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O'Connor SAJ, Watson EJR, Grech-Sollars M, Finnegan ME, Honeyfield L, Quest RA, Waldman AD, Vizcaychipi MP. Perioperative research into memory (PRiMe), part 2: Adult burns intensive care patients show altered structure and function of the default mode network. Burns 2024:S0305-4179(24)00142-6. [PMID: 38890052 DOI: 10.1016/j.burns.2024.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 03/24/2024] [Accepted: 05/02/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Long-term cognitive impairment (LTCI) is experienced by up to two thirds of patients discharged from burns intensive care units (BICUs), however little is known about its neurobiological basis. This study investigated if patients previously admitted to BICU showed structural and functional MRI changes of the Default Mode Network (DMN). METHODS Fifteen patients previously admitted to BICU with a significant burns injury, and 15 matched volunteers, underwent structural and functional MRI scans. Functional connectivity, fractional anisotropy and cortical thickness of the main DMN subdivisions (anterior DMN (aDMN), posterior DMN (pDMN) and right (rTPJ) and left (lTPJ) temporo-parietal junctions) were compared between patients and volunteers, with differences correlated against cognitive performance. RESULTS Functional connectivity between rTPJ and pDMN (t = 2.91, p = 0.011) and between rTPJ and lTPJ (t = 3.18, p = 0.008) was lower in patients compared to volunteers. Functional connectivity between rTPJ and pDMN correlated with cognitive performance (r2 =0.33, p < 0.001). Mean fractional anisotropy of rTPJ (t = 2.70, p = 0.008) and lTPJ (T = 2.39, p = 0.015) was lower in patients but there was no difference in cortical thickness. CONCLUSIONS Patients previously admitted to BICU show structural and functional disruption of the DMN. Since functional changes correlate with cognitive performance, this should direct further research into intensive-care-related cognitive impairment.
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Affiliation(s)
- Stuart A J O'Connor
- Magill Department of Anaesthesia, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK; Department of Academic Anaesthesia, Pain and Intensive Care Medicine (APMIC), Imperial College London, London, UK
| | - Edward J R Watson
- Magill Department of Anaesthesia, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK; Department of Academic Anaesthesia, Pain and Intensive Care Medicine (APMIC), Imperial College London, London, UK.
| | - Matthew Grech-Sollars
- Department of Computer Science, University College London, London, UK; Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Mary E Finnegan
- Department of Imaging, Imperial College Healthcare NHS Trust, London, UK; Department of Bioengineering, Imperial College London, London, UK
| | - Lesley Honeyfield
- Department of Imaging, Imperial College Healthcare NHS Trust, London, UK
| | - Rebecca A Quest
- Department of Imaging, Imperial College Healthcare NHS Trust, London, UK; Department of Bioengineering, Imperial College London, London, UK
| | - Adam D Waldman
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK; Department of Brain Sciences, Imperial College London, London, UK
| | - Marcela P Vizcaychipi
- Magill Department of Anaesthesia, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK; Department of Academic Anaesthesia, Pain and Intensive Care Medicine (APMIC), Imperial College London, London, UK
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Kurtz P, van den Boogaard M, Girard TD, Hermann B. Acute encephalopathy in the ICU: a practical approach. Curr Opin Crit Care 2024; 30:106-120. [PMID: 38441156 DOI: 10.1097/mcc.0000000000001144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
PURPOSE OF REVIEW Acute encephalopathy (AE) - which frequently develops in critically ill patients with and without primary brain injury - is defined as an acute process that evolves rapidly and leads to changes in baseline cognitive status, ranging from delirium to coma. The diagnosis, monitoring, and management of AE is challenging. Here, we discuss advances in definitions, diagnostic approaches, therapeutic options, and implications to outcomes of the clinical spectrum of AE in ICU patients without primary brain injury. RECENT FINDINGS Understanding and definitions of delirium and coma have evolved. Delirium is a neurocognitive disorder involving impairment of attention and cognition, usually fluctuating, and developing over hours to days. Coma is a state of unresponsiveness, with absence of command following, intelligible speech, or visual pursuit, with no imaging or neurophysiological evidence of cognitive motor dissociation. The CAM-ICU(-7) and the ICDSC are validated, guideline-recommended tools for clinical delirium assessment, with identification of clinical subtypes and stratification of severity. In comatose patients, the roles of continuous EEG monitoring and neuroimaging have grown for the early detection of secondary brain injury and treatment of reversible causes. SUMMARY Evidence-based pharmacologic treatments for delirium are limited. Dexmedetomidine is effective for mechanically ventilated patients with delirium, while haloperidol has minimal effect of delirium but may have other benefits. Specific treatments for coma in nonprimary brain injury are still lacking.
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Affiliation(s)
- Pedro Kurtz
- D'Or Institute of Research and Education
- Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Mark van den Boogaard
- Radboud University Medical Center, Department of Intensive Care, Nijmegen, The Netherlands
| | - Timothy D Girard
- Center for Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) in the Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Bertrand Hermann
- Medical Intensive Care Unit, Hôpital Européen Georges Pompidou, Assistance Publique des Hôpitaux de Paris - Centre (APHP-Centre)
- INSERM UMR 1266, Institut de Psychiatrie et Neurosciences de Paris (IPNP), Université Paris Cité, Paris, France
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3
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Kumar N. Advances in post intensive care unit care: A narrative review. World J Crit Care Med 2023; 12:254-263. [DOI: 10.5492/wjccm.v12.i5.254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 09/29/2023] [Accepted: 11/08/2023] [Indexed: 12/07/2023] Open
Abstract
As the treatment options, modalities and technology have grown, mortality in intensive care unit (ICU) has been on the decline. More and more patients are being discharged to wards and in the care of their loved ones after prolonged treatment at times and sometimes in isolation. These survivors have a lower life expectancy and a poorer quality of life. They can have substantial familial financial implications and an economic impact on the healthcare system in terms of increased and continued utilisation of services, the so-called post intensive care syndrome (PICS). But it is not only the patient who is the sufferer. The mental health of the loved ones and family members may also be affected, which is termed as PICS-family. In this review, we shall be reviewing the definition, epidemiology, clinical features, diagnosis and evaluation, treatment and follow up of PICS. We shall also focus on measures to prevent, rehabilitate and understand the ICU stay from patients’ perspective on how to redesign the ICU, post ICU care needs for a better patient outcome.
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Affiliation(s)
- Nishant Kumar
- Department of Anaesthesiology and Critical Care, Lady Hardinge Medical College and Associated Hospitals, New Delhi 110001, India
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Vlisides PE, Li D, Maywood M, Zierau M, Lapointe AP, Brooks J, McKinney AM, Leis AM, Mentz G, Mashour GA. Electroencephalographic Biomarkers, Cerebral Oximetry, and Postoperative Cognitive Function in Adult Noncardiac Surgical Patients: A Prospective Cohort Study. Anesthesiology 2023; 139:568-579. [PMID: 37364282 PMCID: PMC10592490 DOI: 10.1097/aln.0000000000004664] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023]
Abstract
BACKGROUND Perioperative neurocognitive disorders are a major public health issue, although there are no validated neurophysiologic biomarkers that predict cognitive function after surgery. This study tested the hypothesis that preoperative posterior electroencephalographic alpha power, alpha frontal-parietal connectivity, and cerebral oximetry would each correlate with postoperative neurocognitive function. METHODS This was a single-center, prospective, observational study of adult (older than 18 yr) male and female noncardiac surgery patients. Whole-scalp, 16-channel electroencephalography and cerebral oximetry were recorded in the preoperative, intraoperative, and immediate postoperative settings. The primary outcome was the mean postoperative T-score of three National Institutes of Health Toolbox Cognition tests-Flanker Inhibitory Control and Attention, List Sorting Working Memory, and Pattern Comparison Processing Speed. These tests were obtained at preoperative baseline and on the first two postoperative mornings. The lowest average score from the first two postoperative days was used for the primary analysis. Delirium was a secondary outcome (via 3-min Confusion Assessment Method) measured in the postanesthesia care unit and twice daily for the first 3 postoperative days. Last, patient-reported outcomes related to cognition and overall well-being were collected 3 months postdischarge. RESULTS Sixty-four participants were recruited with a median (interquartile range) age of 59 (48 to 66) yr. After adjustment for baseline cognitive function scores, no significant partial correlation (ρ) was detected between postoperative cognition scores and preoperative relative posterior alpha power (%; ρ = -0.03, P = 0.854), alpha frontal-parietal connectivity (via weight phase lag index; ρ = -0.10, P = 0.570, respectively), or preoperative cerebral oximetry (%; ρ = 0.21, P = 0.246). Only intraoperative frontal-parietal theta connectivity was associated with postoperative delirium (F[1,6,291] = 4.53, P = 0.034). No electroencephalographic or oximetry biomarkers were associated with cognitive or functional outcomes 3 months postdischarge. CONCLUSIONS Preoperative posterior alpha power, frontal-parietal connectivity, and cerebral oximetry were not associated with cognitive function after noncardiac surgery. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Phillip E. Vlisides
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI USA
- Center for Consciousness Science, University of Michigan, Ann Arbor, MI USA
| | - Duan Li
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI USA
| | - Michael Maywood
- Department of Ophthalmology, William Beaumont Hospital, Royal Oak, MI, USA
| | - Mackenzie Zierau
- College of Health Professions, University of Detroit Mercy, Detroit, MI USA
| | - Andrew P. Lapointe
- Department of Radiology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Joseph Brooks
- Department of Orthopaedic Surgery, Michigan Medicine, Ann Arbor, MI USA
| | - Amy M. McKinney
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI USA
| | - Aleda M. Leis
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI USA
| | - Graciela Mentz
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI USA
| | - George A. Mashour
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI USA
- Center for Consciousness Science, University of Michigan, Ann Arbor, MI USA
- Neuroscience Graduate Program, University of Michigan Medical School, Ann Arbor, MI USA
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Sonneville R, Benghanem S, Jeantin L, de Montmollin E, Doman M, Gaudemer A, Thy M, Timsit JF. The spectrum of sepsis-associated encephalopathy: a clinical perspective. Crit Care 2023; 27:386. [PMID: 37798769 PMCID: PMC10552444 DOI: 10.1186/s13054-023-04655-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 09/19/2023] [Indexed: 10/07/2023] Open
Abstract
Sepsis-associated encephalopathy is a severe neurologic syndrome characterized by a diffuse dysfunction of the brain caused by sepsis. This review provides a concise overview of diagnostic tools and management strategies for SAE at the acute phase and in the long term. Early recognition and diagnosis of SAE are crucial for effective management. Because neurologic evaluation can be confounded by several factors in the intensive care unit setting, a multimodal approach is warranted for diagnosis and management. Diagnostic tools commonly employed include clinical evaluation, metabolic tests, electroencephalography, and neuroimaging in selected cases. The usefulness of blood biomarkers of brain injury for diagnosis remains limited. Clinical evaluation involves assessing the patient's mental status, motor responses, brainstem reflexes, and presence of abnormal movements. Electroencephalography can rule out non-convulsive seizures and help detect several patterns of various severity such as generalized slowing, epileptiform discharges, and triphasic waves. In patients with acute encephalopathy, the diagnostic value of non-contrast computed tomography is limited. In septic patients with persistent encephalopathy, seizures, and/or focal signs, magnetic resonance imaging detects brain injury in more than 50% of cases, mainly cerebrovascular complications, and white matter changes. Timely identification and treatment of the underlying infection are paramount, along with effective control of systemic factors that may contribute to secondary brain injury. Upon admission to the ICU, maintaining appropriate levels of oxygenation, blood pressure, and metabolic balance is crucial. Throughout the ICU stay, it is important to be mindful of the potential neurotoxic effects associated with specific medications like midazolam and cefepime, and to closely monitor patients for non-convulsive seizures. The potential efficacy of targeted neurocritical care during the acute phase in optimizing patient outcomes deserves to be further investigated. Sepsis-associated encephalopathy may lead to permanent neurologic sequelae. Seizures occurring in the acute phase increase the susceptibility to long-term epilepsy. Extended ICU stays and the presence of sepsis-associated encephalopathy are linked to functional disability and neuropsychological sequelae, underscoring the necessity for long-term surveillance in the comprehensive care of septic patients.
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Affiliation(s)
- Romain Sonneville
- INSERM UMR 1137, Université Paris Cité, 75018, Paris, France.
- Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital, APHP, 46 Rue Henri Huchard, 75877, Paris Cedex, France.
| | - Sarah Benghanem
- Department of Intensive Care Medicine, Cochin University Hospital, APHP, 75014, Paris, France
| | - Lina Jeantin
- Department of Neurology, Rothschild Foundation, Paris, France
| | - Etienne de Montmollin
- INSERM UMR 1137, Université Paris Cité, 75018, Paris, France
- Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital, APHP, 46 Rue Henri Huchard, 75877, Paris Cedex, France
| | - Marc Doman
- Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital, APHP, 46 Rue Henri Huchard, 75877, Paris Cedex, France
| | - Augustin Gaudemer
- INSERM UMR 1137, Université Paris Cité, 75018, Paris, France
- Department Radiology, Bichat-Claude Bernard University Hospital, APHP, 75018, Paris, France
| | - Michael Thy
- Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital, APHP, 46 Rue Henri Huchard, 75877, Paris Cedex, France
| | - Jean-François Timsit
- INSERM UMR 1137, Université Paris Cité, 75018, Paris, France
- Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital, APHP, 46 Rue Henri Huchard, 75877, Paris Cedex, France
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Ott J, Oh-Park M, Boukrina O. Association of delirium and spatial neglect in patients with right-hemisphere stroke. PM R 2023; 15:1075-1082. [PMID: 36377594 DOI: 10.1002/pmrj.12922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 10/14/2022] [Accepted: 11/02/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Delirium, an acute and fluctuating decline in cognitive functioning, increases mortality and length of hospital stays (LOS) and adversely affects functional outcomes. Previous studies suggested that the incidence of delirium may be increased in right-hemisphere strokes. Similarly, spatial neglect, a disabling deficit in unilateral spatial processing, is more common and more severe following a right-sided stroke. Spatial neglect has been established as a risk factor for delirium. OBJECTIVE It was hypothesized that functionally relevant spatial neglect and delirium are associated in patients with right-hemisphere stroke during acute inpatient rehabilitation. Data were examined from consecutive unilateral stroke patients evaluated with the 3-minute diagnostic interview for confusion assessment method (3D-CAM) and the Catherine Bergego Scale (CBS) via the Kessler Foundation Neglect Assessment Process (KF-NAP). DESIGN A retrospective, cohort study. SETTING Data collected in an acute inpatient rehabilitation facility. PARTICIPANTS Six hundred twenty six patients with stroke were included. MAIN OUTCOME MEASURES The measures were the relative risk of patients with right-hemisphere stroke having delirium when also positive for spatial neglect compared to patients with right-hemisphere stroke without spatial neglect, the incidence of 3D-CAM positive results by stroke hemisphere, and the effect of spatial neglect and delirium on functional outcomes for patients with right-brain stroke patients. RESULTS There was a significantly higher risk of delirium in patients with right-hemisphere stroke with spatial neglect compared to patients with right-hemisphere stroke without spatial neglect. The rates of 3D-CAM positive results were not statistically different for left- compared to right-hemisphere strokes. Both delirium and spatial neglect had significant adverse effects on right-hemisphere stroke patients' functional independence. CONCLUSIONS The results demonstrate an association between spatial neglect and delirium in patients with right hemisphere stroke in the acute inpatient rehabilitation setting. Because of the negative effect of these impairments on functional outcomes after stroke, prevention, early detection, and targeted treatments should be prioritized for these patients.
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Affiliation(s)
- Jamie Ott
- Department of Physical Medicine and Rehabilitation, University of Washington, Seattle, Washington, USA
| | - Mooyeon Oh-Park
- Burke Rehabilitation Hospital, Department of Rehabilitation Medicine, Albert Einstein College of Medicine, Montefiore Health System, White Plains, New York, USA
| | - Olga Boukrina
- Department of Physical Medicine and Rehabilitation, University of Washington, Seattle, Washington, USA
- Center for Stroke Rehabilitation Research, Kessler Foundation, West Orange, New Jersey, USA
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Cuninghame S, Jerath A, Gorsky K, Sivajohan A, Francoeur C, Withington D, Burry L, Cuthbertson BH, Orser BA, Martin C, Owen AM, Slessarev M. Effect of inhaled anaesthetics on cognitive and psychiatric outcomes in critically ill adults: a systematic review and meta-analysis. Br J Anaesth 2023; 131:314-327. [PMID: 37344338 DOI: 10.1016/j.bja.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 04/17/2023] [Accepted: 05/04/2023] [Indexed: 06/23/2023] Open
Abstract
BACKGROUND Sedation of critically ill patients with inhaled anaesthetics may reduce lung inflammation, time to extubation, and ICU length of stay compared with intravenous (i.v.) sedatives. However, the impact of inhaled anaesthetics on cognitive and psychiatric outcomes in this population is unclear. In this systematic review, we aimed to summarise the effect of inhaled anaesthetics on cognitive and psychiatric outcomes in critically ill adults. METHODS We searched MEDLINE, EMBASE, and PsycINFO for case series, retrospective, and prospective studies in critically ill adults sedated with inhaled anaesthetics. Outcomes included delirium, psychomotor and neurological recovery, long-term cognitive dysfunction, ICU memories, anxiety, depression, post-traumatic stress disorder (PTSD), and instruments used for assessment. RESULTS Thirteen studies were included in distinct populations of post-cardiac arrest survivors (n=4), postoperative noncardiac patients (n=3), postoperative cardiac patients (n=2), and mixed medical-surgical patients (n=4). Eight studies reported delirium incidence, two neurological recovery, and two ICU memories. One study reported on psychomotor recovery, long-term cognitive dysfunction, anxiety, depression, and PTSD. A meta-analysis of five trials found no difference in delirium incidence between inhaled and i.v. sedatives (relative risk 0.95 [95% confidence interval: 0.59-1.54]). Compared with i.v. sedatives, inhaled anaesthetics were associated with fewer hallucinations and faster psychomotor recovery but no differences in other outcomes. There was heterogeneity in the instruments used and timing of these assessments. CONCLUSIONS Based on the limited evidence available, there is no difference in cognitive and psychiatric outcomes between adults exposed to volatile sedation or intravenous sedation in the ICU. Future studies should incorporate outcome assessment with validated tools during and after hospital stay. SYSTEMATIC REVIEW PROTOCOL PROSPERO CRD42021236455.
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Affiliation(s)
- Sean Cuninghame
- Department of Medicine, Western University, London, ON, Canada
| | - Angela Jerath
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Schulich Heart Program, Sunnybrook Research Institute, Toronto, ON, Canada; Institute for Health Policy, Management and Evaluation, University of Toronto, ON, Canada
| | - Kevin Gorsky
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Asaanth Sivajohan
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Conall Francoeur
- Centre de Recherche CHU de Québec-Université Laval, Quebec City, QC, Canada
| | - Davinia Withington
- Department of Anesthesia, Montreal Children's Hospital, Montreal, QC, Canada; Department of Anesthesia, McGill University, Montreal, QC, Canada
| | - Lisa Burry
- Departments of Pharmacy and Medicine, Mount Sinai Hospital, Toronto, ON, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Brian H Cuthbertson
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Institute for Health Policy, Management and Evaluation, University of Toronto, ON, Canada
| | - Beverley A Orser
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Claudio Martin
- Department of Medicine, Western University, London, ON, Canada
| | - Adrian M Owen
- Western Institute for Neuroscience, Western University, London, ON, Canada; Department of Psychology and Department of Physiology and Pharmacology, Western University, London, Canada
| | - Marat Slessarev
- Department of Medicine, Western University, London, ON, Canada; Western Institute for Neuroscience, Western University, London, ON, Canada.
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Rengel KF, Mart MF, Wilson JE, Ely EW. Thinking Clearly: The History of Brain Dysfunction in Critical Illness. Crit Care Clin 2023; 39:465-477. [PMID: 37230551 DOI: 10.1016/j.ccc.2023.01.004] [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: 05/27/2023]
Abstract
Brain dysfunction during critical illness (ie, delirium and coma) is extremely common, and its lasting effect has only become increasingly understood in the last two decades. Brain dysfunction in the intensive care unit (ICU) is an independent predictor of both increased mortality and long-term impairments in cognition among survivors. As critical care medicine has grown, important insights regarding brain dysfunction in the ICU have shaped our practice including the importance of light sedation and the avoidance of deliriogenic drugs such as benzodiazepines. Best practices are now strategically incorporated in targeted bundles of care like the ICU Liberation Campaign's ABCDEF Bundle.
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Affiliation(s)
- Kimberly F Rengel
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 450, 4th Floor, Nashville, TN 37203, USA; Department of Anesthesiology, Division of Anesthesia Critical Care Medicine, Vanderbilt University Medical Center, 1211 21st Avenue South, MAB 422, Nashville, TN 37213, USA.
| | - Matthew F Mart
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 450, 4th Floor, Nashville, TN 37203, USA; Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, Nashville, TN 37232, USA; Geriatric Research, Education, and Clinical Center (GRECC), Tennessee Valley Veterans Affairs Health System, VA Tennessee Valley Healthcare system, 1310 24th Avenue South, Nashville, TN 37212, USA
| | - Jo Ellen Wilson
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 450, 4th Floor, Nashville, TN 37203, USA; Geriatric Research, Education, and Clinical Center (GRECC), Tennessee Valley Veterans Affairs Health System, VA Tennessee Valley Healthcare system, 1310 24th Avenue South, Nashville, TN 37212, USA; Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Vanderbilt Psychiatric Hospital, 1601 23rd Avenue South, Nashville, TN 37212, USA
| | - E Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 450, 4th Floor, Nashville, TN 37203, USA; Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, Nashville, TN 37232, USA; Geriatric Research, Education, and Clinical Center (GRECC), Tennessee Valley Veterans Affairs Health System, VA Tennessee Valley Healthcare system, 1310 24th Avenue South, Nashville, TN 37212, USA
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Bassi T, Rohrs E, Nicholas M, Reynolds S. Meta-analysis of serological biomarkers at hospital admission for the likelihood of developing delirium during hospitalization. Front Neurol 2023; 14:1179243. [PMID: 37360340 PMCID: PMC10288875 DOI: 10.3389/fneur.2023.1179243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 05/11/2023] [Indexed: 06/28/2023] Open
Abstract
Importance Identifying biomarkers that, at hospital admission, predict subsequent delirium will help to focus our clinical efforts on prevention and management. Objective The study aimed to investigate biomarkers at hospital admission that may be associated with delirium during hospitalization. Data sources A librarian at the Fraser Health Authority Health Sciences Library performed searches from 28 June 2021 to 9 July 2021, using the following sources: Medline, EMBASE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register, and the Database of Abstracts of Reviews and Effects. Study selection The inclusion criteria were articles in English that investigated the link between serum concentration of biomarkers at hospital admission and delirium during hospitalization. Exclusion criteria were single case reports, case series, comments, editorials, letters to the editor, articles that were not relevant to the review objective, and articles concerning pediatrics. After excluding duplicates, 55 studies were included. Data extraction and synthesis This meta-analysis followed the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) protocol. Independent extraction, with the consensus of multiple reviewers, was used to determine the final studies included. The weight and heterogeneity of the manuscripts were calculated using inverse covariance with a random-effects model. Main outcomes and measures Differences in mean serum concentration of biomarkers at hospital admission between patients who did and did not develop delirium during hospitalization. Results Our search found evidence that patients who developed delirium during hospitalization had, at hospital admission, significantly greater concentrations of certain inflammatory biomarkers and one blood-brain barrier leakage marker than patients who did not develop delirium during hospitalization (differences in the mean: cortisol: 3.36 ng/ml, p < 0.0001; CRP: 41.39 mg/L, p < 0.00001; IL-6: 24.05 pg/ml, p < 0.00001; S100β 0.07 ng/ml, p < 0.00001). These differences were independent of other confounding variables such as the patient's severity of illness. A significantly lower serum concentration, at hospital admission, of acetylcholinesterase (difference in the means -0.86 U/ml, p = 0.004) was also associated with an increased vulnerability to developing delirium during hospitalization. Conclusion and relevance Our meta-analysis supports the hypothesis that patients with hypothalamic-pituitary axis dysfunction, increased blood-brain barrier permeability, and chronic overload of the cholinergic system, at hospital admission, are more vulnerable to developing delirium during hospitalization.
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Affiliation(s)
- Thiago Bassi
- Lungpacer Medical USA Inc., Exton, PA, United States
| | - Elizabeth Rohrs
- Advancing Innovation in Medicine Institute, New Westminster, BC, Canada
- Biomedical, Physiology and Kinesiology Department, Simon Fraser University, Burnaby, BC, Canada
| | - Michelle Nicholas
- Advancing Innovation in Medicine Institute, New Westminster, BC, Canada
- Biomedical, Physiology and Kinesiology Department, Simon Fraser University, Burnaby, BC, Canada
| | - Steven Reynolds
- Advancing Innovation in Medicine Institute, New Westminster, BC, Canada
- Biomedical, Physiology and Kinesiology Department, Simon Fraser University, Burnaby, BC, Canada
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10
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Nassar AP, Ely EW, Fiest KM. Long-term outcomes of intensive care unit delirium. Intensive Care Med 2023; 49:677-680. [PMID: 36964214 DOI: 10.1007/s00134-023-07029-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 03/03/2023] [Indexed: 03/26/2023]
Affiliation(s)
- Antonio Paulo Nassar
- Department of Critical Care, A.C. Camargo Cancer Center, Rua Professor Antonio Prudente, 211, 6th Floor, Intensive Care Unit, São Paulo, SP, CEP 01509-0100, Brazil.
| | - Eugene Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, and the Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, TN, USA
| | - Kirsten M Fiest
- Department of Critical Care Medicine, University of Calgary, Calgary, Canada
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Vasunilashorn SM, Lunardi N, Newman JC, Crosby G, Acker L, Abel T, Bhatnagar S, Cunningham C, de Cabo R, Dugan L, Hippensteel JA, Ishizawa Y, Lahiri S, Marcantonio ER, Xie Z, Inouye SK, Terrando N, Eckenhoff RG. Preclinical and translational models for delirium: Recommendations for future research from the NIDUS delirium network. Alzheimers Dement 2023; 19:2150-2174. [PMID: 36799408 PMCID: PMC10576242 DOI: 10.1002/alz.12941] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 12/19/2022] [Accepted: 12/20/2022] [Indexed: 02/18/2023]
Abstract
Delirium is a common, morbid, and costly syndrome that is closely linked to Alzheimer's disease (AD) and AD-related dementias (ADRD) as a risk factor and outcome. Human studies of delirium have advanced our knowledge of delirium incidence and prevalence, risk factors, biomarkers, outcomes, prevention, and management. However, understanding of delirium neurobiology remains limited. Preclinical and translational models for delirium, while challenging to develop, could advance our knowledge of delirium neurobiology and inform the development of new prevention and treatment approaches. We discuss the use of preclinical and translational animal models in delirium, focusing on (1) a review of current animal models, (2) challenges and strategies for replicating elements of human delirium in animals, and (3) the utility of biofluid, neurophysiology, and neuroimaging translational markers in animals. We conclude with recommendations for the development and validation of preclinical and translational models for delirium, with the goal of advancing awareness in this important field.
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Affiliation(s)
- Sarinnapha M. Vasunilashorn
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Nadia Lunardi
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia, USA
| | - John C. Newman
- Department of Medicine, University of California, San Francisco, California, USA
- Buck Institute for Research on Aging, Novato, California, USA
| | - Gregory Crosby
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesiology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Leah Acker
- Department of Anesthesiology, Duke University, Durham, Massachusetts, USA
| | - Ted Abel
- Department of Neuroscience and Pharmacology, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Seema Bhatnagar
- Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Colm Cunningham
- School of Biochemistry and Immunology, Trinity Biomedical Sciences Institute, Dublin, Ireland
- Trinity College Institute of Neuroscience, Trinity College, Dublin, Ireland
| | - Rafael de Cabo
- Translational Gerontology Branch, Intramural Research Program, National Institute on Aging, Baltimore, Maryland, USA
| | - Laura Dugan
- Vanderbilt Brain Institute, Vanderbilt University, Nashville, Tennessee, USA
- Division of Geriatric Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- VA Tennessee Valley Geriatric Research, Education, and Clinical Center (GRECC), Nashville, Tennessee, USA
| | - Joseph A. Hippensteel
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Yumiko Ishizawa
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Shouri Lahiri
- Department of Neurology, Neurosurgery, and Biomedical Sciences, Cedar-Sinai Medical Center, Los Angeles, California, USA
| | - Edward R. Marcantonio
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Zhongcong Xie
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sharon K. Inouye
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Niccolò Terrando
- Department of Anesthesiology, Duke University, Durham, North Carolina, USA
- Department of Cell Biology, Duke University, Durham, North Carolina, USA
- Department of Immunology, Duke University, Durham, North Carolina, USA
- Duke Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, USA
| | - Roderic G. Eckenhoff
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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12
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Gao L, Gaba A, Li P, Saxena R, Scheer FAJL, Akeju O, Rutter MK, Hu K. Heart rate response and recovery during exercise predict future delirium risk-A prospective cohort study in middle- to older-aged adults. JOURNAL OF SPORT AND HEALTH SCIENCE 2023; 12:312-323. [PMID: 34915199 DOI: 10.1016/j.jshs.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 11/10/2021] [Accepted: 11/17/2021] [Indexed: 05/17/2023]
Abstract
BACKGROUND Delirium is a neurocognitive disorder characterized by an abrupt decline in attention, awareness, and cognition after surgical/illness-induced stressors on the brain. There is now an increasing focus on how cardiovascular health interacts with neurocognitive disorders given their overlapping risk factors and links to subsequent dementia and mortality. One common indicator for cardiovascular health is the heart rate response/recovery (HRR) to exercise, but how this relates to future delirium is unknown. METHODS Electrocardiogram data were examined in 38,740 middle- to older-aged UK Biobank participants (mean age = 58.1 years, range: 40-72 years; 47.3% males) who completed a standardized submaximal exercise stress test (15-s baseline, 6-min exercise, and 1-min recovery) and required hospitalization during follow-up. An HRR index was derived as the product of the heart rate (HR) responses during exercise (peak/resting HRs) and recovery (peak/recovery HRs) and categorized into low/average/high groups as the bottom quartile/middle 2 quartiles/top quartile, respectively. Associations between 3 HRR groups and new-onset delirium were investigated using Cox proportional hazards models and a 2-year landmark analysis to minimize reverse causation. Sociodemographic factors, lifestyle factors/physical activity, cardiovascular risk, comorbidities, cognition, and maximal workload achieved were included as covariates. RESULTS During a median follow-up period of 11 years, 348 participants (9/1000) newly developed delirium. Compared with the high HRR group (16/1000), the risk for delirium was almost doubled in those with low HRR (hazard ratio = 1.90, 95% confidence interval (95%CI): 1.30-2.79, p = 0.001) and average HRR (hazard ratio = 1.54, 95%CI: 1.07-2.22, p = 0.020)). Low HRR was equivalent to being 6 years older, a current smoker, or ≥3 additional cardiovascular disease risks. Results were robust in sensitivity analysis, but the risk appeared larger in those with better cognition and when only postoperative delirium was considered (n = 147; hazard ratio = 2.66, 95%CI: 1.46-4.85, p = 0.001). CONCLUSION HRR during submaximal exercise is associated with future risk for delirium. Given that HRR is potentially modifiable, it may prove useful for neurological risk stratification alongside traditional cardiovascular risk factors.
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Affiliation(s)
- Lei Gao
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; Medical Biodynamics Program, Brigham and Women's Hospital, Boston, MA 02115, USA; Division of Sleep Medicine, Harvard Medical School, Boston, MA 02115, USA.
| | - Arlen Gaba
- Medical Biodynamics Program, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Peng Li
- Medical Biodynamics Program, Brigham and Women's Hospital, Boston, MA 02115, USA; Division of Sleep Medicine, Harvard Medical School, Boston, MA 02115, USA
| | - Richa Saxena
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA 02114, USA; Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester M13 9PL, UK
| | - Frank A J L Scheer
- Division of Sleep Medicine, Harvard Medical School, Boston, MA 02115, USA; Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA 02142, USA
| | - Oluwaseun Akeju
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Martin K Rutter
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester M13 9PL, UK; Diabetes, Endocrinology and Metabolism Centre, Manchester University National Health Service Foundation Trust, Manchester M13 9WL, UK
| | - Kun Hu
- Medical Biodynamics Program, Brigham and Women's Hospital, Boston, MA 02115, USA; Division of Sleep Medicine, Harvard Medical School, Boston, MA 02115, USA; Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA 02142, USA
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13
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Bommarito G, Garibotto V, Frisoni GB, Assal F, Lalive PH, Allali G. The Two-Way Route between Delirium Disorder and Dementia: Insights from COVID-19. NEURODEGENER DIS 2023; 22:91-103. [PMID: 37054684 DOI: 10.1159/000530566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/23/2023] [Indexed: 04/15/2023] Open
Abstract
BACKGROUND Delirium disorder is a frequent neurological complication of SARS-CoV-2 infection and associated with increased disease severity and mortality. Cognitive impairment is a major risk factor for developing delirium disorder during COVID-19, which, in turn, increases the risk of subsequent neurological complications and cognitive decline. SUMMARY The bidirectional connection between delirium disorder and dementia likely resides at multiple levels, and its pathophysiological mechanisms during COVID-19 include endothelial damage, blood-brain barrier dysfunction, and local inflammation, with activation of microglia and astrocytes. Here, we describe the putative pathogenic pathways underlying delirium disorder during COVID-19 and highlight how they cross with the ones leading to neurodegenerative dementia. KEY MESSAGES The analysis of the two-sided link can offer useful insights for confronting with long-term neurological consequences of COVID-19 and framing future prevention and early treatment strategies.
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Affiliation(s)
- Giulia Bommarito
- Department of Clinical Neurosciences, Lausanne University Hospitals and University of Lausanne, Lausanne, Switzerland
| | - Valentina Garibotto
- Division of Nuclear Medicine and Molecular Imaging, Geneva University Hospitals and NIMTlab, University of Geneva, Geneva, Switzerland
| | - Giovanni B Frisoni
- Memory Center and LANVIE-Laboratory of Neuroimaging of Aging, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Frédéric Assal
- Department of Clinical Neurosciences, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Patrice H Lalive
- Department of Clinical Neurosciences, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of Laboratory Medicine, Diagnostic Department, Geneva University Hospitals, Geneva, Switzerland
| | - Gilles Allali
- Department of Clinical Neurosciences, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
- Division of Cognitive and Motor Aging, Department of Neurology, Albert Einstein College of Medicine, Yeshiva University, Bronx, New York, USA
- Leenaards Memory Center, Lausanne University Hospitals and University of Lausanne, Lausanne, Switzerland
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Abstract
PURPOSE OF REVIEW Sepsis, defined as life-threatening organ dysfunction caused by a dysregulated host response to infection, is a leading cause of hospital and ICU admission. The central and peripheral nervous system may be the first organ system to show signs of dysfunction, leading to clinical manifestations such as sepsis-associated encephalopathy (SAE) with delirium or coma and ICU-acquired weakness (ICUAW). In the current review, we want to highlight developing insights into the epidemiology, diagnosis, prognosis, and treatment of patients with SAE and ICUAW. RECENT FINDINGS The diagnosis of neurological complications of sepsis remains clinical, although the use of electroencephalography and electromyography can support the diagnosis, especially in noncollaborative patients, and can help in defining disease severity. Moreover, recent studies suggest new insights into the long-term effects associated with SAE and ICUAW, highlighting the need for effective prevention and treatment. SUMMARY In this manuscript, we provide an overview of recent insights and developments in the prevention, diagnosis, and treatment of patients with SAE and ICUAW.
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Affiliation(s)
- Simone Piva
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital
| | - Michele Bertoni
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital
| | - Nicola Gitti
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia
| | - Francesco A. Rasulo
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital
- ’Alessandra Bono’ University Research Center on Long-term Outcome in Critical Illness Survivors, University of Brescia, Brescia, Italy
| | - Nicola Latronico
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital
- ’Alessandra Bono’ University Research Center on Long-term Outcome in Critical Illness Survivors, University of Brescia, Brescia, Italy
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15
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Bai Y, Belardinelli P, Thoennes C, Blum C, Baur D, Laichinger K, Lindig T, Ziemann U, Mengel A. Cortical reactivity to transcranial magnetic stimulation predicts risk of post-stroke delirium. Clin Neurophysiol 2023; 148:97-108. [PMID: 36526534 DOI: 10.1016/j.clinph.2022.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/14/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Post-stroke delirium (PSD) is a frequent and with regard to outcome unfavorable complication in acute stroke. The neurobiological mechanisms predisposing to PSD remain poorly understood, and biomarkers predicting its risk have not been established. We tested the hypothesis that hypoexcitable or disconnected brain networks predispose to PSD by measuring brain reactivity to transcranial magnetic stimulation with electroencephalography (TMS-EEG). METHODS We conducted a cross-sectional study in 33 acute stroke patients within 48 hours of stroke onset. Brain reactivity to single-pulse TMS of dorsolateral prefrontal cortex, primary motor cortex and superior parietal lobule of the right hemisphere was quantified by response intensity, effective connectivity, perturbational complexity index (PCIST), and natural frequency of the TMS-EEG response. PSD development was clinically tracked every 8 hours before and for 7 days following TMS-EEG. RESULTS Fourteen patients developed PSD while 19 patients did not. The PSD group showed lower excitability, effective connectivity, PCIST and natural frequency compared to the non-PSD group. The maximum PCIST over all three TMS sites demonstrated largest classification accuracy with a ROC-AUC of 0.943. This effect was independent of lesion size, affected hemisphere and stroke severity. Maximum PCIST and maximum natural frequency correlated inversely with delirium duration. CONCLUSIONS Brain reactivity to TMS-EEG can unravel brain network states of reduced excitability, effective connectivity, perturbational complexity and natural frequency that identify acute stroke patients at high risk for development of delirium. SIGNIFICANCE Findings provide novel insight into the pathophysiology of pre-delirium brain states and may promote effective delirium prevention strategies in those patients at high risk.
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Affiliation(s)
- Yang Bai
- Department of Neurology & Stroke, University of Tübingen, Tübingen, Germany; Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany; School of Basic Medical Sciences, Hangzhou Normal University, Hangzhou, China
| | - Paolo Belardinelli
- Department of Neurology & Stroke, University of Tübingen, Tübingen, Germany; Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany; Center for Mind/Brain Sciences - CIMeC, University of Trento, Italy
| | - Catrina Thoennes
- Department of Neurology & Stroke, University of Tübingen, Tübingen, Germany; Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Corinna Blum
- Department of Neurology & Stroke, University of Tübingen, Tübingen, Germany; Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - David Baur
- Department of Neurology & Stroke, University of Tübingen, Tübingen, Germany; Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Kornelia Laichinger
- Department of Neurology & Stroke, University of Tübingen, Tübingen, Germany; Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Tobias Lindig
- Department of Neuroradiology, University of Tübingen, Tübingen, Germany
| | - Ulf Ziemann
- Department of Neurology & Stroke, University of Tübingen, Tübingen, Germany; Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany.
| | - Annerose Mengel
- Department of Neurology & Stroke, University of Tübingen, Tübingen, Germany; Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
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Ferlini L, Gaspard N. What's new on septic encephalopathy? Ten things you need to know. Minerva Anestesiol 2023; 89:217-225. [PMID: 35833857 DOI: 10.23736/s0375-9393.22.16689-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Sepsis associated encephalopathy (SAE) is a frequent complication of sepsis and is associated with a higher risk of short-term mortality and long-term cognitive impairment. The EEG is a sensitive complement of the clinical examination that can also detect and quantify encephalopathy and identify features with prognostic value, such as lack of reactivity. Moreover, despite their effect on outcome is still debated, the EEG is the only tool to detect non-convulsive seizures which can occur in a septic setting. Understanding the pathophysiology of SAE is fundamental to define potential therapeutic targets. Neuroinflammation plays an important role in the development of SAE and many blood and imaging biomarkers have recently shown a promising ability to distinguish SAE form non-SAE patient. In recent years, some interesting mediators of inflammation were successfully targeted in animal models, with a significant reduction in the neuroinflammation and in sepsis-induced cognitive decline. However, the complexity of the host response to sepsis currently limits the use of immunomodulation therapies in humans. Alteration in regulatory systems of cerebral blood flow, namely cerebral autoregulation (CA) and neurovascular coupling, contribute to SAE development. Nowadays, clinicians have access to different tools to assess them at the bedside and CA-based blood pressure protocols should be implemented to optimize cerebral perfusion. Its inauspicious consequences, its complex physiopathology and the lack of efficacious treatment make of SAE a highly active research subject.
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Affiliation(s)
- Lorenzo Ferlini
- Department of Neurology, Hôpital Erasme, University of Brussels, Brussels, Belgium
| | - Nicolas Gaspard
- Department of Neurology, Hôpital Erasme, University of Brussels, Brussels, Belgium -
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17
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Ramnarain D, Pouwels S, Fernández-Gonzalo S, Navarra-Ventura G, Balanzá-Martínez V. Delirium-related psychiatric and neurocognitive impairment and the association with post-intensive care syndrome-A narrative review. Acta Psychiatr Scand 2023; 147:460-474. [PMID: 36744298 DOI: 10.1111/acps.13534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 01/21/2023] [Accepted: 01/23/2023] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Delirium is common among patients admitted to the intensive care unit (ICU) and its impact on the neurocognitive and psychiatric state of survivors is of great interest. These new-onset or worsening conditions, together with physical alterations, are called post-intensive care syndrome (PICS). Our aim is to update on the latest screening and follow-up options for psychological and cognitive sequelae of PICS. METHOD This narrative review discusses the occurrence of delirium in ICU settings and the relatively new concept of PICS. Psychiatric and neurocognitive morbidities that may occur in survivors of critical illness following delirium are addressed. Future perspectives for practice and research are discussed. RESULTS There is no "gold standard" for diagnosing delirium in the ICU, but two extensively validated tools, the confusion assessment method for the ICU and the intensive care delirium screening checklist, are often used. PICS complaints are frequent in ICU survivors who have suffered delirium and have been recognized as an important public health and socio-economic problem worldwide. Depression, anxiety, post-traumatic stress disorder, and long-term cognitive impairment are recurrently exhibited. Screening tools for these deficits are discussed, as well as the suggestion of early assessment after discharge and at 3 and 12 months. CONCLUSIONS Delirium is a complex but common phenomenon in the ICU and a risk factor for PICS. Its diagnosis is challenging with potential long-term adverse outcomes, including psychiatric and cognitive difficulties. The implementation of screening and follow-up protocols for PICS sequelae is warranted to ensure early detection and appropriate management.
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Affiliation(s)
- Dharmanand Ramnarain
- Department of Intensive Care Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands.,Department of Intensive Care Medicine, Saxenburgh Medical Center, Hardenberg, The Netherlands.,Departmentof Medical and Clinical Psychology, Center of Research on Psychological and Somatic disease (CoRPS), Tilburg University, Tilburg, The Netherlands
| | - Sjaak Pouwels
- Department of Intensive Care Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands.,Department of General, Abdominal and Minimally Invasive Surgery, Helios Klinikum, Krefeld, Germany
| | - Sol Fernández-Gonzalo
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain.,Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain.,Department of Clinical and Health Psychology, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Guillem Navarra-Ventura
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Vicent Balanzá-Martínez
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain.,Teaching Unit of Psychiatry and Psychological Medicine, Department of Medicine, University of Valencia, Valencia, Spain
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18
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Kant IMJ, de Bresser J, van Montfort SJT, Witkamp TD, Walraad B, Spies CD, Hendrikse J, van Dellen E, Slooter AJC, Winterer G, Pischon T, Boraschi D, Schneider R, N#x00FC;rnberg P, Norman Zacharias MP, Morgeli R, Olbert M, Lachmann G, Borchers F, Ofosu K, Yurek F, Wolf A, Gallinat J, Hendrikse J, Slooter A, van Dellen E, Stamatakis E, Preller J, Menon D, Moreno-Lopez L, Winzeck S, Feinkohl I, Italiani P, Melillo D, Camera GD, Krause R, Heidtke K, Kuhn S, Kronabel M, Dscietzig TB, Armbruster FP, Hafen B, Ruppert J, Bocher A, Helmschrodt A, Weyer M, Hartmann K, Diehl I, Weber S, Fillmer A, Ittermann B. Postoperative delirium is associated with grey matter brain volume loss. Brain Commun 2023; 5:fcad013. [PMID: 36819940 PMCID: PMC9933897 DOI: 10.1093/braincomms/fcad013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 08/12/2022] [Accepted: 01/26/2023] [Indexed: 02/03/2023] Open
Abstract
Delirium is associated with long-term cognitive dysfunction and with increased brain atrophy. However, it is unclear whether these problems result from or predisposes to delirium. We aimed to investigate preoperative to postoperative brain changes, as well as the role of delirium in these changes over time. We investigated the effects of surgery and postoperative delirium with brain MRIs made before and 3 months after major elective surgery in 299 elderly patients, and an MRI with a 3 months follow-up MRI in 48 non-surgical control participants. To study the effects of surgery and delirium, we compared brain volumes, white matter hyperintensities and brain infarcts between baseline and follow-up MRIs, using multiple regression analyses adjusting for possible confounders. Within the patients group, 37 persons (12%) developed postoperative delirium. Surgical patients showed a greater decrease in grey matter volume than non-surgical control participants [linear regression: B (95% confidence interval) = -0.65% of intracranial volume (-1.01 to -0.29, P < 0.005)]. Within the surgery group, delirium was associated with a greater decrease in grey matter volume [B (95% confidence interval): -0.44% of intracranial volume (-0.82 to -0.06, P = 0.02)]. Furthermore, within the patients, delirium was associated with a non-significantly increased risk of a new postoperative brain infarct [logistic regression: odds ratio (95% confidence interval): 2.8 (0.7-11.1), P = 0.14]. Our study was the first to investigate the association between delirium and preoperative to postoperative brain volume changes, suggesting that delirium is associated with increased progression of grey matter volume loss.
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Affiliation(s)
- Ilse M J Kant
- Department of Intensive Care Medicine and University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht 3584 CX, The Netherlands,Department of Information Technology and Digital Innovation, Leiden University Medical Center, Leiden 2333 ZA, The Netherlands
| | - Jeroen de Bresser
- Department of Radiology, Leiden University Medical Center, Leiden 2333 ZA, The Netherlands
| | - Simone J T van Montfort
- Department of Intensive Care Medicine and University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht 3584 CX, The Netherlands
| | - Theodoor D Witkamp
- Department of Radiology and University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht 3584 CX, The Netherlands
| | - Bob Walraad
- Department of Intensive Care Medicine and University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht 3584 CX, The Netherlands
| | - Claudia D Spies
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité – Universitätsmedizin Berlin, Berlin 10117, Germany
| | - Jeroen Hendrikse
- Department of Radiology and University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht 3584 CX, The Netherlands
| | - Edwin van Dellen
- Department of Intensive Care Medicine and University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht 3584 CX, The Netherlands,Department of Psychiatry and University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht 3584 CX, The Netherlands
| | - Arjen J C Slooter
- Correspondence to: Arjen Slooter Department of Intensive Care Medicine University Medical Center Utrecht Brain Center Utrecht University, Heidelberglaan 100 Utrecht 3584 CX, The Netherlands E-mail:
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19
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Girard TD, Pandharipande PP. Early mobilisation during critical illness: good for the body and brain. THE LANCET. RESPIRATORY MEDICINE 2023:S2213-2600(23)00011-5. [PMID: 36708729 DOI: 10.1016/s2213-2600(23)00011-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 01/03/2023] [Indexed: 01/27/2023]
Affiliation(s)
- Timothy D Girard
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Critical Illness, Brain dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Pratik P Pandharipande
- Critical Illness, Brain dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN 37232, USA; Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
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20
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Guran E, Hu J, Wefel JS, Chung C, Cata JP. Perioperative considerations in patients with chemotherapy-induced cognitive impairment: a narrative review. Br J Anaesth 2022; 129:909-922. [PMID: 36270848 DOI: 10.1016/j.bja.2022.08.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 08/01/2022] [Accepted: 08/23/2022] [Indexed: 11/02/2022] Open
Abstract
Patients with cancer may suffer from a decline in their cognitive function after various cancer therapies, including surgery, radiation, and chemotherapy, and in some cases, this decline in cognitive function persists even years after completion of treatment. Chemobrain or chemotherapy-induced cognitive impairment, a well-established clinical syndrome, has become an increasing concern as the number of successfully treated cancer patients has increased significantly. Chemotherapy-induced cognitive impairment can originate from direct neurotoxicity, neuroinflammation, and oxidative stress, resulting in alterations in grey matter volume, white matter integrity, and brain connectivity. Surgery has been associated with exacerbating the inflammatory response associated with chemotherapy and predisposes patients to develop postoperative cognitive dysfunction. As the proportion of patients living longer after these therapies increases, the magnitude of impact and growing concern of post-treatment cognitive dysfunction in these patients has also come to the fore. We review the clinical presentation, potential mechanisms, predisposing factors, diagnostic methods, neuropsychological testing, and imaging findings of chemotherapy-induced cognitive impairment and its intersection with postoperative cognitive dysfunction.
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Affiliation(s)
- Ekin Guran
- Department of Anaesthesiology and Reanimation, University of Health Sciences, Ankara Oncology Training and Research Hospital, Ankara, Turkey; Anaesthesiology and Surgical Oncology Research Group, Houston, TX, USA
| | - Jian Hu
- Department of Cancer Biology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey S Wefel
- Department of Neuro-Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Caroline Chung
- Department of Neuro-Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Juan P Cata
- Anaesthesiology and Surgical Oncology Research Group, Houston, TX, USA; Department of Anaesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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21
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Martinez-Orengo N, Tahmazian S, Lai J, Wang Z, Sinharay S, Schreiber-Stainthorp W, Basuli F, Maric D, Reid W, Shah S, Hammoud DA. Assessing organ-level immunoreactivity in a rat model of sepsis using TSPO PET imaging. Front Immunol 2022; 13:1010263. [PMID: 36439175 PMCID: PMC9685400 DOI: 10.3389/fimmu.2022.1010263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 10/17/2022] [Indexed: 11/11/2022] Open
Abstract
There is current need for new approaches to assess/measure organ-level immunoreactivity and ensuing dysfunction in systemic inflammatory response syndrome (SIRS) and sepsis, in order to protect or recover organ function. Using a rat model of systemic sterile inflammatory shock (intravenous LPS administration), we performed PET imaging with a translocator protein (TSPO) tracer, [18F]DPA-714, as a biomarker for reactive immunoreactive changes in the brain and peripheral organs. In vivo dynamic PET/CT scans showed increased [18F]DPA-714 binding in the brain, lungs, liver and bone marrow, 4 hours after LPS injection. Post-LPS mean standard uptake values (SUVmean) at equilibrium were significantly higher in those organs compared to baseline. Changes in spleen [18F]DPA-714 binding were variable but generally decreased after LPS. SUVmean values in all organs, except the spleen, positively correlated with several serum cytokines/chemokines. In vitro measures of TSPO expression and immunofluorescent staining validated the imaging results. Noninvasive molecular imaging with [18F]DPA-714 PET in a rat model of systemic sterile inflammatory shock, along with in vitro measures of TSPO expression, showed brain, liver and lung inflammation, spleen monocytic efflux/lymphocytic activation and suggested increased bone marrow hematopoiesis. TSPO PET imaging can potentially be used to quantify SIRS and sepsis-associated organ-level immunoreactivity and assess the effectiveness of therapeutic and preventative approaches for associated organ failures, in vivo.
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Affiliation(s)
- Neysha Martinez-Orengo
- Center for Infectious Disease Imaging, Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, MD, United States
| | - Sarine Tahmazian
- Center for Infectious Disease Imaging, Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, MD, United States
| | - Jianhao Lai
- Center for Infectious Disease Imaging, Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, MD, United States
| | - Zeping Wang
- Center for Infectious Disease Imaging, Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, MD, United States
| | - Sanhita Sinharay
- Center for Infectious Disease Imaging, Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, MD, United States
| | - William Schreiber-Stainthorp
- Center for Infectious Disease Imaging, Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, MD, United States
| | - Falguni Basuli
- Chemistry and Synthesis Center, National Heart, Lung, and Blood Institute, National Institutes of Health, Rockville, MD, United States
| | - Dragan Maric
- Flow and Imaging Cytometry Core Facility, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States
| | - William Reid
- Center for Infectious Disease Imaging, Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, MD, United States
| | - Swati Shah
- Center for Infectious Disease Imaging, Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, MD, United States
| | - Dima A. Hammoud
- Center for Infectious Disease Imaging, Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, MD, United States
- *Correspondence: Dima A. Hammoud,
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22
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Sauer M, Sievert A, Wrobel M, Schmude P, Richter G. Acoustocerebrography in septic patients: A randomized and controlled pilot study. FRONTIERS IN MEDICAL TECHNOLOGY 2022; 4:920674. [PMID: 36203789 PMCID: PMC9531262 DOI: 10.3389/fmedt.2022.920674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 08/22/2022] [Indexed: 11/17/2022] Open
Abstract
Sepsis-associated encephalopathy (SAE) is a common organ dysfunction in patients with severe sepsis or septic shock and leads to higher mortality and longer hospital stay. The diagnosis remains an exclusion process; none of the available measurements are specific for SAE. The aim of the presented prospective and controlled clinical study was to evaluate the possible role of molecular acoustics in determining acute brain injury in septic patients using an acoustocerebrography (ACG) system. ACG is a multifrequency, transcranial ultrasound method that measures the attenuation and time of flight to detect changes in the brain tissue. After approval from the local research ethics committee (of the University Hospital of Rostock: Reg. No.: A 2016-0026), 20 patients were included in two study groups: septic shock group (SG) and control group (CG; postoperative nonseptic patients). All patients were screened several times with the ACG on different days. Blood parameters of organ function, sepsis-related organ failure assessment score, and delirium scores [Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and Intensive Care Delirium Screening Checklist (ICDSC)] were obtained as well. A neurologist examined all patients at inclusion. Predictive analysis was done using a data-driven statistical method and by deriving a parameter from the ACG data. The study was registered under “clinicaltrials.gov” (Reg. No.: NCT03173196). All patients in the SG were CAM-ICU-positive at inclusion (ICDSC: in mean 4.0) and had clinical signs of SAE. In contrast, all patients in the CG were CAM-ICU-negative, with an ICDSC score of 0. Predictive analysis using the ACG data presented an accuracy of 83.4% with a specificity of 89.0% and a sensitivity of 75.1%. The ACG method may be helpful for the monitoring and diagnosing acute brain injury; however, the results of this first report should be verified by further clinical studies. Further investigations should include long-established instruments of SAE diagnosis, e.g., electroencephalography, MRI, and biomarkers, to compare the results with the ACG measurements.
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Affiliation(s)
- Martin Sauer
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Rostock, Rostock, Germany
- Fraunhofer Institute Cell Therapy and Immunology, Leipzig, Germany
- Department of Intensive Care and Emergency Medicine, Hospital Magdeburg, Magdeburg, Germany
- Correspondence: Martin Sauer
| | - Anika Sievert
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Rostock, Rostock, Germany
| | - Miroslaw Wrobel
- Fraunhofer Institute Cell Therapy and Immunology, Leipzig, Germany
| | - Paul Schmude
- Fraunhofer Institute Cell Therapy and Immunology, Leipzig, Germany
| | - Georg Richter
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Rostock, Rostock, Germany
- Fraunhofer Institute Cell Therapy and Immunology, Leipzig, Germany
- Department of Intensive Care and Emergency Medicine, Hospital Magdeburg, Magdeburg, Germany
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23
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Voiriot G, Oualha M, Pierre A, Salmon-Gandonnière C, Gaudet A, Jouan Y, Kallel H, Radermacher P, Vodovar D, Sarton B, Stiel L, Bréchot N, Préau S, Joffre J. Chronic critical illness and post-intensive care syndrome: from pathophysiology to clinical challenges. Ann Intensive Care 2022; 12:58. [PMID: 35779142 PMCID: PMC9250584 DOI: 10.1186/s13613-022-01038-0] [Citation(s) in RCA: 55] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 06/20/2022] [Indexed: 12/24/2022] Open
Abstract
Background Post‐intensive care syndrome (PICS) encompasses physical, cognition, and mental impairments persisting after intensive care unit (ICU) discharge. Ultimately it significantly impacts the long‐term prognosis, both in functional outcomes and survival. Thus, survivors often develop permanent disabilities, consume a lot of healthcare resources, and may experience prolonged suffering. This review aims to present the multiple facets of the PICS, decipher its underlying mechanisms, and highlight future research directions. Main text This review abridges the translational data underlying the multiple facets of chronic critical illness (CCI) and PICS. We focus first on ICU-acquired weakness, a syndrome characterized by impaired contractility, muscle wasting, and persisting muscle atrophy during the recovery phase, which involves anabolic resistance, impaired capacity of regeneration, mitochondrial dysfunction, and abnormalities in calcium homeostasis. Second, we discuss the clinical relevance of post-ICU cognitive impairment and neuropsychological disability, its association with delirium during the ICU stay, and the putative role of low-grade long-lasting inflammation. Third, we describe the profound and persistent qualitative and quantitative alteration of the innate and adaptive response. Fourth, we discuss the biological mechanisms of the progression from acute to chronic kidney injury, opening the field for renoprotective strategies. Fifth, we report long-lasting pulmonary consequences of ARDS and prolonged mechanical ventilation. Finally, we discuss several specificities in children, including the influence of the child’s pre-ICU condition, development, and maturation. Conclusions Recent understandings of the biological substratum of the PICS’ distinct features highlight the need to rethink our patient trajectories in the long term. A better knowledge of this syndrome and precipitating factors is necessary to develop protocols and strategies to alleviate the CCI and PICS and ultimately improve patient recovery.
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Affiliation(s)
- Guillaume Voiriot
- Service de Médecine Intensive Réanimation, Hôpital Tenon, Sorbonne Université, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Mehdi Oualha
- Pediatric Intensive Care Unit, Necker Hospital, APHP, Centre - Paris University, Paris, France
| | - Alexandre Pierre
- Institut Pasteur de Lille, U1167 - RID-AGE - Facteurs de Risque et Déterminants Moléculaires des Maladies Liées au Vieillissement, University Lille, Inserm, CHU Lille, 59000, Lille, France.,Department of Intensive Care Medicine, Critical Care Center, CHU Lille, 59000, Lille, France.,Faculté de Médecine de Tours, Centre d'Etudes des Pathologies Respiratoires, INSERM U1100, University Lille, Tours, France
| | - Charlotte Salmon-Gandonnière
- Service de Médecine Intensive Réanimation, CHRU de Tours, Réseau CRICS-TRIGGERSEP F-CRIN Research Network, Tours, France
| | - Alexandre Gaudet
- Department of Intensive Care Medicine, Critical Care Center, CHU Lille, 59000, Lille, France.,Faculté de Médecine de Tours, Centre d'Etudes des Pathologies Respiratoires, INSERM U1100, University Lille, Tours, France.,Institut Pasteur de Lille, U1019-UMR9017-CIIL-Centre d'Infection et d'Immunité de Lille, 59000, Lille, France
| | - Youenn Jouan
- Service de Médecine Intensive Réanimation, CHRU de Tours, Réseau CRICS-TRIGGERSEP F-CRIN Research Network, Tours, France
| | - Hatem Kallel
- Service de Réanimation, Centre Hospitalier de Cayenne, French Guiana, Cayenne, France
| | - Peter Radermacher
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, 89070, Ulm, Germany
| | - Dominique Vodovar
- Centre AntiPoison de Paris, Hôpital Fernand Widal, APHP, 75010, Paris, France.,Faculté de Pharmacie, UMRS 1144, 75006, Paris, France.,Université de Paris, UFR de Médecine, 75010, Paris, France
| | - Benjamine Sarton
- Critical Care Unit, University Hospital of Purpan, Toulouse, France.,Toulouse NeuroImaging Center, ToNIC, Inserm 1214, Paul Sabatier University, Toulouse, France
| | - Laure Stiel
- Service de Réanimation Médicale, Groupe Hospitalier de la Région Mulhouse Sud Alsace, Mulhouse, France.,INSERM, LNC UMR 1231, FCS Bourgogne Franche Comté LipSTIC LabEx, Dijon, France
| | - Nicolas Bréchot
- Service de Médecine Intensive Réanimation, Sorbonne Université, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,College de France, Center for Interdisciplinary Research in Biology (CIRB)-UMRS INSERM U1050 - CNRS 7241, Paris, France
| | - Sébastien Préau
- Institut Pasteur de Lille, U1167 - RID-AGE - Facteurs de Risque et Déterminants Moléculaires des Maladies Liées au Vieillissement, University Lille, Inserm, CHU Lille, 59000, Lille, France.,Service de Médecine Intensive Réanimation, CHRU de Tours, Réseau CRICS-TRIGGERSEP F-CRIN Research Network, Tours, France
| | - Jérémie Joffre
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, 94143, USA. .,Medical Intensive Care Unit, Saint Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France. .,Sorbonne University, Centre de Recherche Saint-Antoine INSERM U938, 75012, Paris, France.
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24
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Ito H, Hosomi S, Koyama Y, Matsumoto H, Imamura Y, Ogura H, Oda J. Sepsis-Associated Encephalopathy: A Mini-Review of Inflammation in the Brain and Body. Front Aging Neurosci 2022; 14:912866. [PMID: 35711904 PMCID: PMC9195626 DOI: 10.3389/fnagi.2022.912866] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 05/06/2022] [Indexed: 11/13/2022] Open
Abstract
Sepsis is defined as a life-threatening multi-organ dysfunction triggered by an uncontrolled host response to infectious disease. Systemic inflammation elicited by sepsis can cause acute cerebral dysfunction, characterized by delirium, coma, and cognitive dysfunction, known as septic encephalopathy. Recent evidence has reported the underlying mechanisms of sepsis. However, the reasons for the development of inflammation and degeneration in some brain regions and the persistence of neuroinflammation remain unclear. This mini-review describes the pathophysiology of region-specific inflammation after sepsis-associated encephalopathy (SAE), clinical features, and future prospects for SAE treatment. The hippocampus is highly susceptible to inflammation, and studies that perform treatments with antibodies to cytokine receptors, such as interleukin-1β, are in progress. Future development of clinically applicable therapies is expected.
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Affiliation(s)
- Hiroshi Ito
- Department of Traumatology and Acute Critical Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Sanae Hosomi
- Department of Traumatology and Acute Critical Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
- *Correspondence: Sanae Hosomi,
| | - Yoshihisa Koyama
- Department of Neuroscience and Cell Biology, Osaka University Graduate School of Medicine, Osaka, Japan
- Addiction Research Unit, Osaka Psychiatric Research Center, Osaka Psychiatric Medical Center, Osaka, Japan
| | - Hisatake Matsumoto
- Department of Traumatology and Acute Critical Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Yukio Imamura
- Department of Traumatology and Acute Critical Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Jun Oda
- Department of Traumatology and Acute Critical Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
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25
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Hogg E, Frank S, Oft J, Benway B, Rashid MH, Lahiri S. Urinary Tract Infection in Parkinson’s Disease. JOURNAL OF PARKINSON'S DISEASE 2022; 12:743-757. [PMID: 35147552 PMCID: PMC9108555 DOI: 10.3233/jpd-213103] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Urinary tract infection (UTI) is a common precipitant of acute neurological deterioration in patients with Parkinson’s disease (PD) and a leading cause of delirium, functional decline, falls, and hospitalization. Various clinical features of PD including autonomic dysfunction and altered urodynamics, frailty and cognitive impairment, and the need for bladder catheterization contribute to an increased risk of UTI. Sepsis due to UTI is a feared consequence of untreated or undertreated UTI and a leading cause of morbidity in PD. Emerging research suggests that immune-mediated brain injury may underlie the pathogenesis of UTI-induced deterioration of PD symptoms. Existing strategies to prevent UTI in patients with PD include use of topical estrogen, prophylactic supplements, antibiotic bladder irrigation, clean catheterization techniques, and prophylactic oral antibiotics, while bacterial interference and vaccines/immunostimulants directed against common UTI pathogens are potentially emerging strategies that are currently under investigation. Future research is needed to mitigate the deleterious effects of UTI in PD.
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Affiliation(s)
- Elliot Hogg
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Samuel Frank
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jillian Oft
- Department of Infectious Diseases, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Brian Benway
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | - Shouri Lahiri
- Departments of Neurology, Neurosurgery, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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26
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Assessment of potential selection bias in neuroimaging studies of postoperative delirium and cognitive decline: lessons from the SAGES study. Brain Imaging Behav 2022; 16:1732-1740. [PMID: 35278158 PMCID: PMC9283208 DOI: 10.1007/s11682-022-00644-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2022] [Indexed: 12/19/2022]
Abstract
Due to cost and participant burden, neuroimaging studies are often performed in relatively small samples of voluntary participants. This may lead to selection bias. It is important to identify factors associated with participation in neuroimaging studies and understand their effect on outcome measures. We investigated the effect of postoperative delirium on long-term (over 48 months) cognitive decline (LTCD) in 560 older surgical patients (≥ 70 years), including a nested MRI cohort (n = 146). We observed a discrepancy in the effect of delirium on cognitive decline as a function of MRI participation. Although overall difference in cognitive decline due to delirium was not greater than what might be expected due to chance (p = .21), in the non-MRI group delirium was associated with a faster pace of LTCD (-0.063, 95% CI -0.094 to -0.032, p < .001); while in the MRI group the effect of delirium was less and not significant (-0.023, 95% CI -0.076, 0.030, p = .39). Since this limits our ability to investigate the neural correlates of delirium and cognitive decline using MRI data, we attempted to mitigate the observed discrepancy using inverse probability weighting for MRI participation. The approach was not successful and the difference of the effect of delirium in slope was essentially unchanged. There was no evidence that the MRI sub-group experienced delirium that differed in severity relative to MRI non-participants. We could not attribute the observed discrepancy to selection bias based on measured factors. It may reflect a power issue due to the smaller MRI subsample or selection bias from unmeasured factors.
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27
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Lai H, Mubashir T, Shiwalkar N, Ahmad H, Balogh J, Williams G, Bauer C, Maroufy V. Association of pre-admission opioid abuse and/or dependence on major complications in traumatic brain injury (TBI) patients. J Clin Anesth 2022; 79:110719. [PMID: 35276593 DOI: 10.1016/j.jclinane.2022.110719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 02/23/2022] [Accepted: 02/28/2022] [Indexed: 11/17/2022]
Abstract
SETTING In the last few decades, an opioid related health crisis has been a challenging problem in many countries around the world, especially the United States. Better understanding of the association of pre-admission opioid abuse and/or dependence (POAD) on specific major complications in traumatic brain injury (TBI) patients can aid the medical team in improving patient care management and outcomes. STUDY OBJECTIVE Our goal is to assess and quantify the risk of POAD on in-hospital mortality and major complications in TBI patients. DESIGN We conducted a retrospective study and used the National Inpatient Sample (NIS) database from 2004 to 2015 to investigate the impact of POAD on in-hospital mortality and major complications in TBI patients. We utilized propensity score matching and conditional logistic regression models, adjusted with injury severity score (ISS) and comorbidities, to obtain the adjusted odds ratios (OR). MAIN RESULTS POAD TBI patients had lower risks of in-hospital mortality (OR 0.58; p < 0.001) and acute myocardial infarction (OR 0.53; p = 0.045), while a higher risk of respiratory (OR 1.59; p < 0.001) and neurologic complications (OR 2.54; p < 0.001), compared to non-POAD TBI patients. Additionally, POAD patients were significantly more likely to have sepsis (OR 2.16, p < 0.001), malnutrition (OR 1.56, p < 0.001), delirium (OR 2.81, p < 0.001), respiratory failure (OR 1.79, p < 0.001), and acute renal failure (OR 1.83, p < 0.001). POAD TBI patients had shorter length of hospital stay compared to non-POAD TBI patients (mean 8.0 vs 9.2 days, p < 0.001). CONCLUSIONS POAD TBI patients have a lower in-hospital mortality, shorter duration of hospitalization and a lower risk of acute myocardial infarction, while they are more likely to have respiratory failure, delirium, sepsis, malnutrition, and acute renal failure compared to TBI patients without POAD. Prospective study is warranted to further confirm these findings.
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Affiliation(s)
- Hongyin Lai
- Department of Biostatistics and Data Science, UTHealth School of Public Health, 1200 Pressler St, Houston, TX 77030, USA
| | - Talha Mubashir
- Department of Anesthesiology, UTHealth McGovern Medical School, 6410 Fannin St, Houston, TX 77030, USA
| | - Nimisha Shiwalkar
- Department of Anesthesiology and Critical Care, Zen Multispecialty Hospital and Research Center, Mumbai, India
| | - Hunza Ahmad
- Department of Anesthesiology, UTHealth McGovern Medical School, 6410 Fannin St, Houston, TX 77030, USA
| | - Julius Balogh
- Department of Anesthesiology, University of Arkansas for Medical Sciences, 4301 West Markham, #515, Little Rock, AR 72205, USA
| | - George Williams
- Department of Anesthesiology, UTHealth McGovern Medical School, 6410 Fannin St, Houston, TX 77030, USA
| | - Cici Bauer
- Department of Biostatistics and Data Science, UTHealth School of Public Health, 1200 Pressler St, Houston, TX 77030, USA
| | - Vahed Maroufy
- Department of Biostatistics and Data Science, UTHealth School of Public Health, 1200 Pressler St, Houston, TX 77030, USA.
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28
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Boukrina O, Kowalczyk M, Koush Y, Kong Y, Barrett A. Brain Network Dysfunction in Poststroke Delirium and Spatial Neglect: An fMRI Study. Stroke 2022; 53:930-938. [PMID: 34619987 PMCID: PMC8885764 DOI: 10.1161/strokeaha.121.035733] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 08/16/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND PURPOSE Delirium, an acute reduction in cognitive functioning, hinders stroke recovery and contributes to cognitive decline. Right-hemisphere stroke is linked with higher delirium incidence, likely, due to the prevalence of spatial neglect (SN), a right-brain disorder of spatial processing. This study tested if symptoms of delirium and SN after right-hemisphere stroke are associated with abnormal function of the right-dominant neural networks specialized for maintaining attention, orientation, and arousal. METHODS Twenty-nine participants with right-hemisphere ischemic stroke undergoing acute rehabilitation completed delirium and SN assessments and functional neuroimaging scans. Whole-brain functional connectivity of 4 right-hemisphere seed regions in the cortical-subcortical arousal and attention networks was assessed for its relationship to validated SN and delirium severity measures. RESULTS Of 29 patients, 6 (21%) met the diagnostic criteria for delirium and 16 (55%) for SN. Decreased connectivity of the right basal forebrain to brain stem and basal ganglia predicted more severe SN. Increased connectivity of the arousal and attention network regions with the parietal, frontal, and temporal structures in the unaffected hemisphere was also found in more severe delirium and SN. CONCLUSIONS Delirium and SN are associated with decreased arousal network activity and an imbalance of cortico-subcortical hemispheric connectivity. Better understanding of neural correlates of poststroke delirium and SN will lead to improved neuroscience-based treatment development for these disorders. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03349411.
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Affiliation(s)
- Olga Boukrina
- Center for Stroke Rehabilitation Research, Kessler Foundation, West Orange, NJ, 07052, USA
- Department of Physical Medicine and Rehabilitation, Rutgers-New Jersey Medical School, Newark, NJ, 07103, USA
| | - Mateusz Kowalczyk
- Rocco Ortenzio Neuroimaging Center, Kessler Foundation, West Orange, NJ, 07052, USA
| | - Yury Koush
- Magnetic Resonance Research Center, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Yekyung Kong
- Department of Physical Medicine and Rehabilitation, Rutgers-New Jersey Medical School, Newark, NJ, 07103, USA
- Kessler Institute for Rehabilitation, West Orange, NJ, 07052, USA
| | - A.M. Barrett
- Center for Visual and Neurocognitive Rehabilitation, Atlanta VA Medical Center, Decatur, 30033 GA, USA
- Neurology, Emory University School of Medicine, Atlanta, 30322, GA
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29
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Tingey JL, Dasher NA, Bunnell AE, Starosta AJ. Intensive Care-Related Cognitive Impairment: A Biopsychosocial Overview. PM R 2022; 14:259-272. [PMID: 35077003 DOI: 10.1002/pmrj.12773] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 01/21/2022] [Accepted: 01/21/2022] [Indexed: 11/10/2022]
Abstract
Advancements in critical care medicine have improved survival rates for patients experiencing critical illness in intensive care units (ICUs). While mortality has declined, more than half of ICU survivors experience functional impairments that persist beyond discharge. Of particular concern is ICU-related cognitive impairment, which can extend across the care continuum, ranging from acute and transient presentations in the ICU (eg, delirium) to long-term impairments years after discharge. ICU-related cognitive impairment has received increased attention in the literature, particularly as it relates to ICU survivors who have received and survived critical care in the context of SARS-CoV-2 pandemic and are now experiencing post-acute sequelae of SARS-CoV-2 infection. The medical complexity and heterogeneity of ICU survivors, coupled with the multifactorial etiology of ICU-related cognitive impairments, lead to challenges in how to optimize care for ICU survivors at various stages of recovery. This review aims to provide an overview of cognitive outcomes associated with critical illness by integrating recent literature focused on etiology, assessment, and interventions in the context of ICU-related cognitive impairments. The narrative review employs a biopsychosocial framework to comprehensively evaluate the multifactorial nature of ICU-related cognitive outcomes. Authors also highlight multidisciplinary teams composed of key rehabilitation providers are likely best suited for optimizing recovery trajectories of ICU survivors. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Jamie L Tingey
- Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, WA, United States
| | - Nickolas A Dasher
- Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, WA, United States
| | - Aaron E Bunnell
- Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, WA, United States
| | - Amy J Starosta
- Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, WA, United States
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Pistacchi M, Gioulis M, Marsala SZ. Association between delirium and cognitive impairment: there is a link? Curr Alzheimer Res 2022; 19:47-55. [PMID: 35048808 DOI: 10.2174/1567205019666220120114552] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 12/15/2021] [Accepted: 12/27/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Delirium and dementia are both disorders involving global cognitive impairment that can occur separately or at the same time in the elderly. OBJECTIVE The aim of this study was to examine the frequency, correlation and relative risk between delirium and cognitive impairment in a prospective population study starting at basal line (onset of delirium) over a period of five years. The secondary aim was to determine any possible correlation between the kind of delirium and a specific type of dementia. MATERIAL AND METHODS We studied 325 patients, diagnosed according to the DSM-IV. The neuropsychological, moods and delirium disorders were evaluated with Hamilton Depression Rating Scale, Delirium Rating Scale-Revised-98, MMSE, Rey auditory-verbal learning test, Digit Span, Symbol Digit Modalities Test, Raven Progressive Matrices, ADL and IADL. RESULTS The prevalence of delirium in our population was 89 cases (27.4%): 78 patients (48 women and 30 men) showed evolution toward dementia (mean age was 67.9 ± 6.1 years for men and 68.4 ± 9.1 for women), and 11 patients (5 men and 6 women) presented only isolated delirium without evolution toward cognitive impairment (mean age of men was 68.1 ± 5.1 years and of women 66.4 ± 7.1). The neuropsychological study of the patients with delirium with dementia evolution revealed statistically significant differences over time with statistically significant intergroup difference and predisposition toward depression. CONCLUSION The association between delirium and cognitive impairment and the possible role of delirium as an early marker of neurodegenerative diseases need to be future investigated.
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Affiliation(s)
- Michele Pistacchi
- Neurology Service, San Giacomo Hospital, Via dei Carpani 16z, 31033 Castelfranco Veneto (TV), Italy
| | - Manuela Gioulis
- San Martino Hospital, Belluno, Neurology Service, viale europa 22 Belluno, Italy
| | - Sandro Zambito Marsala
- Department od Neurology, Ospedale San Martino, Neurology Service, viale europa 22 Belluno, Italy
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Lam MTY, Malhotra A, LaBuzetta JN, Kamdar BB. Sleep in Critical Illness. Respir Med 2022. [DOI: 10.1007/978-3-030-93739-3_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Nakajima-Ohyama KC, Tansho K, Tanimukai H. An alarm on vitamin D therapy for Alzheimer's disease patients: a case with Alzheimer's disease whose symptoms were exacerbated under chronic use of eldecalcitol. Psychogeriatrics 2022; 22:145-148. [PMID: 34761480 DOI: 10.1111/psyg.12786] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/17/2021] [Accepted: 10/26/2021] [Indexed: 11/30/2022]
Affiliation(s)
| | - Kosuke Tansho
- Department of Nephrology, Kindai University Nara Hospital, Ikoma, Nara, Japan
| | - Hitoshi Tanimukai
- Department of Human Health Sciences, Graduate School of Medicine and Faculty of Medicine, Kyoto University, Kyoto, Japan
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Paixao L, Sun H, Hogan J, Hartnack K, Westmeijer M, Neelagiri A, Zhou DW, McClain LM, Kimchi EY, Purdon PL, Akeju O, Westover MB. ICU delirium burden predicts functional neurologic outcomes. PLoS One 2021; 16:e0259840. [PMID: 34855749 PMCID: PMC8638853 DOI: 10.1371/journal.pone.0259840] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 10/28/2021] [Indexed: 12/13/2022] Open
Abstract
Background We investigated the effect of delirium burden in mechanically ventilated patients, beginning in the ICU and continuing throughout hospitalization, on functional neurologic outcomes up to 2.5 years following critical illness. Methods Prospective cohort study of enrolling 178 consecutive mechanically ventilated adult medical and surgical ICU patients between October 2013 and May 2016. Altogether, patients were assessed daily for delirium 2941days using the Confusion Assessment Method for the ICU (CAM-ICU). Hospitalization delirium burden (DB) was quantified as number of hospital days with delirium divided by total days at risk. Survival status up to 2.5 years and neurologic outcomes using the Glasgow Outcome Scale were recorded at discharge 3, 6, and 12 months post-discharge. Results Of 178 patients, 19 (10.7%) were excluded from outcome analyses due to persistent coma. Among the remaining 159, 123 (77.4%) experienced delirium. DB was independently associated with >4-fold increased mortality at 2.5 years following ICU admission (adjusted hazard ratio [aHR], 4.77; 95% CI, 2.10–10.83; P < .001), and worse neurologic outcome at discharge (adjusted odds ratio [aOR], 0.02; 0.01–0.09; P < .001), 3 (aOR, 0.11; 0.04–0.31; P < .001), 6 (aOR, 0.10; 0.04–0.29; P < .001), and 12 months (aOR, 0.19; 0.07–0.52; P = .001). DB in the ICU alone was not associated with mortality (HR, 1.79; 0.93–3.44; P = .082) and predicted neurologic outcome less strongly than entire hospital stay DB. Similarly, the number of delirium days in the ICU and for whole hospitalization were not associated with mortality (HR, 1.00; 0.93–1.08; P = .917 and HR, 0.98; 0.94–1.03, P = .535) nor with neurological outcomes, except for the association between ICU delirium days and neurological outcome at discharge (OR, 0.90; 0.81–0.99, P = .038). Conclusions Delirium burden throughout hospitalization independently predicts long term neurologic outcomes and death up to 2.5 years after critical illness, and is more predictive than delirium burden in the ICU alone and number of delirium days.
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Affiliation(s)
- Luis Paixao
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
| | - Haoqi Sun
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
| | - Jacob Hogan
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Katie Hartnack
- Antioch University New England, Keene, NH, United States of America
| | - Mike Westmeijer
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Anudeepthi Neelagiri
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States of America
| | - David W. Zhou
- Harvard Medical School, Boston, MA, United States of America
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, MA, United States of America
| | - Lauren M. McClain
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
| | - Eyal Y. Kimchi
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
| | - Patrick L. Purdon
- Harvard Medical School, Boston, MA, United States of America
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Oluwaseun Akeju
- Harvard Medical School, Boston, MA, United States of America
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - M. Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
- * E-mail:
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Abstract
Delirium, an acute disturbance in mental status due to another medical condition, is common and morbid in the intensive care unit. Despite its clear association with multiple common risk factors and important outcomes, including mortality and long-term cognitive impairment, both the ultimate causes of and ideal treatments for delirium remain unclear. Studies suggest that neuroinflammation, hypoxia, alterations in energy metabolism, and imbalances in multiple neurotransmitter pathways contribute to delirium, but commonly used treatments (e.g., antipsychotic medications) target only one or a few of these potential mechanisms and are not supported by evidence of efficacy. At this time, the optimal treatment for delirium during critical illness remains avoidance of risk factors, though ongoing trials may expand on the promise shown by agents such as melatonin and dexmedetomidine. Expected final online publication date for the Annual Review of Medicine, Volume 73 is January 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
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Affiliation(s)
- Niall T Prendergast
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA
| | - Perry J Tiberio
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA
| | - Timothy D Girard
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA;
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Bowman EML, Cunningham EL, Page VJ, McAuley DF. Phenotypes and subphenotypes of delirium: a review of current categorisations and suggestions for progression. Crit Care 2021; 25:334. [PMID: 34526093 PMCID: PMC8441952 DOI: 10.1186/s13054-021-03752-w] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 08/31/2021] [Indexed: 02/08/2023] Open
Abstract
Delirium is a clinical syndrome occurring in heterogeneous patient populations. It affects 45-87% of critical care patients and is often associated with adverse outcomes including acquired dementia, institutionalisation, and death. Despite an exponential increase in delirium research in recent years, the pathophysiological mechanisms resulting in the clinical presentation of delirium are still hypotheses. Efforts have been made to categorise the delirium spectrum into clinically meaningful subgroups (subphenotypes), using psychomotor subtypes such as hypoactive, hyperactive, and mixed, for example, and also inflammatory and non-inflammatory delirium. Delirium remains, however, a constellation of symptoms resulting from a variety of risk factors and precipitants with currently no successful targeted pharmacological treatment. Identifying specific clinical and biological subphenotypes will greatly improve understanding of the relationship between the clinical symptoms and the putative pathways and thus risk factors, precipitants, natural history, and biological mechanism. This will facilitate risk factor mitigation, identification of potential methods for interventional studies, and informed patient and family counselling. Here, we review evidence to date and propose a framework to identify subphenotypes. Endotype identification may be done by clustering symptoms with their biological mechanism, which will facilitate research of targeted treatments. In order to achieve identification of delirium subphenotypes, the following steps must be taken: (1) robust records of symptoms must be kept at a clinical level. (2) Global collaboration must facilitate large, heterogeneous research cohorts. (3) Patients must be clustered for identification, validation, and mapping of subphenotype stability.
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Affiliation(s)
- Emily M L Bowman
- Centre for Public Health, Block B, Institute of Clinical Sciences, Royal Victoria Hospital Site, Queen's University Belfast, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland.
| | - Emma L Cunningham
- Centre for Public Health, Block B, Institute of Clinical Sciences, Royal Victoria Hospital Site, Queen's University Belfast, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland
| | - Valerie J Page
- Department of Anaesthetics, Watford General Hospital, Vicarage Road, Watford, WD19 4DZ, UK
| | - Daniel F McAuley
- Centre for Experimental Medicine, Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland
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Huang H, Li H, Zhang X, Shi G, Xu M, Ru X, Chen Y, Patel MB, Ely EW, Lin S, Zhang G, Zhou J. Association of postoperative delirium with cognitive outcomes: A meta-analysis. J Clin Anesth 2021; 75:110496. [PMID: 34482263 DOI: 10.1016/j.jclinane.2021.110496] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 08/26/2021] [Accepted: 08/29/2021] [Indexed: 10/20/2022]
Abstract
STUDY OBJECTIVE To determine the association between postoperative delirium (POD) and cognitive outcomes at least 1 month after surgery in elderly patients, and synthesize the dynamic risk trajectory of cognition impairment after POD. DESIGN Meta-analysis searching PubMed, Cochrane and EMBASE from inception to November 1, 2020. The terms postoperative delirium, delirium after surgery, postsurgical delirium, postoperative cogniti*, postoperative cognitive dysfunction, postoperative cognition decline, cognitive decline, cognitive impair* and dement* were searched alone or in combination. MEASUREMENTS Inclusion criteria were prospective cohort studies investigating the association between POD and cognitive outcomes in patients aged ≥60 years underwent surgery. The primary outcome was the association between POD and cognitive outcomes at 1 or more months after surgery. We considered cognitive outcomes measured up to 12 months after surgery as short-term and beyond 12 months as long-term. Two authors performed the study screening, data extraction and quality assessments. Effect sizes were calculated as Hedges g or Odds ratio (OR) based on random- and fixed-effects models. Meta-regression was conducted to analyze the role of potential contributors to heterogeneity. MAIN RESULTS Eighteen studies were included. Our result showed a significant and medium association between POD and cognitive outcomes after at least 1 month postoperatively (g = 0.61 95% CI 0.43-0.79; I2 = 65.1%), indicating that patients with POD were associated with worse cognitive outcomes. The association of POD with short- and long-term cognitive impairment were also both significant (short-term: g = 0.46 95% CI 0.24-0.68; I2 = 53.1%; and long-term: g = 0.82 95% CI 0.57-1.06; I2 = 57.1%). A multivariate meta-regression suggested that age and measure of delirium were significant sources of heterogeneity. POD was also associated with the significant risk for dementia (OR = 6.08 95% CI 3.80-9.72; I2 = 0) as well as attention (OR = 1.74 95% CI 1.13-2.68; I2 = 0), executive (OR = 1.33 95% CI 1.00-1.80; I2 = 0) and memory impairment (OR = 1.59 95% CI 1.20-2.10; I2 = 43.0%). Additionally, our results showed that the risk trajectory for cognitive decline associated with POD within five years after surgery revealed exponential growth. CONCLUSIONS This is the first meta-analysis quantifying the association between POD and cognitive outcomes. Our results showed that POD was significantly associated with worse cognitive outcomes, including short- and long-term cognitive outcomes following surgery.
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Affiliation(s)
- Huawei Huang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Haoyi Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaokang Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guangzhi Shi
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ming Xu
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaojuan Ru
- Department of Neuro-epidemiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - You Chen
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Electrical Engineering & Computer Science, Vanderbilt University, Nashville, TN, USA
| | - Mayur B Patel
- Section of Surgical Sciences, Departments of Surgery & Neurosurgery, Division of Trauma, Surgical Critical Care, and Emergency General Surgery, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Hearing & Speech Sciences, Vanderbilt University Medical Center, Nashville, TN, USA; Geriatric Research and Education Clinical Center, Surgical Services, Veteran Affairs Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Eugene Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Song Lin
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guobin Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
| | - Jianxin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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Turner AD, Sullivan T, Drury K, Hall TA, Williams CN, Guilliams KP, Murphy S, Iqbal O’Meara AM. Cognitive Dysfunction After Analgesia and Sedation: Out of the Operating Room and Into the Pediatric Intensive Care Unit. Front Behav Neurosci 2021; 15:713668. [PMID: 34483858 PMCID: PMC8415404 DOI: 10.3389/fnbeh.2021.713668] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 07/26/2021] [Indexed: 11/13/2022] Open
Abstract
In the midst of concerns for potential neurodevelopmental effects after surgical anesthesia, there is a growing awareness that children who require sedation during critical illness are susceptible to neurologic dysfunctions collectively termed pediatric post-intensive care syndrome, or PICS-p. In contrast to healthy children undergoing elective surgery, critically ill children are subject to inordinate neurologic stress or injury and need to be considered separately. Despite recognition of PICS-p, inconsistency in techniques and timing of post-discharge assessments continues to be a significant barrier to understanding the specific role of sedation in later cognitive dysfunction. Nonetheless, available pediatric studies that account for analgesia and sedation consistently identify sedative and opioid analgesic exposures as risk factors for both in-hospital delirium and post-discharge neurologic sequelae. Clinical observations are supported by animal models showing neuroinflammation, increased neuronal death, dysmyelination, and altered synaptic plasticity and neurotransmission. Additionally, intensive care sedation also contributes to sleep disruption, an important and overlooked variable during acute illness and post-discharge recovery. Because analgesia and sedation are potentially modifiable, understanding the underlying mechanisms could transform sedation strategies to improve outcomes. To move the needle on this, prospective clinical studies would benefit from cohesion with regard to datasets and core outcome assessments, including sleep quality. Analyses should also account for the wide range of diagnoses, heterogeneity of this population, and the dynamic nature of neurodevelopment in age cohorts. Much of the related preclinical evidence has been studied in comparatively brief anesthetic exposures in healthy animals during infancy and is not generalizable to critically ill children. Thus, complementary animal models that more accurately "reverse translate" critical illness paradigms and the effect of analgesia and sedation on neuropathology and functional outcomes are needed. This review explores the interactive role of sedatives and the neurologic vulnerability of critically ill children as it pertains to survivorship and functional outcomes, which is the next frontier in pediatric intensive care.
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Affiliation(s)
- Ashley D. Turner
- Division of Pediatric Critical Care, Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, United States
| | - Travis Sullivan
- Department of Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA, United States
| | - Kurt Drury
- Department of Pediatrics, Division of Pediatric Critical Care, Doernbecher Children’s Hospital, Oregon Health & Science University, Portland, OR, United States
| | - Trevor A. Hall
- Department of Pediatrics, Division of Pediatric Psychology, Pediatric Critical Care and Neurotrauma Recovery Program, Doernbecher Children’s Hospital, Oregon Health & Science University, Portland, OR, United States
| | - Cydni N. Williams
- Department of Pediatrics, Division of Pediatric Critical Care, Doernbecher Children’s Hospital, Oregon Health & Science University, Portland, OR, United States
| | - Kristin P. Guilliams
- Division of Pediatric Critical Care, Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, United States
- Division of Pediatric Neurology, Department of Neurology, Washington University in St. Louis, St. Louis, MO, United States
- Division of Neuroradiology, Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, MO, United States
| | - Sarah Murphy
- Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - A. M. Iqbal O’Meara
- Department of Pediatrics, Child Health Research Institute, Children’s Hospital of Richmond at Virginia Commonwealth University School of Medicine, Richmond, VA, United States
- Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
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Luz LFDS, Santos MCD, Ramos TA, Almeida CBD, Rover MC, Dal'Pizzol CP, Pohren CLDS, Martins AVDS, Boniatti MM. Delirium and quality of life in critically ill patients: a prospective cohort study. Rev Bras Ter Intensiva 2021; 32:426-432. [PMID: 33053033 PMCID: PMC7595710 DOI: 10.5935/0103-507x.20200072] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 03/23/2020] [Indexed: 11/20/2022] Open
Abstract
Objective To evaluate the association between the incidence of delirium in the intensive care unit and quality of life 1 month after hospital discharge. Methods This was a prospective cohort study conducted in the intensive care units of two medium-complexity hospitals from December 2015 to December 2016. Delirium was identified using the Confusion Assessment Method for the Intensive Care Unit scale. At the time of hospital discharge, functional capacity and cognition were assessed with the Barthel index and the Mini Mental State Examination, respectively. Thirty days after patient discharge, the World Health Organization Quality of Life-BREF questionnaire was administered by telephone. Results A total of 216 patients were included. Delirium was identified in 127 (58.8%) of them. Patients with delirium exhibited greater functional dependence (median Barthel index 50.0 [21.2 - 70.0] versus 80.0 [60.0 - 95.0]; p < 0.001) and lower cognition (Mini Mental State Examination score 12.9 ± 7.5 versus 20.7 ± 9.8; p < 0.001) at hospital discharge. There was no difference in any of the quality-of-life domains evaluated 1 month after hospital discharge between patients with and without delirium. Conclusion Our findings suggest that patients with delirium in the intensive care unit do not have worse quality of life 1 month after hospital discharge, despite presenting greater cognitive impairment and functional disability at the time of hospital discharge.
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Affiliation(s)
| | | | - Tiago Almeida Ramos
- Serviço de Medicina Intensiva, Hospital de Clínicas de Porto Alegre - Porto Alegre (RS), Brasil
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Prediction of Postictal Delirium Following Status Epilepticus in the ICU: First Insights of an Observational Cohort Study. Crit Care Med 2021; 49:e1241-e1251. [PMID: 34259657 DOI: 10.1097/ccm.0000000000005212] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To identify early predictors of postictal delirium in adult patients after termination of status epilepticus. DESIGN Retrospective study. SETTING ICUs at a Swiss tertiary academic medical center. PATIENTS Status epilepticus patients treated on the ICUs for longer than 24 hours from 2012 to 2018. INTERVENTIONS None. METHODS Primary outcome was postictal delirium during post-status epilepticus treatment defined as an Intensive Care Delirium Screening Checklist greater than or equal to 4. Associations with postictal delirium were secondary outcomes. A time-dependent multivariable Cox proportional hazards model was used to identify risks of postictal delirium. It included variables that differed between patients with and without delirium and established risk factors for delirium (age, sex, number of inserted catheters, illness severity [quantified by the Sequential Organ Failure Assessment and Status Epilepticus Severity Score], neurodegenerative disease, dementia, alcohol/drug consumption, infections, coma during status epilepticus, dose of benzodiazepines, anesthetics, and mechanical ventilation). MEASUREMENTS AND MAIN RESULTS Among 224 patients, post-status epilepticus Intensive Care Delirium Screening Checklist was increased in 83% with delirium emerging in 55% with a median duration of 2 days (interquartile range 1-3 d). Among all variables, only the history of alcohol and/or drug consumption was associated with increased hazards for delirium in multivariable analyses (hazard ratio = 3.35; 95% CI, 1.53-7.33). CONCLUSIONS Our study provides first exploratory insights into the risks of postictal delirium in adult status epilepticus patients treated in the ICU. Delirium following status epilepticus is frequent, lasting mostly 2-3 days. Our findings that with the exception of a history of alcohol and/or drug consumption, other risk factors of delirium were not found to be associated with a risk of postictal delirium may be related to the limited sample size and the exploratory nature of our study. Further investigations are needed to investigate the role of established risk factors in other status epilepticus cohorts. In the meantime, our results indicate that the risk of delirium should be especially considered in patients with a history of alcohol and/or drug consumption.
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Incidence and influencing factors of post-intensive care cognitive impairment. Intensive Crit Care Nurs 2021; 67:103106. [PMID: 34246526 DOI: 10.1016/j.iccn.2021.103106] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 04/27/2021] [Accepted: 05/14/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate the incidence and risks factors of short-term post-intensive care (ICU) cognitive impairment. DESIGN Prospective, observational study. SETTING Closed university-affiliated intensive care unit. PATIENTS We enrolled consecutive patients >18 yrs of age expected to be in intensive care unit for ≥24 hours. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The score of Montreal Cognitive Assessment (MoCA) less than 26 was defined as cognitive impairment at hospital discharge and short-term post-ICU cognitive impairment was diagnosed in 185 of 409 assessed patients (45.2%). According to univariate analysis, age, years of education, occupation, past medical history, main ICU diagnosis, Acute Physiology and Chronic Evaluation Scoring System (APACHE II) score, Sequential Organ Failure Assessment (SOFA) score, Charlson comorbidity index, ICU length-of-stay (LOS), total hospital LOS, sedation, vasoactive agents, muscle relaxants, mechanical ventilation and duration of mechanical ventilation, constraints, early active mobilisation, hypoxemia, frequency and severity of delirium, blood pressure, rescue experience, and infection were significant predictors of post-ICU cognitive impairment. Multivariate analysis results showed that the frequency and severity of delirium, and advanced age were risk factors of post-ICU cognitive impairment; high years of education and early active mobilisation were protective factors. CONCLUSIONS Incidence of post-ICU cognitive impairment is at a high level, which is similar to former researches' results; the frequency and severity of delirium, and advanced age were risk factors of post-ICU cognitive impairment; high years of education and early active mobilisation were protective factors of post-ICU cognitive impairment.
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Abstract
Delirium, a form of acute brain dysfunction, is very common in the critically ill adult patient population. Although its pathophysiology is poorly understood, multiple factors associated with delirium have been identified, many of which are coincident with critical illness. To date, no drug or non-drug treatments have been shown to improve outcomes in patients with delirium. Clinical trials have provided a limited understanding of the contributions of multiple triggers and processes of intensive care unit (ICU) acquired delirium, making identification of therapies difficult. Delirium is independently associated with poor long term outcomes, including persistent cognitive impairment. A longer duration of delirium is associated with worse long term cognition after adjustment for age, education, pre-existing cognitive function, severity of illness, and exposure to sedatives. Interestingly, differences in prevalence are seen between ICU survivor populations, with survivors of acute respiratory distress syndrome experiencing higher rates of cognitive impairment at early follow-up compared with mixed ICU survivor populations. Although cognitive performance improves over time for some ICU survivors, impairment is persistent in others. Studies have so far been unable to identify patients at higher risk of long term cognitive impairment; this is an active area of scientific investigation.
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Affiliation(s)
- M Elizabeth Wilcox
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, ON, Canada
| | - Timothy D Girard
- Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Catherine L Hough
- Division of Pulmonary and Critical Care Medicine, Oregon Health & Science University, Portland, OR, USA
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42
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Abstract
An aging-related reduction in the brain's functional reserve may explain why delirium is more frequent in the elderly than in younger people insofar as the reserve becomes inadequate to cover the metabolic requirements that are critically increased by stressors. The aim of this paper is to review the normal aging-related changes that theoretically compromise complex mental activities, neuronal and synaptic densities, and the neurocomputational flexibility of the functional reserve. A pivotal factor is diminished connectivity, which is substantially due to the loss of synapses and should specifically affect association systems and cholinergic fibres in delirious patients. However, micro-angiopathy with impaired blood flow autoregulation, increased blood/brain barrier permeability, changes in cerebrospinal fluid dynamics, weakened mitochondrial performance, and a pro-inflammatory involution of the immune system may also jointly affect neurons and their synaptic assets, and even cause the progression of delirium to dementia regardless of the presence of co-existing plaques, tangles, or other pathological markers. On the other hand, the developmental growth in functional reserve during childhood and adolescence makes the brain increasingly resistant to delirium, and residual reserve can allow the elderly to recover. These data support the view that functional reserve is the variable that confronts stressors and governs the risk and intensity of and recovery from delirium. Although people of any age are at risk of delirium, the elderly are at greater risk because aging and age-dependent structural changes inevitably affect the brain's functional reserve.
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43
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Bellelli G, Brathwaite JS, Mazzola P. Delirium: A Marker of Vulnerability in Older People. Front Aging Neurosci 2021; 13:626127. [PMID: 33994990 PMCID: PMC8119654 DOI: 10.3389/fnagi.2021.626127] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 04/06/2021] [Indexed: 12/11/2022] Open
Abstract
Delirium is an acute neuropsychiatric syndrome and one of the most common presenting symptoms of acute medical illnesses in older people. Delirium can be triggered by a single cause, but in most cases, it is multifactorial as it depends on the interaction between predisposing and precipitating factors. Delirium is highly prevalent in older patients across various settings of care and correlates with an increased risk of adverse clinical outcomes. Several pathophysiological mechanisms may contribute to its onset, including neurotransmitter imbalance, neuroinflammation, altered brain metabolism, and impaired neuronal network connectivity. Several screening and diagnostic tools for delirium exist, but they are unfortunately underutilized. Additionally, the diagnosis of delirium superimposed on dementia poses a formidable challenge – especially if dementia is severe. Non-pharmacological approaches for the prevention and multidomain interventions for the treatment of delirium are recommended, given that there is currently no robust evidence of drugs that can prevent or resolve delirium. This article aims to review the current understanding about delirium in older people. To achieve this goal, we will describe the epidemiology and outcomes of the syndrome, the pathophysiological mechanisms that are supposed to be involved, the most commonly used tools for screening and diagnosis, and prevention strategies and treatments recommended. This review is intended as a brief guide for clinicians in hospital wards to improve their knowledge and practice. At the end of the article, we propose an approach to improve the quality of care provided to older patients throughout a systematic detection of delirium.
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Affiliation(s)
- Giuseppe Bellelli
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Acute Geriatrics Unit, San Gerardo Hospital ASST Monza, Monza, Italy
| | - Justin S Brathwaite
- Department of Emergency Medicine, Boston University, Boston, MA, United States
| | - Paolo Mazzola
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Acute Geriatrics Unit, San Gerardo Hospital ASST Monza, Monza, Italy
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44
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Mahajan A, Mason GF. A sobering addition to the literature on COVID-19 and the brain. J Clin Invest 2021; 131:148376. [PMID: 33724953 DOI: 10.1172/jci148376] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Several coronavirus disease 2019 (COVID-19) studies have focused on neuropathology. In this issue of the JCI, Qin, Wu, and Chen et al. focused specifically on people whose acute infection lacked obvious neurological involvement. Severely infected patients showed abnormal gray matter volumes, white matter diffusion, and cerebral blood flow compared with healthy controls and those with mild infection. The data remain associative rather than mechanistic, but correlations with systemic immune markers suggest effects of inflammation, hypercoagulation, or other aspects of disease severity. Mechanistic research is warranted. Given the lack of obvious neurological symptoms, neurocognitive assessments were not performed, but the findings suggest that such assessments may be warranted in severely affected patients, even without obvious symptoms. Further, studying CNS involvement of other disorders with overlapping pathophysiologies such as inflammation, coagulation, hypoxia, or direct viral infection may reveal the causes for COVID-19-related neuropathology.
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Affiliation(s)
- Amit Mahajan
- Department of Radiology & Biomedical Imaging and
| | - Graeme F Mason
- Department of Radiology & Biomedical Imaging and.,Departments of Psychiatry and Biomedical Engineering, Yale University, School of Medicine, New Haven, Connecticut, USA
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Winterer JM, Ofosu K, Borchers F, Hadzidiakos D, Lammers-Lietz F, Spies C, Winterer G, Zacharias N. Neurocognitive disorders in the elderly: altered functional resting-state hyperconnectivities in postoperative delirium patients. Transl Psychiatry 2021; 11:213. [PMID: 33846284 PMCID: PMC8041755 DOI: 10.1038/s41398-021-01304-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 02/03/2021] [Accepted: 03/02/2021] [Indexed: 01/11/2023] Open
Abstract
Postoperative delirium (POD) represents a confusional state during days/weeks after surgery and is particularly frequent in elderly patients. Hardly any fMRI studies were conducted to understand the underlying pathophysiology of POD patients. This prospective observational cohort study aims to examine changes of specific resting-state functional connectivity networks across different time points (pre- and 3-5 months postoperatively) in delirious patients compared to no-POD patients. Two-hundred eighty-three elderly surgical patients underwent preoperative resting-state fMRI (46 POD). One-hundred seventy-eight patients completed postoperative scans (19 POD). For functional connectivity analyses, three functional connectivity networks with seeds located in the orbitofrontal cortex (OFC), nucleus accumbens (NAcc), and hippocampus were investigated. The relationship of POD and connectivity changes between both time points (course connectivity) were examined (ANOVA). Preoperatively, delirious patients displayed hyperconnectivities across the examined functional connectivity networks. In POD patients, connectivities within NAcc and OFC networks demonstrated a decrease in course connectivity [max. F = 9.03, p = 0.003; F = 4.47, p = 0.036, resp.]. The preoperative hyperconnectivity in the three networks in the patients at risk for developing POD could possibly indicate existing compensation mechanisms for subtle brain dysfunction. The observed pathophysiology of network function in POD patients at least partially involves dopaminergic pathways.
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Affiliation(s)
- Jeanne M. Winterer
- grid.6363.00000 0001 2218 4662Department of Psychiatry and Psychotherapy (CCM), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany ,grid.484013.aDepartment of Anesthesiology, Charité (CVK, CCM)–Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany ,Pharmaimage Biomarker Solutions GmbH, Berlin, Germany
| | - Kwaku Ofosu
- grid.484013.aDepartment of Anesthesiology, Charité (CVK, CCM)–Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Friedrich Borchers
- grid.484013.aDepartment of Anesthesiology, Charité (CVK, CCM)–Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Daniel Hadzidiakos
- grid.484013.aDepartment of Anesthesiology, Charité (CVK, CCM)–Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Florian Lammers-Lietz
- grid.484013.aDepartment of Anesthesiology, Charité (CVK, CCM)–Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Claudia Spies
- grid.484013.aDepartment of Anesthesiology, Charité (CVK, CCM)–Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Georg Winterer
- Department of Anesthesiology, Charité (CVK, CCM)-Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany. .,Pharmaimage Biomarker Solutions GmbH, Berlin, Germany.
| | - Norman Zacharias
- grid.484013.aDepartment of Anesthesiology, Charité (CVK, CCM)–Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany ,Pharmaimage Biomarker Solutions GmbH, Berlin, Germany
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46
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Madrigal C, Kim J, Jiang L, Lafo J, Bozzay M, Primack J, Correia S, Erqou S, Wu WC, Rudolph JL. Delirium and Functional Recovery in Patients Discharged to Skilled Nursing Facilities After Hospitalization for Heart Failure. JAMA Netw Open 2021; 4:e2037968. [PMID: 33724390 PMCID: PMC7967078 DOI: 10.1001/jamanetworkopen.2020.37968] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE A substantial number of patients discharged to skilled nursing facilities (SNFs) after heart failure (HF) hospitalization experience regression in function or do not improve. Delirium is one of few modifiable risk factors in this patient population. Therefore, understanding the role of delirium in functional recovery may be useful for improving outcomes. OBJECTIVE To assess the association of delirium with 30-day functional improvement in patients discharged to SNFs after HF hospitalization. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study included patients hospitalized for HF in 129 US Department of Veterans Affairs hospitals who were discharged to SNFs from October 1, 2010, to September 30, 2015. Data were analyzed from June 14 to December 18, 2020. EXPOSURES Delirium, as determined by the Minimum Data Set (MDS) 3.0 Confusion Assessment Method, with dementia as a covariate, determined via International Classification of Diseases, Ninth Revision (ICD-9) coding. MAIN OUTCOMES AND MEASURES The difference between admission and 30-day MDS 3.0 Activities of Daily Living (ADL) scores. RESULTS A total of 20 495 patients (mean [SD] age, 78 [10.3] years; 78.9% White; and 97% male) were included in the analysis. Of the total sample, 882 patients (4.3%) had delirium on an SNF admission. The mean (SD) baseline ADL score on admission to SNF was significantly worse among patients with delirium than without (18.3 [4.7] vs 16.1 [5.2]; P < .001; d = 0.44.). On the 30-day repeated assessment, mean (SD) function (ADL scores) improved for both patients with delirium (0.6 [2.9]) and without delirium (1.8 [3.6]) (P < .001; d = -0.38). In the multivariate adjusted model, delirium was associated with statistically significant lower ADL improvement (difference in ADL score, -1.07; 95% CI, -1.31 to -0.83; P < .001). CONCLUSIONS AND RELEVANCE In this retrospective cohort study, patients with HF discharged to SNFs with delirium were less likely to show improvement in function compared with patients without delirium. Findings suggest a potential need to reexamine how and when health care professionals assess delirium in HF patients throughout their hospitalization and SNF course. Identifying and treating delirium for HF patients earlier in their care trajectory may play an important role in improving care and long-term functional outcomes in this population. Future research is warranted to further investigate the association between delirium and functional recovery for HF and other patient populations.
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Affiliation(s)
- Caroline Madrigal
- Providence VA Medical Center, Center of Innovation in Long Term Services and Supports, Providence, Rhode Island
| | - Jenny Kim
- Providence VA Medical Center, Center of Innovation in Long Term Services and Supports, Providence, Rhode Island
| | - Lan Jiang
- Providence VA Medical Center, Center of Innovation in Long Term Services and Supports, Providence, Rhode Island
| | - Jacob Lafo
- Providence VA Medical Center, Center of Innovation in Long Term Services and Supports, Providence, Rhode Island
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Melanie Bozzay
- Department of Psychiatry & Human Behavior, Brown University, Providence, Rhode Island
- Providence VA Medical Center, Center for Neurorestoration and Neurotechnology, Providence, Rhode Island
| | - Jennifer Primack
- Providence VA Medical Center, Center of Innovation in Long Term Services and Supports, Providence, Rhode Island
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island
- Providence VA Medical Center, Center for Neurorestoration and Neurotechnology, Providence, Rhode Island
| | - Stephen Correia
- Providence VA Medical Center, Center of Innovation in Long Term Services and Supports, Providence, Rhode Island
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island
- Department of Psychiatry & Human Behavior, Brown University, Providence, Rhode Island
- Butler Hospital, Providence, Rhode Island
| | - Sebhat Erqou
- Providence VA Medical Center, Center of Innovation in Long Term Services and Supports, Providence, Rhode Island
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Wen-Chih Wu
- Providence VA Medical Center, Center of Innovation in Long Term Services and Supports, Providence, Rhode Island
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - James L. Rudolph
- Providence VA Medical Center, Center of Innovation in Long Term Services and Supports, Providence, Rhode Island
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island
- Center for Gerontology, Brown University School of Public Health, Providence, Rhode Island
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47
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Munro CL, Liang Z, Ji M, Elías MN, Chen X, Calero K, Ely EW. Family automated voice reorientation (FAVoR) intervention for mechanically ventilated patients in the intensive care unit: Study protocol for a randomized controlled trial. Contemp Clin Trials 2021; 102:106277. [PMID: 33482395 DOI: 10.1016/j.cct.2021.106277] [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: 11/09/2020] [Revised: 01/03/2021] [Accepted: 01/04/2021] [Indexed: 11/27/2022]
Abstract
Delirium in the intensive care unit (ICU) affects up to 80% of critically ill, mechanically ventilated (MV) adults. Delirium is associated with substantial negative outcomes, including increased hospital complications and long-term effects on cognition and health status in ICU survivors. The purpose of this randomized controlled trial is to test the effectiveness of a Family Automated Voice Reorientation (FAVoR) intervention on delirium among critically ill MV patients. The FAVoR intervention uses scripted audio messages, which are recorded by the patient's family and played at hourly intervals during daytime hours. This ongoing orientation to the ICU environment through recorded messages in a voice familiar to the patient may enable the patient to more accurately interpret the environment and thus reduce risk of delirium. The study's primary aim is to test the effect of the FAVoR intervention on delirium in critically ill MV adults in the ICU. The secondary aims are to explore: (1) if the effect of FAVoR on delirium is mediated by sleep, (2) if selected biobehavioral factors moderate the effects of FAVoR on delirium, and (3) the effects of FAVoR on short-term and long-term outcomes, including cognition and health status. Subjects (n = 178) are randomly assigned to the intervention or control group within 48 h of initial ICU admission and intubation. The intervention group receives FAVoR over a 5-day period, while the control group receives usual care. Delirium-free days, sleep and activity, cognition, patient-reported health status and sleep quality, and data regarding iatrogenic/environmental and biobehavioral factors are collected.
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Affiliation(s)
- Cindy L Munro
- University of Miami School of Nursing and Health Studies, 5030 Brunson Drive, Coral Gables, FL, United States.
| | - Zhan Liang
- University of Miami School of Nursing and Health Studies, 5030 Brunson Drive, Coral Gables, FL, United States
| | - Ming Ji
- University of South Florida College of Nursing, 12901 Bruce B. Downs Blvd, Tampa, FL, United States
| | - Maya N Elías
- University of Miami School of Nursing and Health Studies, 5030 Brunson Drive, Coral Gables, FL, United States
| | - Xusheng Chen
- University of Miami School of Nursing and Health Studies, 5030 Brunson Drive, Coral Gables, FL, United States
| | - Karel Calero
- Department of Pulmonary, Critical Care, and Sleep Medicine, University of South Florida College of Medicine, 12901 Bruce B. Downs Blvd, Tampa, FL, United States
| | - E Wesley Ely
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, 2525 West End Avenue Suite 450, Nashville, TN, United States; Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, 1161 21st Ave S, Nashville, TN, United States; Veteran's Affairs TN Valley, Geriatrics Research, Education and Clinical Center (GRECC), 1310 24th Ave S, Nashville, TN, United States
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48
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Giordano G, Pugliese F, Bilotta F. Neuroinflammation, neuronal damage or cognitive impairment associated with mechanical ventilation: A systematic review of evidence from animal studies. J Crit Care 2020; 62:246-255. [PMID: 33454552 DOI: 10.1016/j.jcrc.2020.12.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 11/25/2020] [Accepted: 12/19/2020] [Indexed: 01/01/2023]
Abstract
PURPOSE Long-term cognitive impairment is a complication of critical illness survivors. Beside its lifesaving role, mechanical ventilation has potential complications. The aim of this study is to systematically review the evidence collected in animal studies that correlate mechanical ventilation with neuroinflammation, neuronal damage and cognitive impairment. METHODS We searched MEDLINE and EMBASE databases for studies published from inception until August 31st, 2020, that enrolled mechanically ventilated animals and reported on neuroinflammation or neuronal damage markers changes or cognitive-behavioural impairment. RESULTS Of 5583 studies, 11 met inclusion criteria. Mice, rats, pigs were used. Impact of MV: 4 out of 7 studies reported higher neuroinflammation markers in MV-treated animals and 3 studies reported no differences; 7 out of 8 studies reported a higher neuronal damage and 1 reported no differences; 2 out of 2 studies reported cognitive decline up to 3 days after MV. Higher Tidal volumes are associated with higher changes in brain or serum markers. CONCLUSION Preclinical evidence suggests that MV induces neuroinflammation, neuronal damage and cognitive impairment and these are worsened if sub-optimal MV settings are applied. Future studies, with appropriate methodology, are necessary to evaluate for serum monitoring strategies. TRIAL REGISTRATION NUMBER CRD42019148935.
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Affiliation(s)
- Giovanni Giordano
- Department of Anaesthesia and Intensive Care, Sapienza University of Rome, Roma, Italy.
| | - Francesco Pugliese
- Department of Anaesthesia and Intensive Care, Sapienza University of Rome, Roma, Italy
| | - Federico Bilotta
- Department of Anaesthesia and Intensive Care, Sapienza University of Rome, Roma, Italy
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49
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Wilson JE, Mart MF, Cunningham C, Shehabi Y, Girard TD, MacLullich AMJ, Slooter AJC, Ely EW. Delirium. Nat Rev Dis Primers 2020; 6:90. [PMID: 33184265 PMCID: PMC9012267 DOI: 10.1038/s41572-020-00223-4] [Citation(s) in RCA: 404] [Impact Index Per Article: 101.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/29/2020] [Indexed: 02/06/2023]
Abstract
Delirium, a syndrome characterized by an acute change in attention, awareness and cognition, is caused by a medical condition that cannot be better explained by a pre-existing neurocognitive disorder. Multiple predisposing factors (for example, pre-existing cognitive impairment) and precipitating factors (for example, urinary tract infection) for delirium have been described, with most patients having both types. Because multiple factors are implicated in the aetiology of delirium, there are likely several neurobiological processes that contribute to delirium pathogenesis, including neuroinflammation, brain vascular dysfunction, altered brain metabolism, neurotransmitter imbalance and impaired neuronal network connectivity. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) is the most commonly used diagnostic system upon which a reference standard diagnosis is made, although many other delirium screening tools have been developed given the impracticality of using the DSM-5 in many settings. Pharmacological treatments for delirium (such as antipsychotic drugs) are not effective, reflecting substantial gaps in our understanding of its pathophysiology. Currently, the best management strategies are multidomain interventions that focus on treating precipitating conditions, medication review, managing distress, mitigating complications and maintaining engagement to environmental issues. The effective implementation of delirium detection, treatment and prevention strategies remains a major challenge for health-care organizations globally.
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Affiliation(s)
- Jo Ellen Wilson
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA.
- Department of Psychiatry and Behavioral Sciences, Division of General Psychiatry, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Matthew F Mart
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Colm Cunningham
- School of Biochemistry & Immunology, Trinity Biomedical Sciences Institute & Trinity College Institute of Neuroscience, Trinity College Dublin, Dublin, Republic of Ireland
| | - Yahya Shehabi
- Monash Health School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
- Prince of Wales Clinical School of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Timothy D Girard
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
| | - Arjen J C Slooter
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - E Wesley Ely
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
- Veteran's Affairs TN Valley, Geriatrics Research, Education and Clinical Center (GRECC), Nashville, TN, USA
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50
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Abstract
Better ways to manage preoperative, intraoperative and postoperative care of surgical patients is the bailiwick of anesthesiologists. Although we care for patients of all ages, protecting the cognitive capacity of elderly patients more frequently requires procedures and practices that go beyond routine care for nonelderly adults. This narrative review will consider current understanding of the reasons that elderly patients need enhanced care, and recommendations for that care based on established and recent empirical research. In that latter regard, unless and until we are able to classify anesthetic neurotoxicity as a rare complication, the first-do-no-harm approach should: (1) add anesthesia to surgical intervention on the physiological cost side of the cost/benefit ratio when making decisions about whether and when to proceed with surgery; (2) minimize anesthetic depth and periods of electroencephalographic suppression; (3) limit the duration of continuous anesthesia whenever possible; (4) consider the possibility that regional anesthesia with deep sedation may be as neurotoxic as general anesthesia; and (5) when feasible, use regional anesthesia with light or no sedation.
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