eg, familiarity, distraction, soothing elements). CONCLUSIONS Technology-based interventions have a high potential when multidimensional needs of patients (eg, physical, cognitive, emotional) are incorporated. The 7 pathways pinpoint starting points for building more effective technology-based interventions. Opportunities were discussed for transforming the intensive care unit into a healing environment as a powerful tool to prevent delirium. TRIAL REGISTRATION PROSPERO International Prospective Register of Systematic Reviews CRD42020175874; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=175874.
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Affiliation(s)
- Chan Mi Kim
- Department of Design, Production, and Management, Faculty of Engineering Technology, University of Twente, Enschede, Netherlands
| | | | - Thomas J L van Rompay
- Department of Communication Science, Faculty of Behavioral, Management, and Social Sciences, University of Twente, Enschede, Netherlands
| | - Gijsbertus J Verkerke
- Department of Biomechanical Engineering, Faculty of Engineering Technology, University of Twente, Enschede, Netherlands.,Department of Rehabilitation Medicine, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Geke D S Ludden
- Department of Design, Production, and Management, Faculty of Engineering Technology, University of Twente, Enschede, Netherlands
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Otusanya OT, Hsieh SJ, Gong MN, Gershengorn HB. Impact of ABCDE Bundle Implementation in the Intensive Care Unit on Specific Patient Costs. J Intensive Care Med 2021; 37:833-841. [PMID: 34286609 DOI: 10.1177/08850666211031813] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To measure the impact of full versus partial ABCDE bundle implementation on specific cost centers and related resource utilization. DESIGN Retrospective cohort study. SETTING Two medical ICUs within Montefiore Health System (Bronx, NY). PATIENTS Four hundred and seventy-two mechanically ventilated patients admitted to the medical ICUs during a hospitalization which began and ended between January 1, 2013 and December 31, 2013. INTERVENTIONS The full (A)wakening, (B)reathing, (C)oordination, (D)elirium Monitoring/Management and (E)arly Mobilization bundle was implemented in the intervention ICU while a portion of the bundle (A, B, and D components) was implemented in the comparison ICU. MEASUREMENTS AND MAIN RESULTS Relative to the comparison ICU, implementation of the entire bundle in the intervention ICU was associated with a 27.3% (95% CI: 9.9%, 41.3%; P = 0.004) decrease in total hospital laboratory costs and a 2,888.6% (95% CI: 77.9%, 50,113.2%; P = 0.018) increase in total hospital physical therapy costs. Cost of total hospital medications, diagnostic radiology and respiratory therapy were unchanged. Relative to the comparison ICU, total hospital resource use decreased in the intervention ICU (incidence rate ratio [95% CI], laboratory: 0.68 [0.54, 0.87], P = 0.002; diagnostic radiology: 0.75 [0.59, 0.96], P = 0.020). CONCLUSIONS Full ABCDE bundle implementation resulted in a decrease in total hospital laboratory costs and total hospital laboratory and diagnostic resource utilization while leading to an increase in physical therapy costs.
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Affiliation(s)
- Olufisayo T Otusanya
- Department of Pulmonary Diseases, Critical Care and Environmental Medicine, Tulane University School of Medicine, New Orleans, LA, USA.,Department of Pulmonary, Critical Care and Sleep Medicine, Piedmont Henry Hospital, Stockbridge, GA, USA
| | - S Jean Hsieh
- Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, NY, USA
| | - Michelle Ng Gong
- Division of Pulmonary and Critical Care, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Hayley B Gershengorn
- Division of Pulmonary and Critical Care, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Miami, Miller School of Medicine, Miami, FL, USA
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Young J, Green J, Godfrey M, Smith J, Cheater F, Hulme C, Collinson M, Hartley S, Anwar S, Fletcher M, Santorelli G, Meads D, Hurst K, Siddiqi N, Brooker D, Teale E, Brown A, Forster A, Farrin A, Inouye S. The Prevention of Delirium system of care for older patients admitted to hospital for emergency care: the POD research programme including feasibility RCT. PROGRAMME GRANTS FOR APPLIED RESEARCH 2021. [DOI: 10.3310/pgfar09040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background
Delirium is a distressing, common and serious condition in older people in hospital. Evidence suggests that it could be prevented in about one-third of patients using multicomponent interventions targeting delirium risk factors, but these interventions are not yet routinely available in the NHS.
Objective
The objective was to improve delirium prevention for older people admitted to the NHS.
Design
Project 1 comprised case studies employing qualitative methods (observation, interviews, workshops) in three NHS hospitals to develop the Prevention of Delirium system of care. Project 2 comprised case studies using mixed methods in five NHS hospitals to test the Prevention of Delirium implementation, feasibility and acceptability, and to modify the Prevention of Delirium system of care. Project 3 comprised a multicentre, cluster randomised, controlled, pragmatic feasibility study in eight hospitals, with embedded economic evaluation, to investigate the potential clinical effectiveness and cost-effectiveness of the Prevention of Delirium system of care, compared with standard care, among older patients admitted to hospital for emergency care. The primary objectives related to gathering information to design a definitive trial. Criteria for progression to a definitive trial were as follows: a minimum of six wards (75%) completing the Prevention of Delirium manual milestone checklist and an overall recruitment rate of at least 10% of the potential recruitment pool.
Setting
This study was set in NHS general hospitals.
Participants
In project 1, participants were staff, volunteers, and patient and carer representatives. In project 2, participants were staff, volunteers, patients and carers. In project 3, participants were older patients admitted to elderly care and orthopaedic trauma wards.
Intervention
The developed intervention (i.e. the Prevention of Delirium system of care).
Main outcome measures
For the feasibility study (project 3), the primary outcome measure was the Confusion Assessment Method. The secondary outcome measures were the Nottingham Extended Activities of Daily Living scale, the Clinical Anxiety Scale and the Geriatric Depression Scale Short Form.
Results
Project 1: understanding of delirium prevention was poor. Drawing on evidence, and working with ward teams, we developed the Prevention of Delirium system of care, which targeted 10 delirium risk factors. This multicomponent intervention incorporated systems and mechanisms to introduce and embed delirium prevention into routine ward practices. Project 2: five out of six wards implemented or partially implemented the Prevention of Delirium intervention. A prominent role for hospital volunteers was intended, but most wards were unable to recruit or sustain the numbers needed. We identified four conditions necessary to implement and deliver the Prevention of Delirium intervention: (1) commitment of senior nurse, (2) a named person to drive implementation forward, (3) dedicated time (1 day per week) of an experienced nurse to lead implementation and (4) adequate ward staffing levels. Overall, the intervention was acceptable to staff, volunteers, patients and carers, and did not increase nursing staff workload. In the light of these findings, the Prevention of Delirium system of care was modified for use in project 3. Project 3: 16 wards in eight hospitals (two wards per hospital) were recruited. Out of 4449 patients screened, 3274 (73.6%) were eligible and 713 were registered, resulting in a recruitment rate of 16.0%. Thirty-three (4.6%) participants withdrew. The screened and registered participants were similar, but some between-treatment group imbalances were noted among those registered to the trial. All eight wards allocated to the intervention group completed the Prevention of Delirium manual milestone checklist and delivered the Prevention of Delirium intervention (median time 18.6 weeks for implementation). Overall, fidelity to the intervention was assessed as being high in two wards, medium in five wards and low in one ward. Of the expected 5645 Confusion Assessment Method delirium assessments, 5065 (89.7%) were completed during the first 10 days of admission. The rates of return of the patient-reported questionnaire booklets were 98.0% at baseline, 81.8% at 30 days and 70.5% at 3 months. The return rate of the EuroQol-5 Dimensions questionnaire was 98.6% at baseline, 77.5% at 1 month and 65.3% at 3 months (94–98% fully completed). The completion rate of the resource use questionnaire was lower (48.7%). The number of people with new-onset delirium at 10 days was 24 (7.0%) in the Prevention of Delirium group and 33 (8.9%) in the control group. Multilevel logistic regression analysis showed that participants in the Prevention of Delirium group had non-significant lower odds of developing delirium (odds ratio 0.68, 95% confidence interval 0.37 to 1.26; p = 0.2225). The average cost of the Prevention of Delirium intervention was estimated as £10.98 per patient and the mean costs for the Prevention of Delirium and usual-care groups were £5332 and £4412, respectively, with negligible between-group differences in quality-adjusted life-years. There was conflicting evidence from the trial- and model-based analyses relating to the cost-effectiveness of the Prevention of Delirium intervention. Given this, and in view of issues with the data (e.g. high levels of missingness), the results from the economic evaluation are highly uncertain. The criteria for continuation to a future definitive randomised controlled trial were met. Such a trial would need to recruit 5200 patients in 26 hospital clusters (200 patients per cluster).
Conclusions
The Prevention of Delirium system of care was successfully developed, and a multicentre feasibility study showed that the intervention is capable of implementation and delivery in routine care, with acceptable intervention fidelity and preliminary estimate of effectiveness.
Limitations
A prominent role for volunteers was originally intended in the Prevention of Delirium system of care, but only three of the eight wards allocated to the trial intervention group involved volunteers.
Future work
The findings indicate that a definitive multicentre evaluation of the Prevention of Delirium system of care should be designed and conducted to obtain robust estimates of clinical effectiveness and cost-effectiveness.
Trial registration
Current Controlled Trials ISRCTN28213290 (project 1), ISRCTN65924234 (project 2) and ISRCTN01187372 (project 3).
Funding
This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 4. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- John Young
- Academic Unit for Ageing and Stroke Research, University of Leeds, Leeds, UK
| | - John Green
- Academic Unit for Ageing and Stroke Research, University of Leeds, Leeds, UK
| | - Mary Godfrey
- Academic Unit for Ageing and Stroke Research, University of Leeds, Leeds, UK
| | - Jane Smith
- Academic Unit for Ageing and Stroke Research, University of Leeds, Leeds, UK
| | - Francine Cheater
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Claire Hulme
- College of Medicine and Health, University of Exeter, Exeter, UK
| | | | - Suzanne Hartley
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Shamaila Anwar
- National Institute for Health Research Clinical Research Network, Huddersfield, UK
| | - Marie Fletcher
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | | | - David Meads
- Academic Unit of Health Economics, University of Leeds, Leeds, UK
| | | | - Najma Siddiqi
- Department of Health Sciences, University of York, Hull York Medical School, York, UK
| | - Dawn Brooker
- Association for Dementia Studies, University of Worcester, Worcester, UK
| | - Elizabeth Teale
- Academic Unit for Ageing and Stroke Research, University of Leeds, Leeds, UK
| | - Alex Brown
- Elderly and Intermediate Care Service, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Anne Forster
- Academic Unit for Ageing and Stroke Research, University of Leeds, Leeds, UK
| | - Amanda Farrin
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Sharon Inouye
- Harvard Medical School, Beth Israel Deaconess Medical Center, Marcus Institute for Aging Research, Boston, MA, USA
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9
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Abstract
Opioids are strong analgesics widely employed to treat various types of pain. In 2018, an estimated 168 million opioid prescriptions were dispensed in the United States. Opioids carry a number of side effects and up to 80% of patients treated with opioids experience a minimum of one adverse event. Although uncommon, hallucinosis is an effect experienced with opioids, which may be under-reported and attributed to underlying psychiatric disease rather than to the side effects of the opioid itself. Most of the opioid-induced hallucinoses reported are auditory and visual, and rarely tactile. Although opioid medication prescribing is decreasing in the United States, considering the continued opioid epidemic and deaths related to overdose, it is important for physicians to be aware of this potential adverse effect of opioids in isolation. We present a case of oral hydromorphone causing visual and tactile hallucinations. Discontinuing hydromorphone led to immediate cessation of the patient’s psychotic signs and symptoms. To our knowledge, this is the first description of the use of hydromorphone resulting in tactile hallucinations.
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Affiliation(s)
- Miki Kiyokawa
- Psychiatry, University of Hawaii John A. Burns School of Medicine, Honolulu, USA.,Internal Medicine, University of Hawaii John A. Burns School of Medicine, Honolulu, USA
| | - William F Haning
- Psychiatry, University of Hawaii John A. Burns School of Medicine, Honolulu, USA
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10
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Mortensen CB, Poulsen LM, Andersen‐Ranberg NC, Perner A, Lange T, Estrup S S, Ebdrup BH, Egerod I, Rasmussen BS, Hästbacka J, Caballero J, Citerio G, Morgan MP, Samuelson K, Mathiesen O. Mortality and HRQoL in ICU patients with delirium: Protocol for 1-year follow-up of AID-ICU trial. Acta Anaesthesiol Scand 2020; 64:1519-1525. [PMID: 33460045 DOI: 10.1111/aas.13679] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 07/18/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Intensive care unit (ICU)-acquired delirium is frequent and associated with poor short- and long-term outcomes for patients in ICUs. It therefore constitutes a major healthcare problem. Despite limited evidence, haloperidol is the most frequently used pharmacological intervention against ICU-acquired delirium. Agents intervening against Delirium in the ICU (AID-ICU) is an international, multicentre, randomised, blinded, placebo-controlled trial investigates benefits and harms of treatment with haloperidol in patients with ICU-acquired delirium. The current pre-planned one-year follow-up study of the AID-ICU trial population aims to explore the effects of haloperidol on one-year mortality and health related quality of life (HRQoL). METHODS The AID-ICU trial will include 1000 participants. One-year mortality will be obtained from the trial sites; we will validate the vital status of Danish participants using the Danish National Health Data Registers. Mortality will be analysed by Cox-regression and visualized by Kaplan-Meier curves tested for significance using the log-rank test. We will obtain HRQoL data using the EQ-5D instrument. HRQoL analysis will be performed using a general linear model adjusted for stratification variables. Deceased participants will be designated the worst possible value. RESULTS We expect to publish results of this study in 2022. CONCLUSION We expect that this one-year follow-up study of participants with ICU-acquired delirium allocated to haloperidol vs. placebo will provide important information on the long-term consequences of delirium including the effects of haloperidol. We expect that our results will improve the care of this vulnerable patient group.
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Affiliation(s)
- Camilla B. Mortensen
- Department of Anaesthesiology and Intensive Care Medicine Centre for Anaesthesiological ResearchZealand University Hospital Koege Denmark
| | - Lone M. Poulsen
- Department of Anaesthesiology and Intensive Care Medicine Centre for Anaesthesiological ResearchZealand University Hospital Koege Denmark
- Centre for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Nina C. Andersen‐Ranberg
- Department of Anaesthesiology and Intensive Care Medicine Centre for Anaesthesiological ResearchZealand University Hospital Koege Denmark
- Centre for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Anders Perner
- Centre for Research in Intensive Care (CRIC) Copenhagen Denmark
- Department of Intensive Care, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Theis Lange
- Centre for Research in Intensive Care (CRIC) Copenhagen Denmark
- Department of Public Health Section of Biostatistics University of Copenhagen Copenhagen Denmark
| | - Stine Estrup S
- Department of Anaesthesiology and Intensive Care Medicine Centre for Anaesthesiological ResearchZealand University Hospital Koege Denmark
| | - Bjørn H. Ebdrup
- Centre for Neuropsychiatric Schizophrenia Research (CNSR) & Centre for Clinical Intervention and Neuropsychiatric Schizophrenia Research (CINS) Mental Health Centre GlostrupUniversity of Copenhagen Glostrup Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Ingrid Egerod
- Centre for Research in Intensive Care (CRIC) Copenhagen Denmark
- Department of Intensive Care, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Bodil S. Rasmussen
- Department of Clinical Medicine Aalborg University Hospital Aalborg Denmark
| | - Johanna Hästbacka
- Department of Anaesthesiology Helsinki University Hospital Helsinki Finland
| | - Jesús Caballero
- University Hospital Arnau de VilanovaLeida‐IRBUniversita Autonóma de Barcelona‐UAB Barcelona Spain
| | | | | | - Karin Samuelson
- Division of Nursing Dep of Health Sciences Lund University Lund Sweden
| | - Ole Mathiesen
- Department of Anaesthesiology and Intensive Care Medicine Centre for Anaesthesiological ResearchZealand University Hospital Koege Denmark
- Department of Clinical Medicine Aalborg University Hospital Aalborg Denmark
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11
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Deemer K, Zjadewicz K, Fiest K, Oviatt S, Parsons M, Myhre B, Posadas-Calleja J. Effect of early cognitive interventions on delirium in critically ill patients: a systematic review. Can J Anaesth 2020; 67:1016-1034. [PMID: 32333291 PMCID: PMC7222136 DOI: 10.1007/s12630-020-01670-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 02/10/2020] [Accepted: 03/09/2020] [Indexed: 11/30/2022] Open
Abstract
PURPOSE A systematic review of the literature was conducted to determine the effects of early cognitive interventions on delirium outcomes in critically ill patients. SOURCE Search strategies were developed for MEDLINE, EMBASE, Joanna Briggs Institute, Cochrane, Scopus, and CINAHL databases. Eligible studies described the application of early cognitive interventions for delirium prevention or treatment within any intensive care setting. Study designs included randomized-controlled trials, quasi-experimental trials, and pre/post interventional trials. Two reviewers independently extracted data and assessed risk of bias using Cochrane methodology. PRINCIPAL FINDINGS Four hundred and four citations were found. Seven full-text articles were included in the final review. Six of the included studies had an overall serious, high, or critical risk of bias. After application of cognitive intervention protocols, a significant reduction in delirium incidence, duration, occurrence, and development was found in four studies. Feasibility of cognitive interventions was measured in three studies. Cognitive stimulation techniques were described in the majority of studies. CONCLUSION The study of early cognitive interventions in critically ill patients was identified in a small number of studies with limited sample sizes. An overall high risk of bias and variability within protocols limit the utility of the findings for widespread practice implications. This review may help to promote future large, multi-centre trials studying the addition of cognitive interventions to current delirium prevention practices. The need for robust data is essential to support the implementation of early cognitive interventions protocols.
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Affiliation(s)
- Kirsten Deemer
- Department of Critical Care Medicine, Alberta Health Services, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
| | | | - Kirsten Fiest
- Department of Critical Care Medicine, Alberta Health Services, Calgary, AB, Canada
- Cumming School of Medicine, University of Calgary, South Health Campus ICU, 4448 Front St SE, Calgary, AB, T3M 1M4, Canada
| | | | - Michelle Parsons
- Department of Critical Care Medicine, Alberta Health Services, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
| | | | - Juan Posadas-Calleja
- Department of Critical Care Medicine, Alberta Health Services, Calgary, AB, Canada.
- Alberta Health Services, Calgary, AB, Canada.
- Cumming School of Medicine, University of Calgary, South Health Campus ICU, 4448 Front St SE, Calgary, AB, T3M 1M4, Canada.
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12
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Zrour C, Haddad R, Zoghbi M, Kharsa Z, Hijazi M, Naja W. Prospective, multi-centric benchmark study assessing delirium: prevalence, incidence and its correlates in hospitalized elderly Lebanese patients. Aging Clin Exp Res 2020; 32:689-697. [PMID: 31203529 DOI: 10.1007/s40520-019-01242-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 06/05/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND With the increase in the proportion of elderly Lebanese patients, little is known about delirium's prevalence, incidence and correlated factors. AIMS To identify the prevalence, incidence and factors associated with overall and incident delirium in hospitalized elderly Lebanese patients. METHODS A convenient sample was recruited from three university hospitals affiliated to the Lebanese university faculty of medical sciences. We included patients aged more than 65 years. Baseline factors were examined upon presentation and the confusion assessment method (CAM) was used to detect prevalent delirium upon admission or within the first 48 h. Enrolled patients were then assessed every other day to detect incident delirium cases. RESULTS Among the 230 patients included, delirium prevalence was 17% and incidence 8.7%. We found that a history of falls (odds ratio (OR) = 5.12; p = 0.001), immobilization (OR = 7.33; p = 0.035), polypharmacy (OR = 5.07; p = 0.026) along with tachycardia (OR = 6.94; p = 0.03) and severe anemia (OR = 12.5; p = 0.005) upon admission were significant factors associated with overall delirium (incident and prevalent delirium cases). Whereas, living alone was significantly associated with lower odds for overall delirium (OR = 0.03; p = 0.02). Moreover, current smoking (OR = 14; p = 0.02), low oxygen saturation (OR = 9.6; p = 0.008) and severe anemia (OR = 8.4; p = 0.013) upon admission remained significantly associated with higher odds for incident delirium along with urine catheter placement (OR = 7.8; p = 0.015). CONCLUSION Secondary to the burden of delirium and its impact on mortality among elderly population, trying to understand and adjust modifiable factors would promote more appropriate prevention strategies.
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Affiliation(s)
- Carmen Zrour
- Psychiatry Department, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon. .,, Boulevard de Smet de Naeyer 414, Jette 1090, Brussels, Belgium.
| | - Ramzi Haddad
- Psychiatry Department, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
| | - Marouan Zoghbi
- Family Medicine Department, Faculty of Medical Sciences, Saint Joseph University, Beirut, Lebanon
| | - Zahraa Kharsa
- Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
| | - Mariam Hijazi
- Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
| | - Wadih Naja
- Psychiatry Department, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
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13
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Abdelrahman I, Vieweg R, Irschik S, Steinvall I, Sjöberg F, Elmasry M. Development of delirium: Association with old age, severe burns, and intensive care. Burns 2020; 46:797-803. [PMID: 32183993 DOI: 10.1016/j.burns.2020.02.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 02/17/2020] [Accepted: 02/25/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Delirium is defined as a disturbance of attention and awareness that develops over a short period of time, is a change from the baseline, and typically fluctuates over time. Burn care involves a high prevalence of known risk factors for delirium such as sedation, inflammation, and prolonged stay in hospital. Our aim was to explore the extent of delirium and the impact of factors associated with it for adult patients who have been admitted to hospital with burns. METHODS In this retrospective study, all adult patients who had been admitted with burns during a four-year period were studied, including both those who were treated with intensive care and intermediate care only (no intensive care). Daily records of the assessment of delirium using the Nursing Delirium Screening Scale (Nu-DESC) were analysed together with age, sex, the percentage of total body surface area burned, operations, and numbers of wound care procedures under anaesthesia, concentrations of plasma C-reactive protein, and other clinical variables. Logistic regression was used to analyse factors that were associated with delirium and its effect on mortality, and linear regression was used to analyse its effect on the duration of hospital stay. RESULTS Fifty-one patients (19%) of the total 262 showed signs of delirium (Nu-DESC score of 2 or more) at least once during their stay in hospital. Signs of delirium were recorded in 42/89 patients (47%) who received intensive care, and in 9/173 (5%) who had intermediate care. Independent factors for delirium in the multivariable regression were: age over 74 years; number of operations and wound care procedures under anaesthesia; and the provision of intensive care (area under the curve 0.940, 95% CI 0.899-0.981). Duration of hospital stay, adjusted for age and burn size, was 13.2 (95% CI 7.4-18.9, p < 0.001) days longer in the group who had delirium. We found no independent effects of delirium on mortality. CONCLUSION We found a strong association between delirium and older age, provision ofr intensive care, and number of interventions under anaesthesia. A further 5% of patients who did not receive intensive care also showed signs of delirium, which is a finding that deserves to be thoroughly investigated in the future.
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Affiliation(s)
- Islam Abdelrahman
- Department of Hand Surgery, Plastic Surgery and Burns, and Department of Biomedical and Clinical Sciences Linköping University, Linköping, Sweden.
| | - Rosa Vieweg
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden; Department of Anaesthesiology and Intensive Care, Linköping University, Linköping, Sweden
| | - Stefan Irschik
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Ingrid Steinvall
- Department of Hand Surgery, Plastic Surgery and Burns, and Department of Biomedical and Clinical Sciences Linköping University, Linköping, Sweden
| | - Folke Sjöberg
- Department of Hand Surgery, Plastic Surgery and Burns, and Department of Biomedical and Clinical Sciences Linköping University, Linköping, Sweden; Department of Anaesthesiology and Intensive Care, Linköping University, Linköping, Sweden
| | - Moustafa Elmasry
- Department of Hand Surgery, Plastic Surgery and Burns, and Department of Biomedical and Clinical Sciences Linköping University, Linköping, Sweden
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14
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Li Y, Ma J, Jin Y, Li N, Zheng R, Mu W, Wang J, Si JH, Chen J, Shang HC. Benzodiazepines for treatment of patients with delirium excluding those who are cared for in an intensive care unit. Cochrane Database Syst Rev 2020; 2:CD012670. [PMID: 32108325 PMCID: PMC7047222 DOI: 10.1002/14651858.cd012670.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Delirium is a very common condition associated with significant morbidity, mortality, and costs. Current critical care guidelines recommend first and foremost the use of nonpharmacological strategies in both the prevention and treatment of delirium. Pharmacological interventions may augment these approaches and they are currently used widely in clinical practice to manage the symptoms of delirium. Benzodiazepines are currently used in clinical practice to treat behavioural disturbances associated with delirium but current guidelines do not recommend their use for this indication. The use of these medicines is controversial because there is uncertainty about whether they are effective for patients or have the potential to harm them. OBJECTIVES To assess the effectiveness and safety of benzodiazepines in the treatment of delirium (excluding delirium related to withdrawal from alcohol or benzodiazepines) in any healthcare settings other than intensive care units (ICU). SEARCH METHODS We searched ALOIS: the Cochrane Dementia and Cognitive Improvement Group's Specialized Register up to 10 April 2019. ALOIS contains records of clinical trials identified from monthly searches of a number of major healthcare databases (including MEDLINE, Embase, PsycINFO, CINAHL, LILACS), numerous trial registries (including national, international and pharmaceutical registries), and grey literature sources. SELECTION CRITERIA We included randomised controlled trials (RCTs) conducted in healthcare settings that ranged from nursing homes and long-term care facilities to any hospital setting except for ICUs, involving adult patients with delirium excluding those with delirium related to alcohol or benzodiazepine withdrawal. Included RCTs had to assess the effect of benzodiazepines, at any dose and given by any route, compared with placebo or another drug intended to treat delirium. DATA COLLECTION AND ANALYSIS Two review authors independently assessed study eligibility, extracted data, and assessed the risk of bias of included studies. We decided whether or not to pool data on the basis of clinical heterogeneity between studies. We used GRADE (Grades of Recommendation, Assessment, Development and Evaluation) methods to assess the quality of evidence. MAIN RESULTS We identified only two trials that satisfied the selection criteria. We did not pool the data because of the substantial clinical differences between the trials. In one trial, participants (n = 58) were patients in an acute palliative care unit with advanced cancer who had a mean age of 64 years. All of the participants had delirium, were treated with haloperidol, and were randomised to receive either lorazepam or placebo in combination with it. Due to very serious imprecision, all evidence was of low certainty. We were unable to determine whether there were clinically important differences in the severity of delirium (mean difference (MD) 2.10, 95% CI -0.96 to 5.16; n = 50), length of hospital admission (MD 0.00, 95% CI -3.45 to 3.45; n = 58), mortality from all causes (risk ratio (RR) 0.33, 95% CI 0.04 to 3.02; participants = 58) or any of a number of adverse events. Important effects could not be confirmed or excluded. The study authors did not report the length of the delirium episode. In the other trial, participants (n = 30) were patients in general medical wards with acquired immune deficiency syndrome (AIDS) who had a mean age of 39.2 years. Investigators compared three drug treatments: all participants had delirium, and were randomised to receive lorazepam, chlorpromazine, or haloperidol. Very low-certainty evidence was identified, and we could not determine whether lorazepam differed from either of the other treatments in the effect on severity of delirium, any adverse event, or mortality from all causes. The study authors did not report the length of the delirium episode or the length of hospital admission. AUTHORS' CONCLUSIONS There is no enough evidence to determine whether benzodiazepines are effective when used to treat patients with delirium who are cared for in non-ICU settings. The available evidence does not support their routine use for this indication. Because of the scarcity of data from randomised controlled trials, further research is required to determine whether or not there is a role for benzodiazepines in the treatment of delirium in non-ICU settings.
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Affiliation(s)
- Yan Li
- Beijing Anzhen Hospital, Capital Medical UniversityCenter for AnesthesiologyNo.2 Anzhen RoadChaoyang DistrictBeijingBeijingChina100029
| | - Jun Ma
- Beijing Anzhen Hospital, Capital Medical UniversityCenter for AnesthesiologyNo.2 Anzhen RoadChaoyang DistrictBeijingBeijingChina100029
| | - Yinghui Jin
- Tianjin University of Traditional Chinese MedicineNursing#312 West Anshan RoadTianjinChina
| | - Nan Li
- Tianjin University of Traditional Chinese MedicineTianjin Insititute of Clinical Evaluation#88 Yuquan RoadNankai DistrictTianjinTianjinChina300193
| | - Rui Zheng
- Tianjin University of Traditional Chinese MedicineTianjin Insititute of Clinical Evaluation#88 Yuquan RoadNankai DistrictTianjinTianjinChina300193
| | - Wei Mu
- The 2nd Affiliated Hospital of Tianjin University of traditional Chinese MedicineClinical pharmacology861 Zhenli RoadHebei DistrictTianjinTianjinChina300150
| | - Jiaying Wang
- The Affiliated Wuxi People’s Hospital of Nanjing Medical UniversityRehabilitation and AcupunctureNo.299, Qingyang Road, Liangxi DistrictWuxiJiangsuChina214000
| | - Jin Hua Si
- Tianjin University of Traditional Chinese MedicineLibrary#88 Yuquan RoadNankai DistrictTianjinTianjinChina300193
| | - Jing Chen
- Tianjin University of Traditional Chinese MedicineBaokang Hospital#88 Yuquan RoadNankai DistrictTianjinTianjinChina300193
| | - Hong Cai Shang
- Dongzhimen Hospital, Beijing University of Chinese MedicineKey Laboratory of Chinese Internal Medicine of Ministry of EducationHaiyuncang Lane, Dongcheng DistrictBeijingChina100700
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15
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Gloger AN, Nakonezny PA, Phelan HA. Use of Tailored Feedback Improves Accuracy of Delirium Documentation in the Burn ICU: Results of a Performance Improvement Initiative. J Burn Care Res 2020; 41:299-305. [PMID: 31504614 DOI: 10.1093/jbcr/irz153] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
One of the most widely used tools for delirium assessment in burn intensive care units is the Confusion Assessment Method for the Intensive Care Unit delirium assessment tool. However, some nurses struggle with inaccurate delirium documentation. This performance improvement project was undertaken to assess the impact that routine chart audits with tailored feedback would have on documentation accuracy. An a priori goal of at least 90% documentation accuracy was set by burn leadership at our academic, American Burn Association-verified burn center. For the precorrectional feedback time period, nursing delirium documentation was reviewed for accuracy by the nurse educator. In the postcorrectional feedback time period, an intervention was started, in which the educator sent tailored feedback to nurses with inaccurate delirium documentation. A Poisson regression with robust standard errors was used to compare the proportions of correct delirium documentation for the precorrectional feedback and postcorrectional feedback time periods. The overall rates of correct delirium documentation in the precorrectional feedback time period were 49.15% (SD = 31.86), 95% CI: 36.43 to 66.31. A significant increase was seen in the rates of correct delirium documentation for the postcorrectional feedback time period (91.47% [SD = 8.28], 95% CI: 87.45 to 95.67), P = .0001. In the 4 months prior to starting corrective feedback, zero out of five (0%) audits reached the 90% goal of accurate delirium documentation. In the 8 months in which corrective feedback was being given, 9 out of 15 (60%) audits reached the compliance goal set by leadership. Using corrective feedback improves the accuracy of nursing delirium documentation.
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Affiliation(s)
- Amy N Gloger
- Department of Surgical Services, Parkland Health and Hospital System, Dallas, Texas
| | - Paul A Nakonezny
- Department of Surgery, University of Texas Southwestern Medical Branch, Dallas, Texas
| | - Herb A Phelan
- Department of Surgery, University of Texas Southwestern Medical Branch, Dallas, Texas
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16
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Iwata E, Kondo T, Kato T, Okumura T, Nishiyama I, Kazama S, Ishihara T, Kondo S, Hiraiwa H, Tsuda T, Ito M, Aoyama M, Tanimura D, Awaji Y, Unno K, Murohara T. Prognostic Value of Delirium in Patients With Acute Heart Failure in the Intensive Care Unit. Can J Cardiol 2020; 36:1649-1657. [PMID: 32615071 DOI: 10.1016/j.cjca.2020.01.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 01/07/2020] [Accepted: 01/10/2020] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Delirium is a common adverse event observed in patients admitted to the intensive care unit (ICU). However, the prognostic value of delirium and its determinants have not been thoroughly investigated in patients with acute heart failure (AHF). METHODS We investigated 408 consecutive patients with AHF admitted to the ICU. Delirium was diagnosed by means of the Confusion Assessment Method for ICU tool and evaluated every 8 hours during the patients' ICU stays. RESULTS Delirium occurred in 109 patients (26.7%), and the in-hospital mortality rate was significantly higher in patients with delirium (13.8% vs 2.3%; P < 0.001). Multivariate logistic regression analysis showed that delirium independently predicted in-hospital mortality (odds ratio [OR] 4.33, confidence interval [CI] 1.62-11.52; P = 0.003). Kaplan-Meier analysis showed that the 12-month mortality rate was significantly higher in patients with delirium compared with those without (log-rank test: P < 0.001), and Cox proportional hazards analysis showed that delirium remained an independent predictor of 12-month mortality (hazard ratio 2.19, 95% CI 1.49-3.25; P < 0.001). The incidence of delirium correlated with severity of heart failure as assessed by means of the Get With The Guidelines-Heart Failure risk score (chi-square test: P = 0.003). Age (OR 1.05, 95% CI 1.02-1.09; P = 0.003), nursing home residential status (OR 3.32, 95% CI 1.59-6.94; P = 0.001), and dementia (OR 5.32, 95% CI 2.83-10.00; P < 0.001) were independently associated with the development of delirium. CONCLUSIONS Development of delirium during ICU stay is associated with short- and long-term mortality and is predicted by the severity of heart failure, nursing home residential, and dementia status.
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Affiliation(s)
- Etsuo Iwata
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan; Department of Cardiology, Nagoya Ekisaikai Hospital, Nagoya, Aichi, Japan
| | - Toru Kondo
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan.
| | - Toshiaki Kato
- Department of Cardiology, Nagoya Ekisaikai Hospital, Nagoya, Aichi, Japan
| | - Takahiro Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Itsumure Nishiyama
- Department of Cardiology, Nagoya Ekisaikai Hospital, Nagoya, Aichi, Japan
| | - Shingo Kazama
- Department of Cardiology, Nagoya Ekisaikai Hospital, Nagoya, Aichi, Japan
| | - Toshikazu Ishihara
- Department of Cardiology, Nagoya Ekisaikai Hospital, Nagoya, Aichi, Japan
| | - Sayano Kondo
- Department of Cardiology, Nagoya Ekisaikai Hospital, Nagoya, Aichi, Japan
| | - Hiroaki Hiraiwa
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Takuma Tsuda
- Department of Cardiology, Nagoya Ekisaikai Hospital, Nagoya, Aichi, Japan
| | - Masanori Ito
- Department of Cardiology, Nagoya Ekisaikai Hospital, Nagoya, Aichi, Japan
| | - Morihiko Aoyama
- Department of Cardiology, Nagoya Ekisaikai Hospital, Nagoya, Aichi, Japan
| | - Daisuke Tanimura
- Department of Cardiology, Nagoya Ekisaikai Hospital, Nagoya, Aichi, Japan
| | - Yoshifumi Awaji
- Department of Cardiology, Nagoya Ekisaikai Hospital, Nagoya, Aichi, Japan
| | - Kazumasa Unno
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
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17
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Clinical management of delirium: The response depends on the subtypes. An observational cohort study in 602 patients. Palliat Support Care 2019; 18:4-11. [PMID: 31506133 DOI: 10.1017/s1478951519000609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The hypoactive, hyperactive, and mixed subtypes of delirium differently impact patient management and prognosis, yet the evidence remains sparse. Therefore, we examined the outcome of varying management strategies in the subtypes of delirium. METHODS In this observational cohort study, 602 patients were managed for delirium over 20 days with the following strategies: supportive care alone or in combination with psychotropics, single, dual, or triple+ psychotropic regimens. Cox regression models were calculated for time to remission and benefit rates (BRs) of management strategies. RESULTS Generally, the mixed subtype of delirium caused more severe and persistent delirium, and the hypoactive subtype was more persistent than the hyperactive subtype. The subtypes of delirium were similarly predictive for mortality (P = 0.697) and transfer to inpatient psychiatric care (P = 0.320). In the mixed subtype, overall, psychotropic drugs were administered more often (P = 0.016), and particularly triple+ regimens were administered more commonly compared to hypoactive delirium (P = 0.007). Patients on supportive care benefited most, whereas those on triple+ regimens did worst in terms of remission in all groups of hypoactive, hyperactive, and mixed subtypes (BR: 4.59, CI 2.01-10.48; BR: 4.59, CI 1.76-31.66; BR: 3.36, CI 1.73-6.52; all P < 0.05). SIGNIFICANCE OF RESULTS The mixed subtype was more persistent to management than the hypoactive and hyperactive subtypes. Delirium management remains controversial and, generally, supportive care benefited patients most. Psychopharmacological management for delirium requires careful choosing of and limiting the number of psychotropics.
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Çınar F, Eti Aslan F. Evaluation of Postoperative Delirium: Validity and Reliability of the Nursing Delirium Screening Scale in the Turkish Language. Dement Geriatr Cogn Dis Extra 2019; 9:362-373. [PMID: 31911787 PMCID: PMC6940440 DOI: 10.1159/000501903] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 07/03/2019] [Indexed: 12/30/2022] Open
Abstract
PURPOSE Postoperative delirium is the most well-known form of postoperative cognitive impairment in all patient groups, especially in the elderly. Delirium is a syndrome that causes serious consequences, increasing mortality and morbidity rates and extending the length of hospital stay. The aim of this study was to evaluate the validity and reliability of the Turkish version of the Nursing Delirium Screening Scale (Nu-DESC). METHOD One hundred twelve patients who were hospitalized for a surgical operation in the orthopedics, neurosurgery, and general surgery clinic of a state hospital for 3 months were evaluated concurrently (and independently for delirium). Patients were observed by clinical nurses 3 times over a 24-h period. The presence of delirium was diagnosed by 2 neurologists according to DSM-IV criteria. Student's t test, the χ2 test, and the Mann-Whitney U test were used, and construct validity, intrascale factor analysis, interrater reliability, and specificity and sensitivity (ROC) analyses were performed for descriptive analysis. SPSS 25.0 and MedCalc18.6 were used for statistical analysis. RESULTS Delirium was detected in 28 patients according to the Nu-DESC. The ICC (intraclass correlation) is 0.97 in the 95% confidence interval from 0.96 to 0.98 for agreement between nurses and neurologists for the total Nu-DESC score. Weighted κ rates were between 0.78 and 0.92. In the ROC analysis of the Nu-DESC scale, the optimum cutoff value calculated for the 1,344 observations and 112 patients was determined as >1 according to the maximum sensitivity and the specific situation. Sensitivity at the cut-off point was 92.27; specificity was determined as 92.72. The Youden index was found to be J = 0.845 (0 < J = 0.845 < 1). CONCLUSION We believe that Turkish translation of Nu-DESC is valid and reliable for clinicians, nurses, and researchers and will contribute to delirium studies.
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Affiliation(s)
- Fadime Çınar
- Sabahattin Zaim University, Faculty of Health Sciences, Istanbul, Turkey
| | - Fatma Eti Aslan
- Bahçeşehir University, Faculty of Health Sciences, Istanbul, Turkey
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Kahl KG, Eckermann G, Frieling H, Hillemacher T. Psychopharmacology in transplantation medicine. Prog Neuropsychopharmacol Biol Psychiatry 2019; 88:74-85. [PMID: 30018020 DOI: 10.1016/j.pnpbp.2018.07.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 06/07/2018] [Accepted: 07/05/2018] [Indexed: 12/18/2022]
Abstract
Organ transplantation has become a well-established treatment option in patients with end-stage organ diseases. Although quality of life has markedly improved, psychiatric disorders before and after transplantation are more frequent compared to the general population. Psychopharmacological treatment is recommended for almost all mental disorders according to current guidelines, but may pose particular problems in organ transplant patients. Changes in the metabolism and elimination of drugs during organ insufficiency, drug interactions, and overlapping side effects between psychopharmacological and immunosuppressive drugs are challenging problems in clinical management. Furthermore, questions frequently arise concerning the use of psychopharmacological treatment options for sleeping and anxiety disorders. This article reviews psychopharmacology in organ transplant patients, with particular attention to frequent psychiatric disorders observed in the disease course of end-stage organ diseases.
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Affiliation(s)
- Kai G Kahl
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Medical School, Hannover, Germany; Section Polypharmacy, Working Group on Neuropsychopharmacology and Pharmacopsychiatry (AGNP), Germany.
| | - Gabriel Eckermann
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Medical School, Hannover, Germany; Section Polypharmacy, Working Group on Neuropsychopharmacology and Pharmacopsychiatry (AGNP), Germany
| | - Helge Frieling
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Medical School, Hannover, Germany
| | - Thomas Hillemacher
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Medical School, Hannover, Germany; Department of Psychiatry and Psychotherapy, Klinikum Nürnberg, Universitätsklinik der Paracelsus Medizinischen Privatuniversität, Germany
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Herling SF, Greve IE, Vasilevskis EE, Egerod I, Bekker Mortensen C, Møller AM, Svenningsen H, Thomsen T. Interventions for preventing intensive care unit delirium in adults. Cochrane Database Syst Rev 2018; 11:CD009783. [PMID: 30484283 PMCID: PMC6373634 DOI: 10.1002/14651858.cd009783.pub2] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Delirium is defined as a disturbance in attention, awareness and cognition with reduced ability to direct, focus, sustain and shift attention, and reduced orientation to the environment. Critically ill patients in the intensive care unit (ICU) frequently develop ICU delirium. It can profoundly affect both them and their families because it is associated with increased mortality, longer duration of mechanical ventilation, longer hospital and ICU stay and long-term cognitive impairment. It also results in increased costs for society. OBJECTIVES To assess existing evidence for the effect of preventive interventions on ICU delirium, in-hospital mortality, the number of delirium- and coma-free days, ventilator-free days, length of stay in the ICU and cognitive impairment. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, BIOSIS, International Web of Science, Latin American Caribbean Health Sciences Literature, CINAHL from 1980 to 11 April 2018 without any language limits. We adapted the MEDLINE search for searching the other databases. Furthermore, we checked references, searched citations and contacted study authors to identify additional studies. We also checked the following trial registries: Current Controlled Trials; ClinicalTrials.gov; and CenterWatch.com (all on 24 April 2018). SELECTION CRITERIA We included randomized controlled trials (RCTs) of adult medical or surgical ICU patients receiving any intervention for preventing ICU delirium. The control could be standard ICU care, placebo or both. We assessed the quality of evidence with GRADE. DATA COLLECTION AND ANALYSIS We checked titles and abstracts to exclude obviously irrelevant studies and obtained full reports on potentially relevant ones. Two review authors independently extracted data. If possible we conducted meta-analyses, otherwise we synthesized data narratively. MAIN RESULTS The electronic search yielded 8746 records. We included 12 RCTs (3885 participants) comparing usual care with the following interventions: commonly used drugs (four studies); sedation regimens (four studies); physical therapy or cognitive therapy, or both (one study); environmental interventions (two studies); and preventive nursing care (one study). We found 15 ongoing studies and five studies awaiting classification. The participants were 48 to 70 years old; 48% to 74% were male; the mean acute physiology and chronic health evaluation (APACHE II) score was 14 to 28 (range 0 to 71; higher scores correspond to more severe disease and a higher risk of death). With the exception of one study, all participants were mechanically ventilated in medical or surgical ICUs or mixed. The studies were overall at low risk of bias. Six studies were at high risk of detection bias due to lack of blinding of outcome assessors. We report results for the two most commonly explored approaches to delirium prevention: pharmacologic and a non-pharmacologic intervention.Haloperidol versus placebo (two RCTs, 1580 participants)The event rate of ICU delirium was measured in one study including 1439 participants. No difference was identified between groups, (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.87 to 1.17) (moderate-quality evidence). Haloperidol versus placebo neither reduced or increased in-hospital mortality, (RR 0.98, 95% CI 0.80 to 1.22; 2 studies; 1580 participants (moderate-quality evidence)); the number of delirium- and coma-free days, (mean difference (MD) -0.60, 95% CI -1.37 to 0.17; 2 studies, 1580 participants (moderate-quality of evidence)); number of ventilator-free days (mean 23.8 (MD -0.30, 95% CI -0.93 to 0.33) 1 study; 1439 participants, (high-quality evidence)); length of ICU stay, (MD 0.18, 95% CI -0.60 to 0.97); 2 studies, 1580 participants; high-quality evidence). None of the studies measured cognitive impairment. In one study there were three serious adverse events in the intervention group and five in the placebo group; in the other there were five serious adverse events and three patients died, one in each group. None of the serious adverse events were judged to be related to interventions received (moderate-quality evidence).Physical and cognitive therapy interventions (one study, 65 participants)The study did not measure the event rate of ICU delirium. A physical and cognitive therapy intervention versus standard care neither reduced nor increased in-hospital mortality, (RR 0.94, 95% CI 0.40 to 2.20, I² = 0; 1 study, 65 participants; very low-quality evidence); the number of delirium- and coma-free days, (MD -2.8, 95% CI -10.1 to 4.6, I² = 0; 1 study, 65 participants; very low-quality evidence); the number of ventilator-free days (within the first 28/30 days) was median 27.4 (IQR 0 to 29.2) and 25 (IQR 0 to 28.9); 1 study, 65 participants; very low-quality evidence, length of ICU stay, (MD 1.23, 95% CI -0.68 to 3.14, I² = 0; 1 study, 65 participants; very low-quality evidence); cognitive impairment measured by the MMSE: Mini-Mental State Examination with higher scores indicating better function, (MD 0.97, 95% CI -0.19 to 2.13, I² = 0; 1 study, 30 participants; very low-quality evidence); or measured by the Dysexecutive questionnaire (DEX) with lower scores indicating better function (MD -8.76, 95% CI -19.06 to 1.54, I² = 0; 1 study, 30 participants; very low-quality evidence). One patient experienced acute back pain accompanied by hypotensive urgency during physical therapy. AUTHORS' CONCLUSIONS There is probably little or no difference between haloperidol and placebo for preventing ICU delirium but further studies are needed to increase our confidence in the findings. There is insufficient evidence to determine the effects of physical and cognitive intervention on delirium. The effects of other pharmacological interventions, sedation, environmental, and preventive nursing interventions are unclear and warrant further investigation in large multicentre studies. Five studies are awaiting classification and we identified 15 ongoing studies, evaluating pharmacological interventions, sedation regimens, physical and occupational therapy combined or separately, and environmental interventions, that may alter the conclusions of the review in future.
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Affiliation(s)
- Suzanne Forsyth Herling
- Rigshospitalet, University of CopenhagenThe Neuroscience CentreBlegdamsvej 9CopenhagenDenmark2100
- Herlev and Gentofte Hospital, University of CopenhagenDepartment of AnaesthesiaHerlev Ringvej 75HerlevDenmark2730
| | - Ingrid E Greve
- Bispebjerg and Frederiksberg Hospitals, University of CopenhagenDepartment of Anaesthesia and Intensive careCopenhagenDenmark
| | - Eduard E Vasilevskis
- Division of General Internal Medicine and Public Health, Vanderbilt University and theTennessee Valley Geriatric Research, Education and Clinical Center (GRECC)Department of Medicine1215 21st Ave. S.6005 Medical Center East, NTNashvilleTNUSA37232‐8300
| | - Ingrid Egerod
- Rigshospitalet, University of CopenhagenIntensive Care Unit 4131Blegdamsvej 9Copenhagen ØDenmark2100
| | - Camilla Bekker Mortensen
- Zealand University HospitalIntensive Care Unit, Department of AnaesthesiologyLykkebækvej 1KøgeDenmark4600
| | - Ann Merete Møller
- Herlev and Gentofte Hospital, University of CopenhagenDepartment of AnaesthesiaHerlev Ringvej 75HerlevDenmark2730
- Herlev and Gentofte Hospital, University of CopenhagenCochrane AnaesthesiaHerlev RingvejHerlev Ringvej 75HerlevDenmark2730
- Herlev and Gentofte Hospital, University of CopenhagenCochrane Emergency and Critical CareHerlev Ringvej 75HerlevDenmark2730
| | - Helle Svenningsen
- VIA University CollegeFaculty of Health SciencesAarhus NDenmarkDK‐8200
| | - Thordis Thomsen
- Rigshospitalet, The Abdominal CentreDepartment of Nursing ResearchBlegdamsvej 9CopenhagenDenmark2200
- University of CopenhagenDepartment of Clinical MedicineCopenhagenDenmark
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Miranda F, Arevalo-Rodriguez I, Díaz G, Gonzalez F, Plana MN, Zamora J, Quinn TJ, Seron P. Confusion Assessment Method for the intensive care unit (CAM-ICU) for the diagnosis of delirium in adults in critical care settings. Hippokratia 2018. [DOI: 10.1002/14651858.cd013126] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Fabian Miranda
- Universidad de Chile; Department of Medicine; Santos Dumont 999 Santiago Chile 8380456
| | - Ingrid Arevalo-Rodriguez
- Universidad Tecnológica Equinoccial; Cochrane Ecuador. Centro de Investigación en Salud Pública y Epidemiología Clínica (CISPEC). Facultad de Ciencias de la Salud Eugenio Espejo; Av. Mariscal Sucre s/n y Av. Mariana de Jesús Quito Ecuador
- Hospital Universitario Ramon y Cajal (IRYCIS); Clinical Biostatistics Unit; Madrid Spain
- CIBER Epidemiology and Public Health (CIBERESP); Madrid Spain
| | - Gonzalo Díaz
- Universidad de Chile; Department of Medicine; Santos Dumont 999 Santiago Chile 8380456
| | - Francisco Gonzalez
- Universidad de Chile; Department of Medicine; Santos Dumont 999 Santiago Chile 8380456
| | - Maria N Plana
- Universidad Francisco de Vitoria (UFV) Madrid. CIBER Epidemiology and Public Health (CIBERESP); Ctra. Pozuelo-Majadahonda km. 1.800 Pozuelo de Alarcón Madrid Spain 28223
| | - Javier Zamora
- Hospital Universitario Ramon y Cajal (IRYCIS); Clinical Biostatistics Unit; Madrid Spain
- CIBER Epidemiology and Public Health (CIBERESP); Madrid Spain
- Women’s Health Research Unit, Centre for Primary Care and Public Health, Queen Mary University of London; London UK
| | - Terry J Quinn
- University of Glasgow; Institute of Cardiovascular and Medical Sciences; New Lister Campus Glasgow Royal Infirmary Glasgow UK G4 0SF
| | - Pamela Seron
- Universidad de La Frontera; CIGES, Departamento de Medicina Interna, Facultad de Medicina; Montt112, 3º piso Temuco Araucania Chile 4780000
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Schubert M, Schürch R, Boettger S, Garcia Nuñez D, Schwarz U, Bettex D, Jenewein J, Bogdanovic J, Staehli ML, Spirig R, Rudiger A. A hospital-wide evaluation of delirium prevalence and outcomes in acute care patients - a cohort study. BMC Health Serv Res 2018; 18:550. [PMID: 30005646 PMCID: PMC6045819 DOI: 10.1186/s12913-018-3345-x] [Citation(s) in RCA: 100] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 07/01/2018] [Indexed: 12/15/2022] Open
Abstract
Background Delirium is a well-known complication in cardiac surgery and intensive care unit (ICU) patients. However, in many other settings its prevalence and clinical consequences are understudied. The aims of this study were: (1) To assess delirium prevalence in a large, diverse cohort of acute care patients classified as either at risk or not at risk for delirium; (2) To compare these two groups according to defined indicators; and (3) To compare delirious with non-delirious patients regarding hospital mortality, ICU and hospital length of stay, nursing hours and cost per case. Methods This cohort study was performed in a Swiss university hospital following implementation of a delirium management guideline. After excluding patients aged < 18 years or with a length of stay (LOS) < 1 day, 29′278 patients hospitalized in the study hospital in 2014 were included. Delirium period prevalence was calculated based on a Delirium Observation Scale (DOS) score ≥ 3 and / or Intensive Care Delirium Screening Checklist (ICDSC) scores ≥4. Results Of 10′906 patients admitted, DOS / ICDSC scores indicated delirium in 28.4%. Delirium was most prevalent (36.2–40.5%) in cardiac surgery, neurosurgery, trauma, radiotherapy and neurology patients. It was also common in geriatrics, internal medicine, visceral surgery, reconstructive plastic surgery and cranio-maxillo-facial surgery patients (prevalence 21.6–28.6%). In the unadjusted and adjusted models, delirious patients had a significantly higher risk of inpatient mortality, stayed significantly longer in the ICU and hospital, needed significantly more nursing hours and generated significantly higher costs per case. For the seven most common ICD-10 diagnoses, each diagnostic group’s delirious patients had worse outcomes compared to those with no delirium. Conclusions The results indicate a high number of patients at risk for delirium, with high delirium prevalence across all patient groups. Delirious patients showed significantly worse clinical outcomes and generated higher costs. Subgroup analyses highlighted striking variations in delirium period-prevalence across patient groups. Due to the high prevalence of delirium in patients treated in care centers for radiotherapy, visceral surgery, reconstructive plastic surgery, cranio-maxillofacial surgery and oral surgery, it is recommended to expand the current focus of delirium management to these patient groups. Electronic supplementary material The online version of this article (10.1186/s12913-018-3345-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Maria Schubert
- Nursing Science, Faculty of Medicine, Department of Public Health, University of Basel, Bernoullistr. 28, 4056, Basel, Switzerland. .,Directorate of Nursing/MTT, Insel Gruppe, University Hospital Inselspital, Bern, Freiburgstr. 44a, 3010, Bern, Switzerland. .,School of Health Professions, Institute of Nursing, Zurich University of Applied Science, Technikumstr. 81, P.O. Box, 8401, Winterthur, Switzerland.
| | - Roger Schürch
- Clinical Trial Unit, Institute of Social and Preventive Medicine, University of Bern, Finkenhubelweg 11, 3012, Bern, Switzerland.,Virginia Tech, Department of Entomology (MC0319), 170 Drillfield Drive, Blacksburg, VA, 24061, USA
| | - Soenke Boettger
- Department of Psychiatry and Psychotherapy, University Hospital Zurich, Raemistr. 100, 8091, Zurich, Switzerland
| | - David Garcia Nuñez
- Department of Psychiatry and Psychotherapy, University Hospital Zurich, Raemistr. 100, 8091, Zurich, Switzerland.,Center for Gender Variance, University Hospital Basel, Spitalstrasse 21, 4056, Basel, Switzerland
| | - Urs Schwarz
- Division of Neurology, University Hospital Zurich, Raemistr. 100, 8091, Zurich, Switzerland
| | - Dominique Bettex
- Institute of Anesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Josef Jenewein
- Department of Psychiatry and Psychotherapy, University Hospital Zurich, Raemistr. 100, 8091, Zurich, Switzerland
| | - Jasmina Bogdanovic
- Nursing Science, Faculty of Medicine, Department of Public Health, University of Basel, Bernoullistr. 28, 4056, Basel, Switzerland
| | - Marina Lynne Staehli
- Nursing Department, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Rebecca Spirig
- Directorate of Nursing/MTT, Insel Gruppe, University Hospital Inselspital, Bern, Freiburgstr. 44a, 3010, Bern, Switzerland.,Nursing and Allied Health Care Professions Office, University Hospital Zurich, Raemistr. 100, 8091, Zurich, Switzerland
| | - Alain Rudiger
- Institute of Anesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
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Key components of the delirium syndrome and mortality: greater impact of acute change and disorganised thinking in a prospective cohort study. BMC Geriatr 2018; 18:24. [PMID: 29370764 PMCID: PMC5785815 DOI: 10.1186/s12877-018-0719-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 01/16/2018] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Delirium increases the risk of mortality during an acute hospital admission. Full syndromal delirium (FSD) is associated with greatest risk and subsyndromal delirium (SSD) is associated with intermediate risk, compared to patients with no delirium - suggesting a dose-response relationship. It is not clear how individual diagnostic symptoms of delirium influence the association with mortality. Our objectives were to measure the prevalence of FSD and SSD, and assess the effect that FSD, SSD and individual symptoms of delirium (from the Confusion Assessment Method-short version (s-CAM)) have on mortality rates. METHODS Exploratory analysis of a prospective cohort (aged ≥70 years) with acute (unplanned) medical admission (4/6/2007-4/11/2007). The outcome was mortality (data censored 6/10/2011). The principal exposures were FSD and SSD compared to no delirium (as measured by the CAM), along with individual delirium symptoms on the CAM. Cox regression was used to estimate the impact FSD and SSD and individual CAM items had on mortality. RESULTS The cohort (n = 610) mean age was 83 (SD 7); 59% were female. On admission, 11% had FSD and 33% had SSD. Of the key diagnostic symptoms for delirium, 17% acute onset, 19% inattention, 17% disorganised thinking and 17% altered level of consciousness. Unadjusted analysis found FSD had an increased hazard ratio (HR) of 2.31 (95% CI 1.71, 3.12), for SSD the HR was 1.26 (1.00, 1.59). Adjusted analysis remained significant for FSD (1.55 95% CI 1.10, 2.18) but nonsignificant for SSD (HR = 0.92 95% CI 0.70, 1.19). Two CAM items were significantly associated with mortality following adjustment: acute onset and disorganised thinking. CONCLUSION We observed a dose-response relationship between mortality and delirium, FSD had the greatest risk and SSD having intermediate risk. The CAM items "acute-onset" and "disorganised thinking" drove the associations observed. Clinically, this highlights the necessity of identifying individual symptoms of delirium.
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Hyde-Wyatt J. Prevention, recognition and management of delirium in patients who are critically ill. Nurs Stand 2017; 32:41-52. [PMID: 29094525 DOI: 10.7748/ns.2017.e10667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2016] [Indexed: 11/09/2022]
Abstract
Delirium is common in patients who are critically ill, often resulting in extended hospital stays and increased mortality and morbidity. There are several subtypes of delirium, which are often undiagnosed and untreated, resulting in suboptimal patient outcomes. This article examines delirium in patients in the intensive care unit, including its signs and symptoms, incidence, causes and subtypes. It outlines the assessment of delirium and the pharmacological and non-pharmacological interventions that can be used to manage the condition, as well as describing the optimal prevention measures.
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Affiliation(s)
- Jaime Hyde-Wyatt
- Northern Lincolnshire and Goole NHS Foundation Trust, Scunthorpe, England
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Jin YH, Li N, Zheng R, Mu W, Lei X, Si JH, Chen J, Shang HC. Benzodiazepines for treatment of delirium in non-ICU settings. Hippokratia 2017. [DOI: 10.1002/14651858.cd012670] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Ying Hui Jin
- Tianjin University of Traditional Chinese Medicine; Nursing; #312 West Anshan Road Tianjin China
| | - Nan Li
- Tianjin University of Traditional Chinese Medicine; Tianjin Insititute of Clinical Evaluation; #88 Yuquan Road Nankai District Tianjin Tianjin China 300193
| | - Rui Zheng
- Tianjin University of Traditional Chinese Medicine; Tianjin Insititute of Clinical Evaluation; #88 Yuquan Road Nankai District Tianjin Tianjin China 300193
| | - Wei Mu
- The 2nd Affiliated Hospital of Tianjin University of traditional Chinese Medicine; Clinical pharmacology; 861 Zhenli Road Hebei District Tianjin Tianjin China 300150
| | - Xiang Lei
- Dongzhimen Hospital, Beijing University of Chinese Medicine; Key Laboratory of Chinese Internal Medicine of Ministry of Education; Haiyuncang Lane, Dongcheng District Beijing Beijing China 100700
| | - Jin Hua Si
- Tianjin University of Traditional Chinese Medicine; Library; #88 Yuquan Road Nankai District Tianjin Tianjin China 300193
| | - Jing Chen
- Tianjin University of Traditional Chinese Medicine; Baokang Hospital; #88 Yuquan Road Nankai District Tianjin Tianjin China 300193
| | - Hong Cai Shang
- Dongzhimen Hospital, Beijing University of Chinese Medicine; Key Laboratory of Chinese Internal Medicine of Ministry of Education; Haiyuncang Lane, Dongcheng District Beijing Beijing China 100700
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Ventilation spontanée au cours du syndrome de détresse respiratoire aiguë. MEDECINE INTENSIVE REANIMATION 2017. [DOI: 10.1007/s13546-017-1259-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Bishara A, Phan SV, Young HN, Liao TV. Glucose Disturbances and Atypical Antipsychotic Use in the Intensive Care Unit. J Pharm Pract 2015; 29:534-538. [PMID: 25952594 DOI: 10.1177/0897190015579452] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE Chronic use of atypical antipsychotics may lead to metabolic abnormalities including hyperglycemia. Although evidence supports acute hyperglycemic episodes associated with atypical antipsychotic use, the acute use of atypical antipsychotics in the intensive care unit (ICU) setting has not been studied. The purpose of this study is to evaluate the occurrence of hyperglycemia in ICU patients receiving newly prescribed atypical antipsychotic. SUMMARY Of the 273 patient charts reviewed, 50 patients were included in this study. Approximately 45% of patients experienced at least 1 hyperglycemic episode (blood glucose >180 mg/dL) after the initiation of an atypical antipsychotic in the ICU. Of the patients experiencing at least 1 hyperglycemic episode, 60% experienced multiple distinct hyperglycemic episodes. In this study, quetiapine was the most commonly used atypical antipsychotic, 19 (38%) patients were discharged from the ICU on the atypical antipsychotic, 6 (12%) patients died in the ICU, and 31 (62%) patients were treated with an antihyperglycemic agent. Logistic regression analysis showed that women and ICU patients with a higher Acute Physiology and Chronic Health Evaluation II (APACHE II) score were significantly more likely to have multiple hyperglycemic episodes. CONCLUSION Patients admitted to the ICU and initiated on an atypical antipsychotic may develop hyperglycemia independent of other glucose-elevating factors. The direct correlation of these agents to resulting acute hyperglycemia is unknown. Further studies are needed to investigate the link between atypical antipsychotics and acute hyperglycemia and the clinical significance of the impact on patient outcomes.
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Affiliation(s)
- Amy Bishara
- Department of Pharmacy, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Stephanie V Phan
- Department of Clinical and Administrative Pharmacy, University of Georgia, Albany, GA, USA
| | - Henry N Young
- Department of Clinical and Administrative Pharmacy, University of Georgia, Albany, GA, USA
| | - T Vivian Liao
- Department of Pharmacy Practice, Mercer University, Mercer University Drive, Atlanta, GA, USA
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Lonardo NW, Mone MC, Nirula R, Kimball EJ, Ludwig K, Zhou X, Sauer BC, Nechodom K, Teng C, Barton RG. Propofol is associated with favorable outcomes compared with benzodiazepines in ventilated intensive care unit patients. Am J Respir Crit Care Med 2014; 189:1383-94. [PMID: 24720509 DOI: 10.1164/rccm.201312-2291oc] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
RATIONALE Mechanically ventilated intensive care unit (ICU) patients are frequently managed using a continuous-infusion sedative. Although recent guidelines suggest avoiding benzodiazepines for sedation, this class of drugs is still widely used. There are limited data comparing sedative agents in terms of clinical outcomes in an ICU setting. OBJECTIVES Comparison of propofol to midazolam and lorazepam in adult ICU patients. METHODS Data were obtained from a multicenter ICU database (2003-2009). Patient selection criteria included age greater than or equal to 18 years, single ICU admission with single ventilation event (>48 h), and treatment with continuously infused sedation (propofol, midazolam, or lorazepam). Propensity score analysis (1:1) was used and mortality measured. Cumulative incidence and competing risk methodology were used to examine time to ICU discharge and ventilator removal. MEASUREMENTS AND MAIN RESULTS There were 2,250 propofol-midazolam and 1,054 propofol-lorazepam matched patients. Hospital mortality was statistically lower in propofol-treated patients as compared with midazolam- or lorazepam-treated patients (risk ratio, 0.76; 95% confidence interval [CI], 0.69-0.82 and risk ratio, 0.78; 95% CI, 0.68-0.89, respectively). Competing risk analysis for 28-day ICU time period showed that propofol-treated patients had a statistically higher probability for ICU discharge (78.9% vs. 69.5%; 79.2% vs. 71.9%; P < 0.001) and earlier removal from the ventilator (84.4% vs. 75.1%; 84.3% vs. 78.8%; P < 0.001) when compared with midazolam- and lorazepam-treated patients, respectively. CONCLUSIONS In this large, propensity-matched ICU population, patients treated with propofol had a reduced risk of mortality and had both an increased likelihood of earlier ICU discharge and earlier discontinuation of mechanical ventilation.
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Electroconvulsive therapy as a treatment for protracted refractory delirium in the intensive care unit--five cases and a review. J Crit Care 2014; 29:881.e1-6. [PMID: 24975569 DOI: 10.1016/j.jcrc.2014.05.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 05/02/2014] [Accepted: 05/18/2014] [Indexed: 12/16/2022]
Abstract
PURPOSE Delirium in the intensive care unit (ICU) is conventionally treated pharmacologically but can progress into a protracted state refractory to medical treatment--a potentially life-threatening condition in itself. METHODS We treated 5 cases of severe protracted delirium in our ICU with electroconvulsive therapy (ECT) after failure of conventional medical therapy. RESULTS The delirious state of long standing agitation, anxiety, and discomfort was controlled in all patients. Electroconvulsive therapy was effective in controlling delirium in 4 patients. The last patient became calm, relieved of stress, and able to cooperate with the ventilator but remained in a state of posttraumatic amnesia after a head trauma. CONCLUSION Although controversial, ECT is nevertheless recognized as an efficient and safe treatment for various psychiatric illnesses including delirium. Considering the significantly increased mortality and severe cognitive decline associated with delirium in the ICU, we find ECT to be a valuable treatment option for this vulnerable patient population. It can be considered when agitation cannot be controlled with medical treatment, when agitation and delirium make weaning impossible, or prolonged deep sedation the only alternative.
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Fortini A, Morettini A, Tavernese G, Facchini S, Tofani L, Pazzi M. Delirium in elderly patients hospitalized in internal medicine wards. Intern Emerg Med 2014; 9:435-41. [PMID: 23771269 DOI: 10.1007/s11739-013-0968-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Accepted: 06/05/2013] [Indexed: 11/30/2022]
Abstract
A prospective observational study was conducted to evaluate the impact of delirium on geriatric inpatients in internal medical wards and to identify predisposing factors for the development of delirium. The study included all patients aged 65 years and older, who were consecutively admitted to the internal medicine wards of two public hospitals in Florence, Italy. On admission, 29 baseline risk factors were examined, cognitive impairment was evaluated by Short Portable Mental Status Questionnaire, and prevalent delirium cases were diagnosed by Confusion Assessment Method (CAM). Enrolled patients were evaluated daily with CAM to detect incident delirium cases. Among the 560 included patients, 19 (3 %) had delirium on admission (prevalent) and 44 (8 %) developed delirium during hospitalization (incident). Prevalent delirium cases were excluded from the statistical analysis. Incident delirium was associated with increased length of hospital stay (p < 0.01) and institutionalization (p < 0.01, OR 3.026). Multivariate analysis found that cognitive impairment on admission (p < 0.0002), diabetes (p < 0.05, OR 1.936), chronic kidney failure (p < 0.05, OR 2.078) and male gender (p < 0.05, OR 2.178) was significantly associated with the development of delirium during hospitalization. Results show that delirium impact is relevant to older patients hospitalized in internal medicine wards. The present study confirms cognitive impairment as a risk factor for incident delirium. The cognitive evaluation proved to be an important instrument to improve identification of patients at high risk for delirium. In this context, our study may contribute to improve application of preventive strategies.
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Affiliation(s)
- Alberto Fortini
- Internal Medicine Unit, Serristori Hospital Figline Valdarno, Florence, Italy,
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Affiliation(s)
- K. Giraud
- Papworth Hospital NHS Foundation Trust; Cambridge UK
| | - A. Vuylsteke
- Papworth Hospital NHS Foundation Trust; Cambridge UK
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Acute Hyperglycemia Associated with Short-Term Use of Atypical Antipsychotic Medications. Drugs 2014; 74:183-94. [DOI: 10.1007/s40265-013-0171-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Managing hyperactive delirium and spinal immobilisation in the intensive care setting: a case study and reflective discussion of the literature. Intensive Crit Care Nurs 2013; 30:138-44. [PMID: 24378239 DOI: 10.1016/j.iccn.2013.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Revised: 11/17/2013] [Accepted: 11/22/2013] [Indexed: 11/23/2022]
Abstract
The management of ventilated patients on intensive care has, at its core, a care bundle; an evidence based group of actions designed to reduce the risk of ventilator-associated pneumonia. One of these is the daily cessation of sedation medication to expedite weaning from ventilatory support. A reflection-on-action exercise was carried out when a spinally injured patient became physically active during a sedation hold. This was attributed to hyperactive delirium. The concern was the conflict between providing evidence based Intensive Care Unit (ICU) therapy care and maintaining spinal immobility. Reflection on this incident led to a literature search for guidance on the likelihood of delirium causing secondary spinal injury in patients with unstable fractures. There was plentiful research on delirium and its consequences but very little examining the link between spinal injury and delirium. In order to be able to provide evidence-based care to future trauma patients the research supporting spinal immobilisation was also examined. The research showed that compliance with ventilator care bundles reduced the risks of acquiring ventilator-associated pneumonia. Research surrounding spinal immobilisation was conflicting and there were no studies linking the consequences of immobilised patients experiencing hyperactive delirium. Through a case study approach the research was reviewed in relation to a particular patient and although literature was lacking some implications for practice could be identified to promote the best possible outcomes. Sedation cessation episodes are an essential part of patient care on intensive care. For spinally injured patients' these may need to be modified to sedation reductions to prevent sudden wakening and uncontrolled movement should the patient be experiencing hyperactive delirium. This case study clearly highlights the need for further research in this area as the consequences of both ventilator associated pneumonia and extending spinal injuries is costly for both patients and hospitals.
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Cachón-Pérez JM, Alvarez-López C, Palacios-Ceña D. [Non-pharmacological steps for the treatment of acute confusional syndrome in the intensive care unit]. ENFERMERIA INTENSIVA 2013; 25:38-45. [PMID: 24342738 DOI: 10.1016/j.enfi.2013.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Revised: 10/01/2013] [Accepted: 11/05/2013] [Indexed: 11/18/2022]
Abstract
UNLABELLED The incidence of delirium in intensive care units is high and it has been under-diagnosed and under-treated. OBJECTIVE To describe the experiences of ICU nurses in the identification and application of non-pharmacological treatments. METHOD A qualitative phenomenological research study was performed, based on focus groups. INCLUSION CRITERIA ICU nurses with one year of more of experience were included. Sample Purpose and snowball technique. DATA COLLECTION Data from the focus groups were transcribed for analysis and a thematic analysis of the texts was performed. RESULTS Four themes were identified: a) the physical and social structure of the ICU b) family involvement, c) need for training of health professionals, and d) encouraging the sleep-wake cycle. CONCLUSIONS It is necessary to control the ICU environment to make it more friendly, to change the routine work to promote relaxation, implement training activities and to make visiting hours flexible.
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Affiliation(s)
- J M Cachón-Pérez
- Unidad de Cuidados Intensivos, Hospital Universitario de Fuenlabrada, Madrid, España.
| | - C Alvarez-López
- Unidad de Cuidados Intensivos, Hospital Universitario de Fuenlabrada, Madrid, España
| | - D Palacios-Ceña
- Unidad de Cuidados Intensivos, Hospital Universitario de Fuenlabrada, Madrid, España
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Abstract
OBJECTIVE To compare and contrast the process used to implement an early mobility program in ICUs at three different medical centers and to assess their impact on clinical outcomes in critically ill patients. DESIGN Three ICU early mobilization quality improvement projects are summarized utilizing the Institute for Healthcare Improvement framework of Plan-Do-Study-Act. INTERVENTION Each of the three ICU early mobilization programs required an interprofessional team-based approach to plan, educate, and implement the ICU early mobility program. Champions from each profession-nursing, physical therapy, physician, and respiratory care-were identified to facilitate changes in ICU culture and clinical practice and to identify and address barriers to early mobility program implementation at each institution. SETTING The medical ICU at Wake Forest University, the medical ICU at Johns Hopkins Hospital, and the mixed medical-surgical ICU at the University of California San Francisco Medical Center. RESULTS Establishing an ICU early mobilization quality improvement program resulted in a reduced ICU and hospital length of stay at all three institutions and decreased rates of delirium and the need for sedation for the patients enrolled in the Johns Hopkins ICU early mobility program. CONCLUSION Instituting a planned, structured ICU early mobility quality improvement project can result in improved outcomes and reduced costs for ICU patients across healthcare systems.
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Abstract
AIMS AND OBJECTIVES To illustrate the potential physical and psychological problems faced by patients after an episode of critical illness, highlight some of the interventions that have been tested and identify areas for future research. BACKGROUND Recovery from critical illness is an international problem and as an issue is likely to increase. For some, recovery from critical illness is prolonged, subject to physical and psychological problems that may negatively impact upon health-related quality of life. METHODS The literature accessed for this review includes the work of a number of key researchers in the field of critical care research. These were identified from a number of sources include (1) personal knowledge of the research field accumulated over the last decade and (2) using the search engine 'The Knowledge Network Scotland'. RESULTS Fatigue and weakness are significant problems for critical care survivors and are common in patients who have been in ICU for more than one week. Psychological problems include anxiety, depression, post-traumatic stress, delirium and cognitive impairment. Prevalence of these problems is difficult to establish for a number of methodological reasons that include the use of self-report questionnaires, the number of different questionnaires used and the variation in administration and timing. Certain subgroups of ICU survivors especially those at the more severe end of the illness severity spectrum are more at risk and this has been demonstrated for both physical and psychological problems. Findings from international studies of a range of potential interventions are presented. However, establishing effectiveness for most of these still has to be empirically demonstrated. CONCLUSION What seems clear is the need for a co-ordinated, multidisciplinary, designated recovery and rehabilitation pathway that begins as soon as the patient is admitted into an intensive care unit.
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Affiliation(s)
- Janice Rattray
- School of Nursing and Midwifery, University of Dundee, Dundee, UK
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Flynn K, Daiches A, Malpus Z, Yonan N, Sanchez M. ‘A post-transplant person’: Narratives of heart or lung transplantation and intensive care unit delirium. Health (London) 2013; 18:352-68. [DOI: 10.1177/1363459313501356] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Exploring patients’ narratives can lead to new understandings about perceived illness states. Intensive Care Unit delirium is when people experience transitory hallucinations, delusions or paranoia in the Intensive Care Unit and little is known about how this experience affects individuals who have had a heart or lung transplant. A total of 11 participants were recruited from two heart and lung transplant services and were invited to tell their story of transplant and Intensive Care Unit delirium. A narrative analysis was conducted and the findings were presented as a shared story. This shared story begins with death becoming prominent before the transplant: ‘you live all the time with Mr Death on your shoulder’. Following the operation, death permeates all aspects of dream worlds, as dreams in intensive care ‘tunes into the subconscious of your fears’. The next part of the shared story offers hope of restitution; however, this does not last as reality creeps in: ‘I thought it was going to be like a miracle cure’. Finally, the restitution narrative is found to be insufficient and individuals differ in the extent to which they can achieve resolution. The societal discourse of a transplant being a ‘gift’, which gives life, leads to internalised responsibility for the ‘success’ or ‘failure’ of the transplant. Participants describe how their experiences impact their sense of self: ‘a post-transplant person’. The clinical implications of these findings are discussed.
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Affiliation(s)
| | | | - Zoey Malpus
- Wythenshawe Heart and Lung Transplant Unit, UK
| | - Nizar Yonan
- Wythenshawe Heart and Lung Transplant Unit, UK
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Psychotropic prescribing in the oldest old attending a geriatric psychiatry service: a retrospective, cross-sectional study. Ir J Psychol Med 2013; 30:187-196. [PMID: 30189496 DOI: 10.1017/ipm.2013.30] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE More people are living beyond their 90s, yet this group has not been much studied. This study aimed to describe a sample of non-agenarians and centerians attending an old age psychiatry service with a focus on pharmacotherapy. METHODS Retrospective, cross-sectional survey of patients aged >90 in contact with the Department of Old Age Psychiatry in a university hospital over a 1-year period. Results were compared with the Beers, the Canadian and Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP) criteria. RESULTS A total of 65 nonagenarians or centerians were identified (mean age 93, 82% female). The majority (65%) resided in a nursing home; dementia was the most common diagnosis (77%), followed by depression (29%). The most commonly prescribed psychotropics were antidepressants (58%), followed by antipsychotics (45%), hypnotics (42%), anti-dementia agents (31%) and anxiolytics (26%). Overall, patients were on a mean of 2.1 (S.D. 1.3, range 0-5) psychotropics and 4.99 (S.D. 2.7, range 0-11) non-psychotropics. Mean Mini Mental State Examination (MMSE) score was 15 (S.D. 8.1). Increasing anticholinergic burden was negatively associated with MMSE scores (B = -1.72, p = 0.013). Residing in a nursing home was associated with a higher rate of antidepressant [OR 5.71 (95% CI 1.9-17.4)], anxiolytic [OR 13.5 (95% CI 1.7-110.4)] and antipsychotic [OR 3.4 (95% CI 1.1-10.4)] use. Potentially inappropriate prescribing included long-term benzodiazepine use (26%) and long-term antipsychotic use (25%). CONCLUSIONS Our sample had a high psychiatric morbidity burden with high levels of psychotropic use. Ongoing review and audit of psychotropic use in elderly patients can identify potentially inappropriate prescribing in a group vulnerable to high levels of polypharmacy and extended psychotropic use.
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Devlin JW, Al-Qadhee NS, Skrobik Y. Pharmacologic prevention and treatment of delirium in critically ill and non-critically ill hospitalised patients: a review of data from prospective, randomised studies. Best Pract Res Clin Anaesthesiol 2013; 26:289-309. [PMID: 23040282 DOI: 10.1016/j.bpa.2012.07.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2012] [Accepted: 07/25/2012] [Indexed: 12/13/2022]
Abstract
Delirium occurs commonly in acutely ill hospitalised patients, particularly in the elderly or in cardiac or orthopaedic surgery patients, or those in intensive care units (ICUs). Delirium worsens outcome. Pharmaceutical agents such as antipsychotics and, in the critically ill, dexmedetomidine, are considered therapeutic despite uncertainty regarding their efficacy and safety. Using MEDLINE, we reviewed randomised controlled trials (RCTs) published between 1977 and April 2012 evaluating a pharmacologic intervention to prevent or treat delirium in critically ill and non-critically ill hospitalised patients. The number of prospective RCTs remains limited. Any conclusions about pharmacologic efficacy are limited by the small size of many studies, the inconsistency by which non-pharmacologic delirium prevention strategies were incorporated, the lack of a true placebo arm and a failure to incorporate ICU and non-ICU clinical outcomes. A research framework for future evaluation of the use of medications in both ICU and non-ICU is proposed.
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Affiliation(s)
- John W Devlin
- Northeastern University School of Pharmacy, Boston, MA 02118, USA.
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Balas MC, Rice M, Chaperon C, Smith H, Disbot M, Fuchs B. Management of delirium in critically ill older adults. Crit Care Nurse 2013; 32:15-26. [PMID: 22855075 DOI: 10.4037/ccn2012480] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Delirium in older adults in critical care is associated with poor outcomes, including longer stays, higher costs, increased mortality, greater use of continuous sedation and physical restraints, increased unintended removal of catheters and self-extubation, functional decline, new institutionalization, and new onset of cognitive impairment. Diagnosing delirium is complicated because many critically ill older adults cannot communicate their needs effectively. Manifestations include reduced ability to focus attention, disorientation, memory impairment, and perceptual disturbances. Nurses often have primary responsibility for detecting and treating delirium, which can be extraordinarily complicated because patients are often voiceless, extremely ill, and require high levels of sedatives to facilitate mechanical ventilation. An aggressive, appropriate, and compassionate management strategy may reduce the suffering and adverse outcomes associated with delirium and improve relationships between nurses, patients, and patients' family members.
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Affiliation(s)
- Michele C Balas
- University of Nebraska Medical Center, College of Nursing, Omaha, Nebraska, USA.
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Kim KN, Kim CH, Kim KI, Yoo HJ, Park SY, Park YH. [Development and validation of the Korean Nursing Delirium Scale]. J Korean Acad Nurs 2012; 42:414-23. [PMID: 22854554 DOI: 10.4040/jkan.2012.42.3.414] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
PURPOSE The aims of this study were to develop and test the validity of the Korean Nursing Delirium Scale (Nu-DESC) for older patients in hospital. METHODS The Korean Nu-DESC was developed based on the Nu-DESC (Gaudreau, 2005), and revised according to nursing records related to signs and symptoms of older patients with delirium (n=361) and the results of a pilot study (n=42) in one general hospital. To test the validity of the Korean Nu-DESC, 75 older patients whom nurses suspected of delirium from 731 older patients from 12 nursing units were assessed by bedside nurses using the Korean Nu-DESC. A Receiver Operating Characteristic Curve of the Korean Nu-DESC was constructed with an accompanying Area Under the Curve (AUC). RESULTS Specific examples such as irritable, kidding, sleeping tendency, which were observed by bedside nurses in Korea, were identified in the five features of signs and symptoms of delirium in the instrument. The Korean Nu-DESC was psycho-metrically valid and had a sensitivity and specificity of .81-.76 and .97-.73, respectively. The AUC were .89, .74. CONCLUSION Results of this study indicate that the Korean Nu-DESC is well-suited for widespread clinical use in busy inpatients settings and shows promise as a research instrument.
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Affiliation(s)
- Kyoung-Nam Kim
- Department of Nursing, Seoul National University Bundang Hospital, Bundang, South Korea
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Zaal IJ, Slooter AJC. Delirium in critically ill patients: epidemiology, pathophysiology, diagnosis and management. Drugs 2012; 72:1457-71. [PMID: 22804788 DOI: 10.2165/11635520-000000000-00000] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Delirium is commonly observed in critically ill patients and is associated with negative outcomes. The pathophysiology of delirium is not completely understood. However, alterations to neurotransmitters, especially acetylcholine and dopamine, inflammatory pathways and an aberrant stress response are proposed mechanisms leading to intensive care unit (ICU) delirium. Detection of delirium using a validated delirium assessment tool makes early treatment possible, which may improve prognosis. Patients at high risk of delirium, especially those with cognitive decline and advanced age, should be identified in the first 24 hours of admission to the ICU. Whether these high-risk patients benefit from haloperidol prophylaxis deserves further study. The effectiveness of a multicomponent, non-pharmacological approach is shown in non-ICU patients, which provides proof of concept for use in the ICU. The few studies on this approach in ICU patients suggest that the burden of ICU delirium may be reduced by early mobility, increased daylight exposure and the use of earplugs. In addition, the combined use of sedation, ventilation, delirium and physical therapy protocols can reduce the frequency and severity of adverse outcomes and should become part of routine practice in the ICU, as should avoidance of deliriogenic medication such as anticholinergic drugs and benzodiazepines. Once delirium develops, symptomatic treatment with antipsychotics is recommended, with haloperidol being the drug of first choice. However, there is limited evidence on the safety and effectiveness of antipsychotics in ICU delirium.
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Affiliation(s)
- Irene J Zaal
- Department of Intensive Care Medicine, University Medical Centre Utrecht, Utrecht, the Netherlands.
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Abstract
OBJECTIVES To review the diagnosis and management of four selected psychiatric emergencies in the intensive care unit: agitated delirium, neuroleptic malignant syndrome, serotonin syndrome, and psychiatric medication overdose. DATA SOURCES Review of relevant medical literature. DATA SYNTHESIS Standardized screening for delirium should be routine. Agitated delirium should be managed with an antipsychotic and, possibly, dexmedetomidine in treatment-refractory cases. Delirium management should also include ensuring a calming environment and adequate pain control, minimizing benzodiazepines and anticholinergics, normalizing the sleep-wake cycle, providing sensory aids as required, and providing early physical and occupational therapy. Neuroleptic malignant syndrome should be treated by discontinuing dopamine blockers, providing supportive therapy, and possibly administering medications (benzodiazepines, dopamine agonists, and/or dantrolene) or electroconvulsive therapy, if indicated. Serotonin syndrome should be treated by discontinuing all serotonergic agents, providing supportive therapy, controlling agitation with benzodiazepines, and possibly administering serotonin2A antagonists. It is often unnecessary to restart psychiatric medications upon which a patient has overdosed in the intensive care unit, though withdrawal syndromes should be prevented, and communication with outpatient prescribers is vital. CONCLUSIONS Understanding the diagnosis and appropriate management of these four psychiatric emergencies is important to provide safe and effective care in the intensive care unit.
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Whom should we rely on when assessing symptoms of critically ill patients? Crit Care Med 2012; 40:2899-900. [PMID: 22986653 DOI: 10.1097/ccm.0b013e31825f7bc5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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King JN, Elliott VA. Self/unplanned extubation: safety, surveillance, and monitoring of the mechanically ventilated patient. Crit Care Nurs Clin North Am 2012; 24:469-79. [PMID: 22920470 DOI: 10.1016/j.ccell.2012.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The purpose of this article is to provide an appreciation for a significant risk to quality of care affecting patients receiving mechanical ventilation: unplanned extubation. A summary of the current literature provides evidence-based recommendations for how to minimize this potentially dangerous complication. In addition, recommendations for proceeding after unplanned extubation are made.
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Affiliation(s)
- Julie N King
- Weinberg Intensive Care Unit, Johns Hopkins Hospital, 401 North Broadway: Wbg 3A, Baltimore, MD 21231, USA.
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Greve I, Vasilevskis EE, Egerod I, Bekker Mortensen C, Møller AM, Svenningsen H, Thomsen T. Interventions for preventing intensive care unit delirium. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2012. [DOI: 10.1002/14651858.cd009783] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Ingrid Greve
- Copenhagen University Hospital, Rigshospitalet; The Heart Centre of Copenhagen, Clinic of Anaesthetics and Intensive Therapy; Blegdamsvej 9 Copenhagen Denmark Dk-2100 Ø
| | - Eduard E Vasilevskis
- Division of General Internal Medicine and Public Health, Vanderbilt University and theTennessee Valley Geriatric Research, Education and Clinical Center (GRECC); Department of Medicine; 1215 21st Ave. S. 6005 Medical Center East, NT Nashville TN USA 37232-8300
| | - Ingrid Egerod
- Rigshospitalet, dept. 9701; The University Hospitals Centre for Nursing and Care Research (UCSF); Blegdamsvej 9 Copenhagen O Denmark 2100
| | - Camilla Bekker Mortensen
- Herlev University Hospital; Intensive Care Unit, Department of Anaesthesiology; Herlev Ringvej 75 Herlev Denmark DK-2730
| | - Ann Merete Møller
- Herlev University Hospital; The Cochrane Anaesthesia Review Group, Rigshospitalet & Department of Anaesthesiology; Herlev Ringvej Herlev Denmark 2730
| | - Helle Svenningsen
- Aarhus University Hospital; Intensive Care Unit; Aarhus DK-8000 Denmark
| | - Thordis Thomsen
- Righospitalet; Abdominal Centre 2-11-2; Blegdamsvej 9 Copenhagen Denmark 2100
- Aarhus University; The Danish Centre of Systematic Reviews in Nursing: An Affiliate Centre of the Joanna Briggs Institute; Hoegh-Guldbergs Gade 6A Aarhus Denmark
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Abstract
Pain is abundant in the intensive care unit (ICU). Successful analgesia demands a comprehensive appreciation for the etiologies of pain, vigilant clinical assessment, and personalized treatments. For the critically ill, frequent threats to mental and bodily integrity magnify the experience of pain, challenging clinicians to respond swiftly and thoughtfully. Because pain is difficult to predict and physiologic correlates are not specific, self-report remains the gold standard assessment. When communication is limited by intubation or cognitive deficits, behavioral pain scales prove useful. Patient-tailored analgesia aspires to mitigate suffering while optimizing alertness and cognitive capacity. Mindfulness of the neuropsychiatric features of pain helps the ICU clinician to clarify limits of traditional analgesia and identify alternative approaches to care. Armed with empirical data and clinical practice recommendations to better conceptualize, identify, and treat pain and its neuropsychiatric comorbidities, the authors (psychiatric consultants, by trade) reinforce holistic approaches to pain management in the ICU. After all, without attempts to understand and relieve suffering on all fronts, pain will remain undertreated.
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Affiliation(s)
- Pierre N Azzam
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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Harrington AL, Dixon TM, Ho CH. Vitamin B12 Deficiency as a Cause of Delirium in a Patient With Spinal Cord Injury. Arch Phys Med Rehabil 2011; 92:1917-20. [DOI: 10.1016/j.apmr.2011.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2011] [Revised: 05/26/2011] [Accepted: 06/08/2011] [Indexed: 10/15/2022]
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Spontaneously regulated vs. controlled ventilation of acute lung injury/acute respiratory distress syndrome. Curr Opin Crit Care 2011; 17:24-9. [PMID: 21157317 DOI: 10.1097/mcc.0b013e328342726e] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
PURPOSE OF REVIEW To present an updated discussion of those aspects of controlled positive pressure breathing and retained spontaneous regulation of breathing that impact the management of patients whose tissue oxygenation is compromised by acute lung injury. RECENT FINDINGS The recent introduction of ventilation techniques geared toward integrating natural breathing rhythms into even the earliest phase of acute respiratory distress syndrome support (e.g., airway pressure release, proportional assist ventilation, and neurally adjusted ventilatory assist), has stimulated a burst of new investigations. SUMMARY Optimizing gas exchange, avoiding lung injury, and preserving respiratory muscle strength and endurance are vital therapeutic objectives for managing acute lung injury. Accordingly, comparing the physiology and consequences of breathing patterns that preserve and eliminate breathing effort has been a theme of persisting investigative interest throughout the several decades over which it has been possible to sustain cardiopulmonary life support outside the operating theater.
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McKay J, Vasilev SA. Perioperative Psychosocial Considerations. Gynecol Oncol 2011. [DOI: 10.1002/9781118003435.ch14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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