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Paulino MC, Conceição C, Silvestre J, Lopes MI, Gonçalves H, Dias CC, Serafim R, Salluh JIF, Póvoa P. Subsyndromal Delirium in Critically Ill Patients-Cognitive and Functional Long-Term Outcomes. J Clin Med 2023; 12:6363. [PMID: 37835007 PMCID: PMC10573694 DOI: 10.3390/jcm12196363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 10/01/2023] [Accepted: 10/02/2023] [Indexed: 10/15/2023] Open
Abstract
Subsyndromal delirium (SSD) in the Intensive Care Unit (ICU) is associated with an increased morbidity with unknown post-discharge functional and cognitive outcomes. We performed a prospective multicenter study to analyze the mental status of patients during their first 72 h after ICU admission and its trajectory, with follow-ups at 3 and 6 months after hospital discharge. Amongst the 106 included patients, SSD occurred in 24.5% (n = 26) and was associated with the duration of mechanical ventilation (p = 0.003) and the length of the ICU stay (p = 0.002). After the initial 72 h, most of the SSD patients (30.8%) improved and no longer had SSD; 19.2% continued to experience SSD and one patient (3.8%) progressed to delirium. The post-hospital discharge survival rate for the SSD patients was 100% at 3 months and 87.5% at 6 months. At admission, 96.2% of the SSD patients were fully independent in daily living activities, 66.7% at 3-month follow-up, and 100% at 6-month follow-up. Most SSD patients demonstrated a cognitive decline from admission to 3-month follow-up and improved at 6 months (IQCODE-SF: admission 3.13, p < 0.001; 3 months 3.41, p = 0.019; 6 months 3.19, p = 0.194). We concluded that early SSD is associated with worse outcomes, mainly a transitory cognitive decline after hospital discharge at 3 months, with an improvement at 6 months. This highlights the need to prevent and identify this condition during ICU stays.
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Affiliation(s)
- Maria Carolina Paulino
- NOVA Medical School, New University of Lisbon, 1150-082 Lisbon, Portugal; (J.S.); (P.P.)
- Department of Intensive Care, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, 1150-199 Lisbon, Portugal;
- Department of Intensive Care, Hospital da Luz Lisboa, 1500-650 Lisbon, Portugal;
| | - Catarina Conceição
- Department of Intensive Care, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, 1150-199 Lisbon, Portugal;
- Lisbon School of Medicine, University of Lisbon (FMUL), 1649-028 Lisbon, Portugal
| | - Joana Silvestre
- NOVA Medical School, New University of Lisbon, 1150-082 Lisbon, Portugal; (J.S.); (P.P.)
- Department of Intensive Care, Hospital dos Lusíadas, 1500-458 Lisbon, Portugal
| | - Maria Inês Lopes
- Department of Intensive Care, Hospital da Luz Lisboa, 1500-650 Lisbon, Portugal;
| | - Hernâni Gonçalves
- Center for Health Technology and Services Research (CINTESIS@RISE), Faculty of Medicine, University of Porto, 4200-450 Porto, Portugal; (H.G.); (C.C.D.)
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, 4200-450 Porto, Portugal
| | - Cláudia Camila Dias
- Center for Health Technology and Services Research (CINTESIS@RISE), Faculty of Medicine, University of Porto, 4200-450 Porto, Portugal; (H.G.); (C.C.D.)
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, 4200-450 Porto, Portugal
| | - Rodrigo Serafim
- D’OR Institute for Research and Education, Rio de Janeiro 22281-100, Brazil; (R.S.); (J.I.F.S.)
- Post-Graduate Program, Federal University of Rio de Janeiro, Rio de Janeiro 21941-913, Brazil
| | - Jorge I. F. Salluh
- D’OR Institute for Research and Education, Rio de Janeiro 22281-100, Brazil; (R.S.); (J.I.F.S.)
- Post-Graduate Program, Federal University of Rio de Janeiro, Rio de Janeiro 21941-913, Brazil
| | - Pedro Póvoa
- NOVA Medical School, New University of Lisbon, 1150-082 Lisbon, Portugal; (J.S.); (P.P.)
- Department of Intensive Care, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, 1150-199 Lisbon, Portugal;
- Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, C 5000 Odense, Denmark
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Denk A, Müller K, Schlosser S, Heissner K, Gülow K, Müller M, Schmid S. Liver diseases as a novel risk factor for delirium in the ICU-Delirium and hepatic encephalopathy are two distinct entities. PLoS One 2022; 17:e0276914. [PMID: 36413529 PMCID: PMC9681112 DOI: 10.1371/journal.pone.0276914] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 10/15/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Delirium prevalence is high in critical care settings. We examined the incidence, risk factors, and outcome of delirium in a medical intensive care unit (MICU) with a particular focus on liver diseases. We analyzed this patient population in terms of delirium risk prediction and differentiation between delirium and hepatic encephalopathy. METHODS We conducted an observational study and included 164 consecutive patients admitted to an MICU of a university hospital. Patients were assessed for delirium using the Confusion Assessment Method for ICUs and the Richmond Agitation-Sedation Scale (RASS). On admission and at the onset of delirium Sequential Organ Failure Assessment (SOFA) score was determined. A population of patients with liver disease was compared to a population with gastrointestinal diseases. In the population with liver diseases, hepatic encephalopathy was graded according to the West Haven classification. We analyzed the incidence, subtype, predisposing, precipitating, and health-care setting-related factors, treatment, outcome of delirium and the association between delirium and hepatic encephalopathy in patients with liver diseases. RESULTS The incidence of delirium was 32.5% (n = 53). Univariable binary regression analyses adjusted by the Holm-Bonferroni method showed that the development of delirium was significantly determined by 10 risk factors: Alcohol abuse (p = 0.016), severity of disease (Simplified Acute Physiology Score (SAPS) II, p = 0.016), liver diseases (p = 0.030) and sepsis (p = 0.016) compared to the control group (gastrointestinal (GI) diseases and others), increased sodium (p = 0.016), creatinine (p = 0.030), urea (p = 0.032) or bilirubin (p = 0.042), decreased hemoglobin (p = 0.016), and mechanical ventilation (p = 0.016). Of note, we identified liver diseases as a novel and relevant risk factor for delirium. Hepatic encephalopathy was not a risk factor for delirium. Delirium and hepatic encephalopathy are both life-threatening but clearly distinct conditions. The median SOFA score for patients with delirium at delirium onset was significantly higher than the SOFA score of all patients at admission (p = 0.008). Patients with delirium had five times longer ICU stays (p = 0.004) and three times higher in-hospital mortality (p = 0.036). Patients with delirium were five times more likely to be transferred to an intensive medical rehabilitation unit for post-intensive care (p = 0.020). Treatment costs per case were more than five times higher in patients with delirium than in patients without delirium (p = 0.004). CONCLUSIONS The 10 risk factors identified in this study should be assessed upon admission to ICU for effective detection, prevention, and treatment of delirium. Liver diseases are a novel risk factor for delirium with a level of significance comparable to sepsis as an established risk factor. Of note, in patients with liver diseases delirium and hepatic encephalopathy should be recognized as distinct entities to initiate appropriate treatment. Therefore, we propose a new algorithm for efficient diagnosis, characterization, and treatment of altered mental status in the ICU. This algorithm integrates the 10 risk factor prediction-model for delirium and prompts grading of the severity of hepatic encephalopathy using the West Haven classification if liver disease is present or newly diagnosed.
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Affiliation(s)
- Alexander Denk
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious diseases, University Hospital Regensburg, Regensburg, Germany
| | - Karolina Müller
- Center for Clinical Studies, University Hospital Regensburg, Regensburg, Germany
| | - Sophie Schlosser
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious diseases, University Hospital Regensburg, Regensburg, Germany
| | - Klaus Heissner
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious diseases, University Hospital Regensburg, Regensburg, Germany
| | - Karsten Gülow
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious diseases, University Hospital Regensburg, Regensburg, Germany
| | - Martina Müller
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious diseases, University Hospital Regensburg, Regensburg, Germany
| | - Stephan Schmid
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious diseases, University Hospital Regensburg, Regensburg, Germany
- * E-mail:
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Epigenetic Mechanisms of Postoperative Cognitive Impairment Induced by Anesthesia and Neuroinflammation. Cells 2022; 11:cells11192954. [PMID: 36230916 PMCID: PMC9563723 DOI: 10.3390/cells11192954] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 09/09/2022] [Accepted: 09/14/2022] [Indexed: 11/17/2022] Open
Abstract
Cognitive impairment after surgery is a common problem, affects mainly the elderly, and can be divided into postoperative delirium and postoperative cognitive dysfunction. Both phenomena are accompanied by neuroinflammation; however, the precise molecular mechanisms underlying cognitive impairment after anesthesia are not yet fully understood. Anesthesiological drugs can have a longer-term influence on protein transcription, thus, epigenetics is a possible mechanism that impacts on cognitive function. Epigenetic mechanisms may be responsible for long-lasting effects and may implicate novel therapeutic approaches. Hence, we here summarize the existing literature connecting postoperative cognitive impairment to anesthesia. It becomes clear that anesthetics alter the expression of DNA and histone modifying enzymes, which, in turn, affect epigenetic markers, such as methylation, histone acetylation and histone methylation on inflammatory genes (e.g., TNF-alpha, IL-6 or IL1 beta) and genes which are responsible for neuronal development (such as brain-derived neurotrophic factor). Neuroinflammation is generally increased after anesthesia and neuronal growth decreased. All these changes can induce cognitive impairment. The inhibition of histone deacetylase especially alleviates cognitive impairment after surgery and might be a novel therapeutic option for treatment. However, further research with human subjects is necessary because most findings are from animal models.
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Fatehi Hassanabad A, Bahrami N, Novick RJ, Ali IS. Delirium and depression in cardiac surgery: A comprehensive review of risk factors, pathophysiology, and management. J Card Surg 2021; 36:2876-2889. [PMID: 34120376 DOI: 10.1111/jocs.15610] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 04/17/2021] [Accepted: 04/19/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Mental health and wellbeing continue to gain more attention as they are inextricably associated with clinical outcomes, particularly quality of life. Many medical ailments and major surgeries affect patients' mental health, including depression and delirium. AIMS The objective of this manuscript was to comprehensively review and critically examine the literature pertaining to cardiac surgery, depression, and delirium. METHODS This is a narrative review article. We performed our search analysis by using the following key words: "Cardiac Surgery", "Depression", "Delirium", "Clinical outcomes", and "Mental Health". Search analysis was done on MedLine PubMed, accessing indexed peer-reviewed publications. RESULTS Cardiac Surgery is a life-altering intervention indicated to improve morbidity and mortality in patients with cardiovascular diseases. Psychiatric conditions before and after cardiac surgery worsen patient prognosis and increase mortality rate. Specifically, preoperative depression increases postoperative depression and is associated with impaired functional status, slow physical recovery, and an increased readmission rate. DISCUSSION Although the exact pathophysiology between depression and cardiovascular disease (CVD) is unknown, several pathways have been implicated. Unmanaged depression can also lead to other psychological conditions such as delirium. Like depression, the exact association between delirium and CVD is not well understood, but believed to be multifactorial. CONCLUSION Herein, we provide a comprehensive review of the links between depression, delirium, and cardiovascular surgery. We critically examine the current data that pertains to the pathophysiology of these debilitating mental health issues in the context of cardiac surgery. Finally, we summarize the various treatment options available for managing depression and delirium in the cardiac surgery patient population.
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Affiliation(s)
- Ali Fatehi Hassanabad
- Section of Cardiac Surgery, Department of Cardiac Sciences, Cumming School of Medicine, Libin Cardiovascular Institute, Calgary, Alberta, Canada
| | - Nabila Bahrami
- Department of Medicine, Department of Medicine, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Richard J Novick
- Section of Cardiac Surgery, Department of Cardiac Sciences, Cumming School of Medicine, Libin Cardiovascular Institute, Calgary, Alberta, Canada
| | - Imtiaz S Ali
- Section of Cardiac Surgery, Department of Cardiac Sciences, Cumming School of Medicine, Libin Cardiovascular Institute, Calgary, Alberta, Canada
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Henao-Castaño AM, Pachón Cetina LE, Monroy Rodríguez JD. Nursing Delirium Screening Scale, a Tool for Early Detection of Delirium: Integrative Review. AQUICHAN 2020. [DOI: 10.5294/aqui.2020.20.4.5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective: To analyze the context and use of the Nursing Delirium Screening Scale (Nu-DESC) for early detection of delirium in adult patients, compiling the available evidence.
Method: Searching for relevant articles on databases such as Cinahl, Medline, Ovid, Scopus, and Web of Science. Inclusion criteria: Articles written in English, Spanish, and Portuguese, published between January 2013 and October 2019. Search terms: “nursing delirium screen,” “inpatient delirium screening,” and “nursing assessment.” We identified 23 articles in which the Nu-DESC was used. Two reviewers independently assessed the articles using the CASPe (Critical Appraisal Skills Program in Spanish) tool.
Results: The Nu-DESC is employed in different contexts such as the adult intensive care unit (ICU), post-anesthetic care unit (PACU), palliative care unit, and hospitalization unit. It is more frequently used in the PACU with a more sensitive threshold (≥ 1); the test showed greater sensitivity of 54.5 % (95 % CI: 32.2–75.6) and specificity of 97.1 % (95 % CI: 95.3–98.4).
Conclusion: The Nu-DESC facilitates the recognition of delirium episodes by the nursing team, makes care quicker and individualized for each patient, avoiding immediate pharmacological interventions, and coordinate interdisciplinary actions for diagnosis, especially in post-anesthetic care units.
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Intensive Care Unit Delirium, Clinical Observations, and Patients' Statements: A Case Study. Dimens Crit Care Nurs 2020; 39:169-179. [PMID: 32467399 DOI: 10.1097/dcc.0000000000000424] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND In clinical practice, nurses use their clinical gaze and make observations in order to assess patients' medical conditions and care needs. However, signs of developing intensive care unit delirium (ICUD) are often difficult to determine, as communication with patients is usually limited because of intubation and the seriousness of their medical condition(s). Usually, ICUD is screened and diagnosed with different, mainly nonverbal instruments, which presupposes that the observer is skilled and experienced in recognizing symptoms and signs of delirium. OBJECTIVES The objectives were to investigate if there was a concordance between data from continuous clinical observations described in the researcher's logbook and patients' statements of their experiences of delirium during their ICU stay. METHODS Inclusion criteria were that the patients had been mechanically ventilated and had stayed in the ICU for a minimum of 36 hours. From this, a multiple-case design (n = 19), based on 1 to 3 hours of observations in the ICU and 2 interviews, was used. The first interview was conducted at the hospital approximately 6 to 14 days after discharge from the ICU, and the second, 4 to 8 weeks following the first interview in patients' homes. Two typical cases were identified and described by a cross-case procedure. RESULTS A concordance between observations and patients' statements was found. Subtle, as well as obvious, signs of delirium were possible to detect by attentive observations over time and listening to what patients were trying to convey with their speech and body language. Experiencing delirium seemed to indicate existential suffering where the abnormal became the normal and not being able to distinguish between reality and fantasies. CONCLUSION A continuity of skilled observations and listening to patients' statements are vital for detection of ongoing ICU delirium or experiences of delirium.
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Facco E. Anesthesia, delirium and the mind-body unit. Minerva Anestesiol 2019; 86:117-120. [PMID: 31820881 DOI: 10.23736/s0375-9393.19.14277-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Enrico Facco
- Department of Neurosciences, University of Padua, Padua, Italy - .,Science of Consciousness Research Group, Department of Psychology, University of Padua, Padua, Italy - .,Institute Franco Granone, Italian Center of Clinical and Experimental Hypnosis (CIICS), Turin, Italy -
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Khalighi E, Tarjoman A, Abdi A, Borji M. The prevalence of delirium in patients in Iran: a systematic review and meta-analysis. FUTURE NEUROLOGY 2019. [DOI: 10.2217/fnl-2018-0044] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Aim: The first systematic review and meta analysis investigating the prevalence of delirium in Iran and the importance of delirium in the health status of patients. Method: This study is a review article to determine the overall prevalence of delirium in patients admitted to the hospitals in Iran, with search time frame to 12 October 2000–12 October 2018. The study examined the prevalence of delirium in general wards and ICUs of Iran according to published article in domestic and foreign journals. The methodological quality of the papers was based on a tool used in previous studies. Data was analyzed using comprehensive meta-analysis (CMA) software. Findings: The findings showed the prevalence of delirium in hospitalized patients in Iran is 21.8% (CI: 17.5–27.5%). The prevalence of delirium in hospitalized patients in Iran based on the hospitalization in ICU is 24.7% (CI: 18.1–32.7%) and in the general ward is 17.5% (CI: 13.6–22.3%). Conclusion: Due to the relatively high prevalence of delirium in patients admitted to hospitals in Iran, prevention is necessary to reduce the incidence of delirium.
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Affiliation(s)
- Ebrahim Khalighi
- Anesthesiologist, Department of Anesthesiology, Medicine Faculty, Ilam University of Medical Science, Ilam, IR Iran
| | - Asma Tarjoman
- Student Research committee, kermanshah University of Medical Sciences, Kermanshah, IR Iran
| | - Alireza Abdi
- Department of Nursing, Faculty of Nursing & Midwifery, kermanshah University of Medical Science, Kermanshah, IR Iran
| | - Milad Borji
- Department of Nursing, Faculty of Nursing & Midwifery, kermanshah University of Medical Science, Kermanshah, IR Iran
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Fischer T, Hosie A, Luckett T, Agar M, Phillips J. Strategies for Pain Assessment in Adult Patients With Delirium: A Scoping Review. J Pain Symptom Manage 2019; 58:487-502.e11. [PMID: 31195076 DOI: 10.1016/j.jpainsymman.2019.05.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 05/31/2019] [Accepted: 05/31/2019] [Indexed: 01/19/2023]
Abstract
CONTEXT Pain and delirium are highly prevalent in the same patient groups. Disturbances in attention, awareness, and cognition are characteristics for delirium and can compromise pain assessment. OBJECTIVES The aim of this review was to examine and map models and understandings of pain and delirium as well as pain assessment instruments and strategies for adult patients with delirium. METHODS A scoping review of all publications that reported on pain assessment in adult patients with delirium was conducted with no time and language constraints, searching Medline, CINAHL, Scopus, Embase, and PsycINFO and systematically assessing for inclusion. Standardized data extraction and a narrative synthesis followed. RESULTS A total of 90 publications were included in the final analysis. Despite being recommended for practice, no evidence for the use of self-report or behavioral pain assessment instruments in patients with delirium was identified, with the exception of limited evidence for the validity of the Critical Care Pain Observation Tool and Behavioral Pain Scale in delirious intensive care patients. Proxy ratings of pain and comprehensive pain assessment hierarchies were also recommended, but not supported by evidence. Current models and/or understandings of pain and delirium were not applied in most publications. CONCLUSION The current literature is insufficient to guide clinical practice in pain assessment in patients with delirium. Future research will be needed to address the validity of existing pain assessment instruments, apply theoretical and conceptual understandings of pain and delirium, and build on prior studies to close evidence gaps.
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Affiliation(s)
| | - Annmarie Hosie
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Ultimo, Australia
| | - Tim Luckett
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Ultimo, Australia
| | - Meera Agar
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Ultimo, Australia
| | - Jane Phillips
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Ultimo, Australia
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Moon KJ, Park H. Outcomes of Patients With Delirium in Long-Term Care Facilities: A Prospective Cohort Study. J Gerontol Nurs 2018; 44:41-50. [DOI: 10.3928/00989134-20180808-08] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 05/30/2018] [Indexed: 01/29/2023]
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Dixon M. Assessment and management of older patients with delirium in acute settings. Nurs Older People 2018; 30:35-42. [PMID: 29717845 DOI: 10.7748/nop.2018.e969] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2018] [Indexed: 11/09/2022]
Abstract
This article aims to assist nurses and nursing students to consider the presentation of delirium in older patients and the resulting assessment and nursing interventions required. It considers the three types of delirium: hyperactive, hypoactive and mixed. It also discusses potential causes of delirium. Older patients are at increased risk of delirium due to factors such as cognitive impairment, co-morbidities and acute illness. Nurses should be confident in the use of the 4AT score to assess patients with delirium. Use of the mnemonic PINCH ME is suggested to guide management of delirious patients in acute settings. Families of patients with delirium have emotional and other care needs and there are several ways in which nurses can meet them.
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Affiliation(s)
- Martha Dixon
- Orthogeriatric care, Homerton University Hospital NHS Foundation Trust, London, England
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Development and validation of an automated delirium risk assessment system (Auto-DelRAS) implemented in the electronic health record system. Int J Nurs Stud 2017; 77:46-53. [PMID: 29035732 DOI: 10.1016/j.ijnurstu.2017.09.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 09/20/2017] [Accepted: 09/22/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND A key component of the delirium management is prevention and early detection. OBJECTIVE To develop an automated delirium risk assessment system (Auto-DelRAS) that automatically alerts health care providers of an intensive care unit (ICU) patient's delirium risk based only on data collected in an electronic health record (EHR) system, and to evaluate the clinical validity of this system. DESIGN Cohort and system development designs were used. SETTING Medical and surgical ICUs in two university hospitals in Seoul, Korea. PARTICIPANTS A total of 3284 patients for the development of Auto-DelRAS, 325 for external validation, 694 for validation after clinical applications. METHODS The 4211 data items were extracted from the EHR system and delirium was measured using CAM-ICU (Confusion Assessment Method for Intensive Care Unit). The potential predictors were selected and a logistic regression model was established to create a delirium risk scoring algorithm to construct the Auto-DelRAS. The Auto-DelRAS was evaluated at three months and one year after its application to clinical practice to establish the predictive validity of the system. RESULTS Eleven predictors were finally included in the logistic regression model. The results of the Auto-DelRAS risk assessment were shown as high/moderate/low risk on a Kardex screen. The predictive validity, analyzed after the clinical application of Auto-DelRAS after one year, showed a sensitivity of 0.88, specificity of 0.72, positive predictive value of 0.53, negative predictive value of 0.94, and a Youden index of 0.59. CONCLUSIONS A relatively high level of predictive validity was maintained with the Auto-DelRAS system, even one year after it was applied to clinical practice.
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Kallenbach TF, Amado LA. Assessment of delirium in the intensive care unit. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2017. [DOI: 10.1080/22201181.2017.1332809] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- TF Kallenbach
- Department of Anaesthesia, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - LA Amado
- Department of Anaesthesia, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
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Brent J, Burkhart K, Dargan P, Hatten B, Megarbane B, Palmer R, White J. Adverse Drug Reactions in the Intensive Care Unit. CRITICAL CARE TOXICOLOGY 2017. [PMCID: PMC7153447 DOI: 10.1007/978-3-319-17900-1_33] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Adverse drug reactions (ADRs) are undesirable effects of medications used in normal doses [1]. ADRs can occur during treatment in an intensive care unit (ICU) or result in ICU admissions. A meta-analysis of 4139 studies suggests the incidence of ADRs among hospitalized patients is 17% [2]. Because of underreporting and misdiagnosis, the incidence of ADRs may be much higher and has been reported to be as high as 36% [3]. Critically ill patients are at especially high risk because of medical complexity, numerous high-alert medications, complex and often challenging drug dosing and medication regimens, and opportunity for error related to the distractions of the ICU environment [4]. Table 1 summarizes the ADRs included in this chapter.
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Affiliation(s)
- Jeffrey Brent
- Department of Medicine, Division of Clinical Pharmacology and Toxicology, University of Colorado, School of Medicine, Aurora, Colorado USA
| | - Keith Burkhart
- FDA, Office of New Drugs/Immediate Office, Center for Drug Evaluation and Research, Silver Spring, Maryland USA
| | - Paul Dargan
- Clinical Toxicology, St Thomas’ Hospital, Silver Spring, Maryland USA
| | - Benjamin Hatten
- Toxicology Associates, University of Colorado, School of Medicine, Denver, Colorado USA
| | - Bruno Megarbane
- Medical Toxicological Intensive Care Unit, Lariboisiere Hospital, Paris-Diderot University, Paris, France
| | - Robert Palmer
- Toxicology Associates, University of Colorado, School of Medicine, Denver, Colorado USA
| | - Julian White
- Toxinology Department, Women’s and Children’s Hospital, North Adelaide, South Australia Australia
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Early Identification of Subsyndromal Delirium in the Critically Ill: Don't Let the Delirium Rise! Crit Care Med 2016; 44:644-5. [PMID: 26901554 DOI: 10.1097/ccm.0000000000001544] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Charlton M, Prosho KA, O'Neil D. Audit of operational noise at the leicester royal infirmary aicu. Intensive Care Med Exp 2015. [PMCID: PMC4797795 DOI: 10.1186/2197-425x-3-s1-a146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Moon KJ, Lee SM. The effects of a tailored intensive care unit delirium prevention protocol: A randomized controlled trial. Int J Nurs Stud 2015; 52:1423-32. [PMID: 26032729 DOI: 10.1016/j.ijnurstu.2015.04.021] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 04/28/2015] [Accepted: 04/29/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND A decreased incidence of delirium following the application of non-pharmacologic intervention protocols to several patient populations has been previously reported. However, few studies have been conducted to examine the effects of their application to intensive care unit (ICU) patients. OBJECTIVES To examine the effects of applying a tailored delirium preventive protocol, developed by the authors, to ICU patients by analyzing its effects on delirium incidence, in-hospital mortality, ICU readmission, and length of ICU stay in a Korean hospital. DESIGN A single-blind randomized controlled trial. SETTINGS A 1049-bed general hospital with a 105-bed ICU. PARTICIPANTS Sixty and 63 ICU patients were randomly assigned to the intervention and control groups, respectively. METHODS The researchers applied the delirium prevention protocol to the intervention group every day for the first 7 days of ICU hospitalization. Delirium incidence, mortality, and re-admission to the ICU during the same hospitalization period were analyzed by logistic regression analysis; the 7- and 30-day in-hospital mortality by Kaplan-Meier survival and Cox proportional hazard regression analysis; and length of ICU stay was assessed by linear regression analysis. RESULTS Application of the protocol had no significant effect on delirium incidence, in-hospital mortality, re-admission to the ICU, or length of ICU stay. Whereas the risk of 30-day in-hospital mortality was not significantly lower in the intervention than in the control group (OR: 0.33; 95% CI: 0.10-1.09), we found a significantly decreased 7-day in-hospital mortality in the intervention group after protocol application (HR: 0.09; 95% CI: 0.01-0.72). CONCLUSIONS Application of a tailored delirium prevention protocol to acute stage patients during the first 7 days of ICU hospitalization appeared to reduce the 7-day in-hospital risk of mortality only for this patient population.
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Affiliation(s)
- Kyoung-Ja Moon
- Department of Nursing, Ulsan College, Ulsan, Republic of Korea
| | - Sun-Mi Lee
- College of Nursing, The Catholic University of Korea, Seoul, Republic of Korea.
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Breu A, Stransky M, Metterlein T, Werner T, Trabold B. Subsyndromal delirium after cardiac surgery. SCAND CARDIOVASC J 2015; 49:207-12. [DOI: 10.3109/14017431.2015.1041423] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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20
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Moon KJ, Piao J, Jin Y, Lee SM. Is Delirium an Unrecognized Threat to Patient Safety in Korean Intensive Care Units? J Nurs Care Qual 2014; 29:91-8. [DOI: 10.1097/ncq.0b013e31829f828b] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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21
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Delirium--a further complication for patients undergoing heart surgery? Crit Care Med 2013; 41:e236-7. [PMID: 23979387 DOI: 10.1097/ccm.0b013e318291c1ac] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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22
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Padmakumar AD, Bhasin V, Wenham TN, Bodenham AR. Evaluation of Noise Levels in Intensive Care Units in Two Large Teaching Hospitals – A Prospective Observational Study. J Intensive Care Soc 2013. [DOI: 10.1177/175114371301400306] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Critically ill patients do not sleep well. One of the major environmental factors influencing sleep is noise. We prospectively measured noise levels and their relation to the time of day and location in different parts of two separate intensive care units (ICUs). Maximum, minimum and average noise levels were collected over 24 hour periods on five random days in both ICUs using digital sound meters, measured by the A-weighted decibel scale (dB (A)). The World Health Organisation (WHO) recommends that the average background noise in hospitals should not exceed 35 dB (A), and that peaks during the night should be less than 40 dB (A). The measured noise levels in both ICUs were well above the WHO standards. We recommend that various aspects, including staff education and modification of ICU design, must be carefully considered to provide an optimum environment for critically ill patients.
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Affiliation(s)
- Anand D Padmakumar
- Specialist Training Registrar ST6, St James's University Hospital, Leeds
| | | | - Timothy N Wenham
- Consultant in Anaesthesia and Intensive Care Medicine, Barnsley Hospital NHS Foundation Trust
| | - Andrew R Bodenham
- Consultant in Anaesthesia and Intensive Care Medicine, Leeds General Infirmary
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23
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Current world literature. Curr Opin Psychiatry 2012; 25:251-9. [PMID: 22456191 DOI: 10.1097/yco.0b013e328352dd8d] [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: 11/25/2022]
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Abstract
A 15-year-old female patient with known type 1 diabetes mellitus was referred because of abdominal pain. On admission, she was alert but dehydrated with marked Kussmaul breathing. Blood glucose was 414 mg/dL (23 mmol/L). Blood gas analysis revealed severe metabolic acidosis (pH: 6.99) with an elevated anion gap (29.8 mmol/L) and an increased base excess (-25.2 mmol/L). At the sixth hour of treatment with intravenous fluids and insulin, the patient became delirious. The delirium persisted despite the normalization of the acidosis and became difficult to manage. Brain imaging studies revealed neither brain edema nor other intracranial pathology. No evidence of intoxication could be found. The patient gradually regained consciousness and was diagnosed as a case of severe diabetic ketoacidosis (DKA) associated with infection. We were unable to find a similar case in the pediatric literature and thought that reporting this unusual case would be a contribution to the literature on DKA in children.
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Affiliation(s)
- Ayşe Nurcan Cebeci
- İstanbul Medeniyet University Göztepe Educational and Research Hospital, Pediatric Endocrinology, Istanbul, Turkey
| | - Ayla Güven
- İstanbul Medeniyet University Göztepe Educational and Research Hospital, Pediatric Endocrinology, Istanbul, Turkey
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25
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Current World Literature. Curr Opin Anaesthesiol 2012; 25:111-20. [DOI: 10.1097/aco.0b013e32834fd93c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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26
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Current World Literature. Curr Opin Anaesthesiol 2011; 24:705-12. [DOI: 10.1097/aco.0b013e32834e25f9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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27
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Managing ICU delirium: Erratum. Curr Opin Crit Care 2011. [DOI: 10.1097/mcc.0b013e32834735cf] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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