1
|
van Gelder TG, Schweitzer VA, Uijtendaal EV, Sikma MA. Catching the Culprit: Benzylpenicillin Neurotoxicity Confirmed by Therapeutic Drug Monitoring in a Critically Ill Patient With Continuous Venovenous Hemofiltration. Ther Drug Monit 2024; 46:556-558. [PMID: 38840334 PMCID: PMC11232934 DOI: 10.1097/ftd.0000000000001215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 04/03/2024] [Indexed: 06/07/2024]
Abstract
ABSTRACT We present the case of a 65-year-old patient who was treated with high-dose benzylpenicillin for severe invasive pneumococcal pneumonia, complicated by acute renal failure managed with continuous venovenous hemofiltration. After cessation of continuous venovenous hemofiltration, the patient experienced multiple tonic-clonic seizures. Therapeutic drug monitoring revealed high total serum concentrations of benzylpenicillin, identifying it as the likely cause of the neurotoxicity. This case study presents the first documented total serum benzylpenicillin concentration associated with neurotoxicity.
Collapse
Affiliation(s)
- Thomas G van Gelder
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Valentijn A Schweitzer
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; and
| | - Esther V Uijtendaal
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Maaike A Sikma
- Intensive Care and Dutch Poisons Information Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| |
Collapse
|
2
|
Carayannopoulos KL, Alshamsi F, Chaudhuri D, Spatafora L, Piticaru J, Campbell K, Alhazzani W, Lewis K. Antipsychotics in the Treatment of Delirium in Critically Ill Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Crit Care Med 2024; 52:1087-1096. [PMID: 38488422 DOI: 10.1097/ccm.0000000000006251] [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: 03/21/2024]
Abstract
OBJECTIVES To conduct a systematic review and meta-analysis assessing whether the use of antipsychotic medications in critically ill adult patients with delirium impacts patient-important outcomes. DATA SOURCES A medical librarian searched Ovid MEDLINE, EMBASE, APA PsycInfo, and Wiley's Cochrane Library as well as clinicaltrials.gov and the World Health Organization International Clinical Trials Registry Platform up to November 2023. STUDY SELECTION Independently and in duplicate, reviewers screened abstracts and titles for eligibility, then full text of qualifying studies. We included parallel-group randomized controlled trials (RCTs) that included critically ill adult patients with delirium. The intervention group was required to receive antipsychotic medications at any dose, whereas the control group received usual care or placebo. DATA EXTRACTION Reviewers extracted data independently and in duplicate using a piloted abstraction form. Statistical analyses were conducted using RevMan software (version 5.4). DATA SYNTHESIS Five RCTs ( n = 1750) met eligibility criteria. The use of antipsychotic medications compared with placebo did not increase the number of delirium- or coma-free days (mean difference 0.90 d; 95% CI, -0.32 to 2.12; moderate certainty), nor did it result in a difference in mortality, duration of mechanical ventilation, ICU, or hospital length of stay. The use of antipsychotics did not result in an increased risk of adverse events (risk ratio 1.27; 95% CI, 0.71-2.30; high certainty). Subgroup analysis of typical versus atypical antipsychotics did not identify any subgroup effect for any outcome. CONCLUSIONS In conclusion, our systematic review and meta-analysis demonstrated with moderate certainty that there is no difference in delirium- or coma-free days when delirious critically ill adults are treated with antipsychotic medications. Further studies in the subset of patients with hyperactive delirium may be of benefit.
Collapse
Affiliation(s)
- Kallirroi Laiya Carayannopoulos
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Dipayan Chaudhuri
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Laura Spatafora
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, Hamilton, ON, Canada
| | - Joshua Piticaru
- Department of Critical Care, St. Joseph's Health Hospital, Syracuse, NY
| | | | - Waleed Alhazzani
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Kimberley Lewis
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
3
|
Xu HB, Xue F, Ye Y, Zhang HG. Association of Delirium with Long-Term Mortality in Critically Ill Patients with COPD Who Survived to Discharge: A Retrospective Cohort Study. Lung 2024:10.1007/s00408-024-00725-y. [PMID: 38914868 DOI: 10.1007/s00408-024-00725-y] [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: 05/22/2024] [Accepted: 06/19/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND Critically ill patients with chronic obstructive pulmonary disease (COPD) face significant mortality after hospital discharge. Delirium is common in patients with COPD, but its impact on long-term mortality in critically ill COPD patients who survive to discharge remains uncertain. METHODS Critically ill patients with COPD who survived to discharge were selected from the Medical Information Mart for Intensive Care IV database. Delirium was assessed using the Confusion Assessment Method for Intensive Care Unit. The primary outcome was 365- and 180-day mortality after discharge. The secondary outcomes included 90- and 30-day mortality following discharge, length of intensive care unit (ICU) and hospital stays, and nursing care needs after hospital discharge. RESULTS Of the 2621 survivors of critically ill COPD patients, 982 had suffered delirium during their ICU stay and 709 died within 365 days after hospital discharge. Delirium was significantly associated with 365-day mortality after hospital discharge (adjusted hazard ratio [HR] 1.22; 95% confidence interval [CI] 1.02-1.47). The results were consistent for 180-, 90-, and 30-day post-discharge mortality (adjusted HR [95% CI]: 1.35 [1.09-1.66], 1.48 [1.16-1.89], and 1.68 [1.21-2.32], respectively). Additionally, patients with delirium had longer ICU and hospital stay (adjusted β 2.75; 95% CI 2.35-3.16 and 4.25; 95% CI 3.51-4.98, respectively) and increased nursing care needs after hospital discharge (adjusted odds ratio, 1.56; 95% CI 1.13-2.14). CONCLUSION ICU delirium was an independent risk factor for both long-term and short-term mortality in critically ill patients with COPD who survived to discharge.
Collapse
Affiliation(s)
- Hong-Bo Xu
- Department of Critical Care Medicine, Shenzhen Nanshan People's Hospital, and the 6th Affiliated Hospital of Shenzhen University Health Science Center, 89 Taoyuan Road, Shenzhen, 518052, China
| | - Fang Xue
- Department of Critical Care Medicine, Shenzhen Nanshan People's Hospital, and the 6th Affiliated Hospital of Shenzhen University Health Science Center, 89 Taoyuan Road, Shenzhen, 518052, China
| | - Yuan Ye
- Department of Critical Care Medicine, Shenzhen Nanshan People's Hospital, and the 6th Affiliated Hospital of Shenzhen University Health Science Center, 89 Taoyuan Road, Shenzhen, 518052, China
| | - Hai-Gang Zhang
- Department of Critical Care Medicine, Shenzhen Nanshan People's Hospital, and the 6th Affiliated Hospital of Shenzhen University Health Science Center, 89 Taoyuan Road, Shenzhen, 518052, China.
| |
Collapse
|
4
|
Huespe I, Giunta D, Acosta K, Avila D, Prado E, Sanghavi D, Bisso IC, Giannasi S, Carini FC. Comparing Bispectral Index Monitoring vs Clinical Assessment for Deep Sedation in the ICU: Effects on Delirium Reduction and Sedative Drug Doses-A Randomized Trial. Chest 2024:S0012-3692(24)00774-8. [PMID: 38901489 DOI: 10.1016/j.chest.2024.05.031] [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: 01/02/2024] [Revised: 04/22/2024] [Accepted: 05/28/2024] [Indexed: 06/22/2024] Open
Abstract
BACKGROUND Sedative overdoses pose a risk of delirium among patients in the ICU, with potential mitigation through the use of a processed EEG monitor (the bispectral index [BIS]) to guide depth of sedation. RESEARCH QUESTION Can BIS-guided deep sedation (Richmond Agitation Sedation Scale RASS score, -4 or -5) reduce sedative dosage and increase delirium-free and coma-free (DFCF) days? STUDY DESIGN AND METHODS A randomized controlled trial was conducted in a tertiary mixed ICU, enrolling patients requiring deep sedation for > 8 h. Patients were assigned randomly to either the clinical assessment (CA) or BIS groups (BIS range, 40-60). Both groups used a BIS sensor, whereas the CA group's screen remained covered. After deep sedation, BIS sensors were removed, and delirium was assessed twice daily by researchers masked to the randomization. The primary outcome was the number of DFCF days within 14 days after deep sedation. Additionally, we compared doses of sedative drugs and BIS values during deep sedation. RESULTS Ninety-nine patients were included in the study. We found no significant difference in DFCF days (P = .1) between CA and BIS arms, but propofol doses were significantly lower in the BIS group (CA group, 1.77 mg/kg/h [95% CI, 1.60-1.93] vs BIS group, 1.44 mg/kg/h [95% CI, 1.04-1.83]; P = .03). During deep sedation, the CA group spent 46% of the total hours (95% CI, 35%-57%) with BIS values of < 40, whereas the BIS group spent 32% (95% CI, 25%-40%; P = .03). Subgroup analysis focusing on patients sedated for > 24 h revealed an increase in DFCF days in the BIS group (CA group: median, 1 day [interquartile range (IQR), 0-9 days] vs BIS group: median, 8 days [IQR, 0-13 days]; P = .04). INTERPRETATION BIS-guided deep sedation did not improve DFCF days, but did reduce sedative drug use. In patients requiring sedation for > 24 h, it showed an improvement in DFCF days. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT03840577; URL: www. CLINICALTRIALS gov.
Collapse
Affiliation(s)
- Ivan Huespe
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Universidad de Buenos Aires, Buenos Aires, Argentina.
| | - Diego Giunta
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Katia Acosta
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Debora Avila
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Eduardo Prado
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Universidad de Buenos Aires, Buenos Aires, Argentina
| | | | | | | | - Federico C Carini
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
5
|
Zelenkov D, Hollins R, Mahoney EJ, Faugno AJ, Poyant J. The Impact of a Pharmacist-Driven Multicomponent Sleep-Promoting Protocol on Delirium in Critically Ill Patients. J Pharm Pract 2024; 37:578-586. [PMID: 36594245 DOI: 10.1177/08971900221148581] [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: 01/04/2023]
Abstract
Background: Sleep deprivation is reported in 80% of patients in the intensive care unit (ICU) and is associated with delirium. Guidelines recommend implementing a sleep-promoting protocol in critically ill patients which may increase the quantity and quality of sleep and may decrease delirium. Our objective was to implement a pharmacist-led interdisciplinary sleep-promoting protocol and analyze its impact on delirium in ICU patients receiving mechanical ventilation (MV). Methods: The study involved pre-implementation education, protocol development, and post-implementation analysis. ICU pharmacists completed prospective patient chart reviews to reduce exposure to deliriogenic medications and assess the need for a pharmacologic sleep aid. The primary outcome was the incidence of delirium and delirium-free days. Secondary outcomes included ICU length of stay (LOS), incidence of MV, and pharmacist medication interventions. Results: Post-protocol patients (n = 185) had a higher incidence of delirium compared to pre-protocol patients (n = 237) (51.3% vs 39.0%; P = .01). Post-protocol patients had a higher average APACHE III score (P = <.001). Delirium-free days were not significantly different between groups (P = .97). Difference in ICU LOS was not significant (P = .80). More patients received MV post-protocol implementation (55.7% vs 36.1%; P < .001). Pharmacists documented a total of 113 medication interventions. Conclusion and Relevance: A pharmacist-led, ICU sleep-promoting protocol was successfully implemented but did not reduce the incidence of delirium or the administration of insomnia agents. Post-protocol patients had higher disease severity and were more likely to receive MV. Incidence of delirium was consistent with the national reported prevalence of ICU delirium. ICU pharmacists on all shifts had an active role in optimizing sleep.
Collapse
Affiliation(s)
| | - Randy Hollins
- Department of Pharmacy, Melrose Wakefield Healthcare, Melrose, MA, USA
| | - Eric J Mahoney
- Department of Surgical Critical Care, Lahey Hospital & Medical Center, Burlington, MA, USA
| | - Anthony J Faugno
- Department of Critical Care, Sleep and Pulmonary Medicine, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Janelle Poyant
- Department of Pharmacy, Tufts Medical Center, Boston, MA, USA
| |
Collapse
|
6
|
Abdelbaky AM, Eldelpshany MS. Patient Outcomes and Management Strategies for Intensive Care Unit (ICU)-Associated Delirium: A Literature Review. Cureus 2024; 16:e61527. [PMID: 38957260 PMCID: PMC11218465 DOI: 10.7759/cureus.61527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2024] [Indexed: 07/04/2024] Open
Abstract
Delirium is a significant public health concern, with tremendous implications for patient outcomes. Intensive care unit (ICU)-related delirium is gaining attention due to the higher prevalence of delirium in ICU-admitted patients. The most common negative outcomes of ICU delirium include cognitive impairments, functional dependence, high incidence of mortality, extended stay in the ICU, and high costs. So far, no single etiological factor has been identified as the sole cause of delirium. Several functional, neurotransmitter, or injury-causing hypotheses have been proposed for ICU delirium. Several risk factors contribute to the development of delirium in patients admitted to the ICU. These are age, gender, types of sedation, physical restraints, medical and surgical interventions, pain, and extended stay in the ICU. The most commonly used assessment modules for ICU delirium are the PREdiction of DELIRium in ICu patients (PRE-DELIRIC), Early PREdiction model for DELIRium in ICu patients (E-PRE-DELERIC), and Lanzhou Model, Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), Intensive Care Delirium Screening Checklist (ICDSC), and Delirium Rating Scale (DRS). There is no proper treatment for ICU delirium; however, it can be managed through various pharmacological and non-pharmacological interventions. Healthcare providers should receive constant education and training on delirium recognition, prevention, and management to enhance patient care and outcomes in the ICU. Further research is needed on the effective prevention and management of ICU delirium.
Collapse
|
7
|
Ma Y, Cui N, Guo Z, Zhang Y, Jin J. Exploring patients' and families' preferences for auditory stimulation in ICU delirium prevention: A qualitative study. Intensive Crit Care Nurs 2024; 82:103629. [PMID: 38252983 DOI: 10.1016/j.iccn.2024.103629] [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: 11/06/2023] [Revised: 01/07/2024] [Accepted: 01/13/2024] [Indexed: 01/24/2024]
Abstract
OBJECTIVES To explore the preferences of patients and families for delirium prevention by auditory stimulation in intensive care units. RESEARCH METHODOLOGY One-on-one, face-to-face, semistructured interviews with 17 participants (6 patients and 11 family members) were conducted at a step-down unit in a tertiary general hospital using a descriptive qualitative design. The data were analyzed via inductive thematic analysis. RESULTS Four major themes and ten subthemes emerged from the interviews: (1) reality orientation; (2) emotional support; (3) links to the outside; and (4) promising future. CONCLUSIONS The results in this qualitative study shed light on patients' and families' preferences for auditory stimulation in preventing ICU delirium. The participation of family members plays a crucial role in preventing ICU delirium. Family members can assist patients in reducing confusion about the situation by providing accurate and clear reality orientation. The emotional support and promising future provided by family members can help patients regain confidence and courage, which are often lacking in ICU patients. Linking patients to the outside world helps them stay connected, understand what is happening outside and reduce feelings of isolation. IMPLICATIONS FOR CLINICAL PRACTICE These findings can help health care staff gain insight into patients' and families' preferences and needs for auditory stimulation. Furthermore, these findings pave the way for crafting effective auditory interventions.
Collapse
Affiliation(s)
- Yajun Ma
- Nursing Department, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.
| | - Nianqi Cui
- School of Nursing, Kunming Medical University, China.
| | - Zhiting Guo
- Nursing Department, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.
| | - Yuping Zhang
- Nursing Department, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.
| | - Jingfen Jin
- Nursing Department, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Key Laboratory of The Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, Zhejiang, China; Changxing Branch Hospital of SAHZU, Huzhou, Zhejiang, China.
| |
Collapse
|
8
|
Owen VS, Sinnadurai S, Morrissey J, Colaco H, Wickson P, Dyjur D, Redlich M, O'Neill B, Zygun DA, Doig CJ, Harris J, Zuege DJ, Stelfox HT, Faris PD, Fiest KM, Niven DJ. Multicentre implementation of a quality improvement initiative to reduce delirium in adult intensive care units: An interrupted time series analysis. J Crit Care 2024; 81:154524. [PMID: 38199062 DOI: 10.1016/j.jcrc.2024.154524] [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: 06/16/2023] [Revised: 12/20/2023] [Accepted: 01/03/2024] [Indexed: 01/12/2024]
Abstract
PURPOSE The ABCDEF bundle may improve delirium outcomes among intensive care unit (ICU) patients, however population-based studies are lacking. In this study we evaluated effects of a quality improvement initiative based on the ABCDEF bundle in adult ICUs in Alberta, Canada. MATERIAL AND METHODS We conducted a pre-post, registry-based clinical trial, analysed using interrupted time series methodology. Outcomes were examined via segmented linear regression using mixed effects models. The main data source was a population-based electronic health record. RESULTS 44,405 consecutive admissions (38,400 unique patients) admitted to 15 general medical/surgical and/or neurologic adult ICUs between 2014 and 2019 were included. The proportion of delirium days per ICU increased from 30.24% to 35.31% during the pre-intervention period. After intervention implementation it decreased significantly (bimonthly decrease of 0.34%, 95%CI 0.18-0.50%, p < 0.01) from 33.48% (95%CI 29.64-37.31%) in 2017 to 28.74% (95%CI 25.22-32.26%) in 2019. The proportion of sedation days using midazolam demonstrated an immediate decrease of 7.58% (95%CI 4.00-11.16%). There were no significant changes in duration of invasive ventilation, proportion of partial coma days, ICU mortality, or potential adverse events. CONCLUSIONS An ABCDEF delirium initiative was implemented on a population-basis within adult ICUs and was successful at reducing the prevalence of delirium.
Collapse
Affiliation(s)
- Victoria S Owen
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Selvi Sinnadurai
- Critical Care Strategic Clinical Network, Alberta Health Services, Alberta, Canada
| | - Jeanna Morrissey
- Critical Care Strategic Clinical Network, Alberta Health Services, Alberta, Canada
| | - Heather Colaco
- Critical Care Strategic Clinical Network, Alberta Health Services, Alberta, Canada
| | - Patty Wickson
- Health Innovation and Evidence, Provincial Clinical Excellence, Alberta Health Services, Alberta, Canada
| | - Donalda Dyjur
- Critical Care Strategic Clinical Network, Alberta Health Services, Alberta, Canada
| | - Melissa Redlich
- Critical Care Strategic Clinical Network, Alberta Health Services, Alberta, Canada
| | - Barbara O'Neill
- Cancer Strategic Clinical Network, Alberta Health Services, Alberta, Canada
| | - David A Zygun
- Critical Care Strategic Clinical Network, Alberta Health Services, Alberta, Canada; Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Christopher J Doig
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Critical Care Strategic Clinical Network, Alberta Health Services, Alberta, Canada; Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jo Harris
- Critical Care Strategic Clinical Network, Alberta Health Services, Alberta, Canada
| | - Danny J Zuege
- Critical Care Strategic Clinical Network, Alberta Health Services, Alberta, Canada; Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Peter D Faris
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Analytics, Alberta Health Services, Alberta, Canada
| | - Kirsten M Fiest
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Critical Care Strategic Clinical Network, Alberta Health Services, Alberta, Canada; Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Daniel J Niven
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Critical Care Strategic Clinical Network, Alberta Health Services, Alberta, Canada; Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
| |
Collapse
|
9
|
Zhou X, Mao W, Zhao L, Zhu H, Chen L, Xie Y, Li L. Effect of thoracic paravertebral nerve block on delirium in patients after video-assisted thoracoscopic surgery: a systematic review and meta-analysis of randomized controlled trials. Front Neurol 2024; 15:1347991. [PMID: 38660094 PMCID: PMC11039859 DOI: 10.3389/fneur.2024.1347991] [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: 01/15/2024] [Accepted: 03/28/2024] [Indexed: 04/26/2024] Open
Abstract
Background Nerve blocks are widely used in various surgeries to alleviate postoperative pain and promote recovery. However, the impact of nerve block on delirium remains contentious. This study aims to systematically evaluate the influence of Thoracic Paravertebral Nerve Block (TPVB) on the incidence of delirium in patients post Video-Assisted Thoracoscopic Surgery (VATS). Methods We conducted a systematic search of PubMed, Embase, Web of Science, Cochrane Library, and Scopus databases in June 2023. The search strategy combined free-text and Medical Subject Headings (MeSH) terms, including perioperative cognitive dysfunction, delirium, postoperative cognitive dysfunction, paravertebral nerve block, thoracic surgery, lung surgery, pulmonary surgery, and esophageal/esophagus surgery. We utilized a random effects model for the analysis and synthesis of effect sizes. Results We included a total of 9 RCTs involving 1,123 participants in our study. In VATS, TPVB significantly reduced the incidence of delirium on postoperative day three (log(OR): -0.62, 95% CI [-1.05, -0.18], p = 0.01, I2 = 0.00%) and postoperative day seven (log(OR): -0.94, 95% CI [-1.39, -0.49], p < 0.001, I2 = 0.00%). Additionally, our study indicates the effectiveness of TPVB in postoperative pain relief (g: -0.82, 95% CI [-1.15, -0.49], p < 0.001, I2 = 72.60%). Conclusion The comprehensive results suggest that in patients undergoing VATS, TPVB significantly reduces the incidence of delirium and notably diminishes pain scores. Systematic review registration CRD42023435528. https://www.crd.york.ac.uk/PROSPERO.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Linji Li
- Department of Anesthesiology, The Second Clinical Medical College, North Sichuan Medical College, Nanchong Central Hospital, Nanchong, China
| |
Collapse
|
10
|
Bakošová L, Kec D, Škorňa M, Jura R, Kundrata Z, Košťálová M, Bednařík J. Screening and differential diagnosis of delirium in neurointensive stroke patients. Heliyon 2024; 10:e25918. [PMID: 38379970 PMCID: PMC10877298 DOI: 10.1016/j.heliyon.2024.e25918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 01/09/2024] [Accepted: 02/05/2024] [Indexed: 02/22/2024] Open
Abstract
Diagnosing delirium in neurointensive care is difficult because symptoms of delirium, such as inappropriate speech, may be related to aphasia due to primary brain injury. Therefore, validated screening tools are needed. The aim of this study was to compare two Czech versions of already validated screening tools - the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) - in a cohort of acute stroke patients. We also aimed to assess the pitfalls of delirium detection in the context of non-convulsive status epilepticus (NCSE). We analysed 138 stroke patients admitted to the neurological intensive care unit (ICU) or stroke unit. According to expert judgement, which was used as the gold standard, 38 patients (27.54%) developed delirium. The sensitivity and specificity of the ICDSC were 91.60% and 95.33%, respectively, and the positive and negative predictive values were 76.76% and 98.54%, respectively. Similarly, the sensitivity and specificity of CAM-ICU were 75.63% and 96.74%, respectively, and the positive and negative predictive values were 79.65% and 95.93%, respectively. We did not detect an episode of NCSE mimicking delirium in any of our stroke patients who were judged to be delirious by expert assessment. Our results suggest that the ICDSC may be a more suitable tool for delirium screening than the CAM-ICU in patients with neurological deficit. NCSE as a mimic of delirium seems to be less common in the acute phase of stroke than previously reported.
Collapse
Affiliation(s)
- Lucia Bakošová
- Faculty of Medicine, Masaryk University, Kamenice 5, Brno, 62500, Czech Republic
- Department of Neurology, The University Hospital Brno, Jihlavská 20, Brno, 62500, Czech Republic
| | - David Kec
- Faculty of Medicine, Masaryk University, Kamenice 5, Brno, 62500, Czech Republic
- Department of Neurology, The University Hospital Brno, Jihlavská 20, Brno, 62500, Czech Republic
| | - Miroslav Škorňa
- Faculty of Medicine, Masaryk University, Kamenice 5, Brno, 62500, Czech Republic
- Department of Neurology, The University Hospital Brno, Jihlavská 20, Brno, 62500, Czech Republic
| | - René Jura
- Faculty of Medicine, Masaryk University, Kamenice 5, Brno, 62500, Czech Republic
- Department of Neurology, The University Hospital Brno, Jihlavská 20, Brno, 62500, Czech Republic
| | - Zdeněk Kundrata
- Faculty of Medicine, Masaryk University, Kamenice 5, Brno, 62500, Czech Republic
- Department of Neurology, The University Hospital Brno, Jihlavská 20, Brno, 62500, Czech Republic
| | - Milena Košťálová
- Faculty of Medicine, Masaryk University, Kamenice 5, Brno, 62500, Czech Republic
- Department of Neurology, The University Hospital Brno, Jihlavská 20, Brno, 62500, Czech Republic
| | - Josef Bednařík
- Faculty of Medicine, Masaryk University, Kamenice 5, Brno, 62500, Czech Republic
- Department of Neurology, The University Hospital Brno, Jihlavská 20, Brno, 62500, Czech Republic
| |
Collapse
|
11
|
Wilcox ME, Burry L, Englesakis M, Coman B, Daou M, van Haren FM, Ely EW, Bosma KJ, Knauert MP. Intensive care unit interventions to promote sleep and circadian biology in reducing incident delirium: a scoping review. Thorax 2024:thorax-2023-220036. [PMID: 38350730 DOI: 10.1136/thorax-2023-220036] [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: 06/19/2023] [Accepted: 01/26/2024] [Indexed: 02/15/2024]
Abstract
RATIONALE/OBJECTIVES Despite plausible pathophysiological mechanisms, research is needed to confirm the relationship between sleep, circadian rhythm and delirium in patients admitted to the intensive care unit (ICU). The objective of this review is to summarise existing studies promoting, in whole or in part, the normalisation of sleep and circadian biology and their impact on the incidence, prevalence, duration and/or severity of delirium in ICU. METHODS A sensitive search of electronic databases and conference proceedings was completed in March 2023. Inclusion criteria were English-language studies of any design that evaluated in-ICU non-pharmacological, pharmacological or mixed intervention strategies for promoting sleep or circadian biology and their association with delirium, as assessed at least daily. Data were extracted and independently verified. RESULTS Of 7886 citations, we included 50 articles. Commonly evaluated interventions include care bundles (n=20), regulation or administration of light therapy (n=5), eye masks and/or earplugs (n=5), one nursing care-focused intervention and pharmacological intervention (eg, melatonin and ramelteon; n=19). The association between these interventions and incident delirium or severity of delirium was mixed. As multiple interventions were incorporated in included studies of care bundles and given that there was variable reporting of compliance with individual elements, identifying which components might have an impact on delirium is challenging. CONCLUSIONS This scoping review summarises the existing literature as it relates to ICU sleep and circadian disruption (SCD) and delirium in ICU. Further studies are needed to better understand the role of ICU SCD promotion interventions in delirium mitigation.
Collapse
Affiliation(s)
- M Elizabeth Wilcox
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Lisa Burry
- Department of Pharmacy, Sinai Health System, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Marina Englesakis
- Library and Information Services, University Health Network, Toronto, Ontario, Canada
| | - Briar Coman
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Marietou Daou
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Frank Mp van Haren
- School of Medicine, Australian National University, Canberra, Australian Capital Territory, Australia
- University of New South Wales Medicine and Health, Sydney, New South Wales, Australia
- Intensive Care Unit, St George Hospital, Sydney, New South Wales, Australia
| | - E Wes Ely
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA
- Geriatric Research, Education and Clinical Center (GRECC), Department of Veterans Affairs Medical Center, Tennessee Valley Health Care System, Nashville, TN, USA
| | - Karen J Bosma
- Department of Medicine, Schulich School of Medicine and Dentistry, London, Ontario, Canada
- Lawson Health Research Institute, London Health Sciences Centre, London, Ontario, Canada
- Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine and Dentistry, London, Ontario, Canada
| | - Melissa P Knauert
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| |
Collapse
|
12
|
Aldecoa C, Bettelli G, Bilotta F, Sanders RD, Aceto P, Audisio R, Cherubini A, Cunningham C, Dabrowski W, Forookhi A, Gitti N, Immonen K, Kehlet H, Koch S, Kotfis K, Latronico N, MacLullich AMJ, Mevorach L, Mueller A, Neuner B, Piva S, Radtke F, Blaser AR, Renzi S, Romagnoli S, Schubert M, Slooter AJC, Tommasino C, Vasiljewa L, Weiss B, Yuerek F, Spies CD. Update of the European Society of Anaesthesiology and Intensive Care Medicine evidence-based and consensus-based guideline on postoperative delirium in adult patients. Eur J Anaesthesiol 2024; 41:81-108. [PMID: 37599617 PMCID: PMC10763721 DOI: 10.1097/eja.0000000000001876] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Abstract
Postoperative delirium (POD) remains a common, dangerous and resource-consuming adverse event but is often preventable. The whole peri-operative team can play a key role in its management. This update to the 2017 ESAIC Guideline on the prevention of POD is evidence-based and consensus-based and considers the literature between 01 April 2015, and 28 February 2022. The search terms of the broad literature search were identical to those used in the first version of the guideline published in 2017. POD was defined in accordance with the DSM-5 criteria. POD had to be measured with a validated POD screening tool, at least once per day for at least 3 days starting in the recovery room or postanaesthesia care unit on the day of surgery or, at latest, on postoperative day 1. Recent literature confirmed the pathogenic role of surgery-induced inflammation, and this concept reinforces the positive role of multicomponent strategies aimed to reduce the surgical stress response. Although some putative precipitating risk factors are not modifiable (length of surgery, surgical site), others (such as depth of anaesthesia, appropriate analgesia and haemodynamic stability) are under the control of the anaesthesiologists. Multicomponent preoperative, intra-operative and postoperative preventive measures showed potential to reduce the incidence and duration of POD, confirming the pivotal role of a comprehensive and team-based approach to improve patients' clinical and functional status.
Collapse
Affiliation(s)
- César Aldecoa
- From the Department of Anaesthesia and Postoperative Critical Care, Hospital Universitario Rio Hortega, Valladolid, Spain (CA), Department of Biomedical Studies, University of the Republic of San Marino, San Marino (GB), Department of Anesthesiology, Critical Care and Pain Medicine, 'Sapienza' University of Rome, Rome, Italy (FB, AF, LM), Specialty of Anaesthetics & NHMRC Clinical Trials Centre, University of Sydney & Department of Anaesthetics and Institute of Academic Surgery, Royal Prince Alfred Hospital (RDS), Department of Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, and Humboldt Universität zu Berlin, Campus Charité Mitte, and Campus Virchow Klinikum (CDS, SK, AM, BN, LV, BW, FY), Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy (PA), Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy (PA), Department of Surgery, Institute of Clinical Sciences, Sahlgrenska University Hospital, Göteborg, Sweden (RA), Geriatria, Accettazione Geriatrica e Centro di ricerca per l'invecchiamento, IRCCS INRCA, Ancona, Italy (AC), School of Biochemistry and Immunology and Trinity College Institute of Neuroscience, Trinity College, Dublin, Ireland (CC), First Department of Anaesthesiology and Intensive Care Medical University of Lublin, Poland (WD), Research Unit of Nursing Science and Health Management, University of Oulu, Oulu, Finland (KI), Section of Surgical Pathophysiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (HK), Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University in Szczecin, Poland (KK), Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia (NG, NL, SP, SR), Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy (NL, SP), Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh, United Kingdom (AMJM), Department of Anaesthesia and Intensive Care, Nykoebing Hospital; University of Southern Denmark, SDU (SK, FR), Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia (ARB), Center for Intensive Care Medicine, Luzerner Kantonsspital, Lucerne, Switzerland (ARB), Department of Health Science, Section of Anesthesiology, University of Florence (SR), Department of Anaesthesia and Critical Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy (SR), School of Health Sciences, Institute of Nursing, ZHAW Zurich University of Applied Science, Winterthur, Switzerland (MS), Departments of Psychiatry and Intensive Care Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands (AJCS), Department of Neurology, UZ Brussel and Vrije Universiteit Brussel, Brussels, Belgium (AJCS) and Dental Anesthesia and Intensive Care Unit, Polo Universitario Ospedale San Paolo, Department of Biomedical, Surgical and Odontoiatric Sciences, University of Milano, Milan, Italy (CT)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
13
|
Devlin JW, Duprey MS, Girard TD. How does haloperidol influence the long-term outcomes of delirium? Intensive Care Med 2024; 50:269-271. [PMID: 38294525 DOI: 10.1007/s00134-024-07321-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 02/01/2024]
Affiliation(s)
- John W Devlin
- Bouve College of Health Sciences, Northeastern University, 360 Huntington Ave, Boston, MA, 140TF RD21602115, USA.
- Department of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA.
| | | | - Timothy D Girard
- Center for Research, Investigation, and Systems Modeling of Acute Illness (CRISMA), Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| |
Collapse
|
14
|
Alzoubi E, Shaheen F, Yousef K. Delirium incidence, predictors and outcomes in the intensive care unit: A prospective cohort study. Int J Nurs Pract 2024; 30:e13154. [PMID: 37044382 DOI: 10.1111/ijn.13154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 02/16/2023] [Accepted: 03/19/2023] [Indexed: 04/14/2023]
Abstract
AIM The aim of this study was to investigate the incidence, predictors, and outcomes of delirium in intensive care units. BACKGROUND Delirium is a common complication in intensive care units. In developing countries, it can be misdiagnosed or unrecognised. DESIGN Prospective cohort study reported according to the strengthening the reporting of observational studies in epidemiology criteria. METHODS We included patients who were conscious, >18 years old, and admitted to the intensive care units for at least 8 h between December 2019 and February 2020. Patients with a Richmond score of -4 or -5, mental disability, receptive aphasia and/or visual or auditory impairment were excluded from the study. Delirium was assessed using the Confusion Assessment Method for the ICU (CAM-ICU), whereas the functional outcome was assessed by the Katz Activity of Daily Living Index. RESULTS This study included 111 patients with a delirium incidence of 31.5%. The severity of illness was the only significant predictor of delirium. Patients with delirium had longer intensive care unit and in-hospital stays in contrast to those without delirium. Delirium was associated with in-hospital and 4-month mortality but not the activities of daily living. CONCLUSIONS Delirium is associated with increased length of stay and mortality. Further investigation to determine whether delirium management can improve outcomes is warranted.
Collapse
Affiliation(s)
- Elaf Alzoubi
- King Abdullah University Hospital, Irbid, Jordan
| | | | - Khalil Yousef
- School of Nursing, University of Jordan, Amman, Jordan
- School of Humanities, Social Science, and Health, University of Wollongong in Dubai, Dubai, United Arab Emirates
| |
Collapse
|
15
|
Sexton MT, Kim A, McGonigle T, Mihalko S, Vandekar SN, Brummel NE, Patel MB, Dittus RS, Heckers S, Pandharipande PP, Ely EW, Wilson JE. In-hospital catatonia, delirium, and coma and mortality: Results from the delirium and catatonia prospective cohort investigation. Schizophr Res 2024; 263:223-228. [PMID: 37580182 PMCID: PMC10843668 DOI: 10.1016/j.schres.2023.07.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 07/25/2023] [Accepted: 07/27/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND Catatonia, a form of acute brain dysfunction typically linked with severe affective and psychotic disorders, occurs in critical illness with delirium and coma. Delirium and coma are associated with mortality, though catatonia's relationship with mortality is unclear. We aim to describe whether catatonia, delirium, and coma are associated with mortality. METHODS We enrolled a convenience cohort of critically ill adults (N = 378) at an academic medical center. We assessed catatonia, delirium, and coma using the Bush-Francis Catatonia Rating Scale, the Confusion Assessment Method for the Intensive Care Unit and the Richmond Agitation-Sedation Scale, respectively. We tested the associations between previous day brain dysfunction state occurrence with in-hospital and one-year mortality using multivariable time-dependent risk models. Additionally, we tested the association between brain dysfunction duration and one-year mortality. RESULTS Catatonia was not associated with death on the day after diagnosis during hospitalization, and neither previous catatonia occurrence nor duration was associated with one-year mortality. Delirium was not associated with death on any day following diagnosis during hospitalization, and neither previous delirium occurrence nor duration was associated with one-year mortality. The occurrence of coma was associated with death on any day after diagnosis during hospitalization (HR 2.30,CI 1.19-4.44,p = 0.014), as well as through one year following hospital discharge (HR 1.68,CI 1.09-2.59,p = 0.02). CONCLUSIONS Coma, but neither catatonia nor delirium, was associated with future day in-hospital and one-year mortality. More research is needed to understand catatonia's clinical impact. Delirium results differ from existing literature likely due to cohort demographics and size. Coma results highlight the prognostic significance of suppressed arousal while critically ill.
Collapse
Affiliation(s)
- Morgan T Sexton
- Critical Illness, Brain Dysfunction, and Survivorship Center, Center for Health Services Research, Nashville, TN, United States of America; Vanderbilt University School of Medicine, Nashville, TN, United States of America
| | - Ahra Kim
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Trey McGonigle
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Sarasota Mihalko
- Critical Illness, Brain Dysfunction, and Survivorship Center, Center for Health Services Research, Nashville, TN, United States of America
| | - Simon N Vandekar
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Nathan E Brummel
- Critical Illness, Brain Dysfunction, and Survivorship Center, Center for Health Services Research, Nashville, TN, United States of America; Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, United States of America
| | - Mayur B Patel
- Critical Illness, Brain Dysfunction, and Survivorship Center, Center for Health Services Research, Nashville, TN, United States of America; Division of Acute Care Surgery, Departments of Surgery, Neurosurgery, and Hearing and Speech Sciences, Section of Surgical Sciences, Vanderbilt Brain Institute, Vanderbilt University Medical Center, Nashville, TN, United States of America; Geriatric Research, Education, and Clinical Center Service, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN, United States of America
| | - Robert S Dittus
- Critical Illness, Brain Dysfunction, and Survivorship Center, Center for Health Services Research, Nashville, TN, United States of America; Geriatric Research, Education, and Clinical Center Service, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN, United States of America; Department of Medicine, Division of General Internal Medicine and Public Health, Center for Health Services Research and Quality Aging, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Stephan Heckers
- Critical Illness, Brain Dysfunction, and Survivorship Center, Center for Health Services Research, Nashville, TN, United States of America; Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Pratik P Pandharipande
- Critical Illness, Brain Dysfunction, and Survivorship Center, Center for Health Services Research, Nashville, TN, United States of America; Division of Anesthesiology Critical Care, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - E Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship Center, Center for Health Services Research, Nashville, TN, United States of America; Geriatric Research, Education, and Clinical Center Service, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN, United States of America; Division of Allergy, Pulmonary and Critical Care, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Jo Ellen Wilson
- Critical Illness, Brain Dysfunction, and Survivorship Center, Center for Health Services Research, Nashville, TN, United States of America; Geriatric Research, Education, and Clinical Center Service, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN, United States of America; Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN, United States of America.
| |
Collapse
|
16
|
Mortensen CB, Andersen-Ranberg NC, Poulsen LM, Granholm A, Rasmussen BS, Kjær MBN, Lange T, Ebdrup BH, Collet MO, Andreasen AS, Bestle MH, Uslu B, Pedersen HS, Nielsen LG, Hästbacka J, Jensen TB, Damgaard K, Sommer T, Morgen M, Dey N, Citerio G, Estrup S, Egerod I, Samuelson K, Perner A, Mathiesen O. Long-term outcomes with haloperidol versus placebo in acutely admitted adult ICU patients with delirium. Intensive Care Med 2024; 50:103-113. [PMID: 38170227 PMCID: PMC10811094 DOI: 10.1007/s00134-023-07282-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 11/16/2023] [Indexed: 01/05/2024]
Abstract
PURPOSE We assessed long-term outcomes in acutely admitted adult patients with delirium treated in intensive care unit (ICU) with haloperidol versus placebo. METHODS We conducted pre-planned analyses of 1-year outcomes in the Agents Intervening against Delirium in the ICU (AID-ICU) trial, including mortality and health-related quality of life (HRQoL) assessed by Euroqol (EQ) 5-dimension 5-level questionnaire (EQ-5D-5L) index values and EQ visual analogue scale (EQ VAS) (deceased patients were assigned the numeric value zero). Outcomes were analysed using logistic and linear regressions with bootstrapping and G-computation, all with adjustment for the stratification variables (site and delirium motor subtype) and multiple imputations for missing HRQoL values. RESULTS At 1-year follow-up, we obtained vital status for 96.2% and HRQoL data for 83.3% of the 1000 randomised patients. One-year mortality was 224/501 (44.7%) in the haloperidol group versus 251/486 (51.6%) in the placebo group, with an adjusted absolute risk difference of - 6.4%-points (95% confidence interval [CI] - 12.8%-points to - 0.2%-points; P = 0.045). These results were largely consistent across the secondary analyses. For HRQoL, the adjusted mean differences were 0.04 (95% CI - 0.03 to 0.11; P = 0.091) for EQ-5D-5L-5L index values, and 3.3 (95% CI - 9.3 to 17.5; P = 0.142) for EQ VAS. CONCLUSIONS In acutely admitted adult ICU patients with delirium, haloperidol treatment reduced mortality at 1-year follow-up, but did not statistically significantly improve HRQoL.
Collapse
Affiliation(s)
- Camilla Bekker Mortensen
- Department of Anaesthesiology and Intensive Care, Zealand University Hospital, Koege, Lykkebækvej 1, 4600, Koege, Denmark.
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden.
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark.
| | - Nina Christine Andersen-Ranberg
- Department of Anaesthesiology and Intensive Care, Zealand University Hospital, Koege, Lykkebækvej 1, 4600, Koege, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Lone Musaeus Poulsen
- Department of Anaesthesiology and Intensive Care, Zealand University Hospital, Koege, Lykkebækvej 1, 4600, Koege, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Anders Granholm
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Bodil Steen Rasmussen
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Maj-Brit Nørregaard Kjær
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Theis Lange
- Centre for Clinical Intervention Research, Copenhagen Trial Unit, Copenhagen University Hospital, Mental Health Center Glostrup, Glostrup, Denmark
- Department of Public Health, Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Bjørn H Ebdrup
- Center for Neuropsychiatric Schizophrenia Research, Mental Health Center Glostrup, Glostrup, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Marie Oxenbøll Collet
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Anne Sofie Andreasen
- Department of Intensive Care, Copenhagen University Hospital, Herlev Hospital, Herlev, Denmark
| | - Morten Heiberg Bestle
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital - North Zealand, Hilleroed, Denmark
| | - Bülent Uslu
- Department of Anesthesiology and Intensive Care, Zealand University Hospital, Roskilde, Denmark
| | - Helle Scharling Pedersen
- Department of Anaesthesiology and Intensive Care, Zealand University Hospital, Koege, Lykkebækvej 1, 4600, Koege, Denmark
- Department of Anesthesiology and Intensive Care, Nykøbing Falster Hospital, Nykøbing, Denmark
| | - Louise Gramstrup Nielsen
- Department of Anesthesiology and Intensive Care, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Johanna Hästbacka
- Department of Anesthesia and Intensive Care, Tampere University Hospital and Tampere University, Tampere, Finland
- Department of Perioperative and Intensive Care Medicine, Helsinki University Hospital and Helsinki University (Former Workplace), Helsinki, Finland
| | - Troels Bek Jensen
- Department of Anaesthesia and Intensive Care, Region Hospital Gødstrup, Herning, Denmark
| | - Kjeld Damgaard
- Department of Anaesthesia and Intensive Care, North Denmark Regional Hospital Hjoerring, Hjoerring, Denmark
| | - Trine Sommer
- Department of Anaesthesia and Intensive Care, University Hospital of Southern Denmark, Aabenraa, Denmark
| | | | - Nilanjan Dey
- Department of Anaesthesia and Intensive Care, Holstebro Hospital, Holstebro, Denmark
| | - Guiseppe Citerio
- Department of Medicine and Surgery, University Milan-Bicocca, Milan, Italy
| | - Stine Estrup
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Ingrid Egerod
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Karin Samuelson
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Anders Perner
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Ole Mathiesen
- Department of Anaesthesiology and Intensive Care, Zealand University Hospital, Koege, Lykkebækvej 1, 4600, Koege, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
17
|
Vizzacchi BA, Dettino ALA, Besen BAMP, Caruso P, Nassar AP. Delirium During Critical Illness and Subsequent Change of Treatment in Patients With Cancer: A Mediation Analysis. Crit Care Med 2024; 52:102-111. [PMID: 37855674 DOI: 10.1097/ccm.0000000000006070] [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: 10/20/2023]
Abstract
OBJECTIVES To assess whether delirium during ICU stay is associated with subsequent change in treatment of cancer after discharge. DESIGN Retrospective cohort study. SETTING A 50-bed ICU in a dedicated cancer center. PATIENTS Patients greater than or equal to 18 years old with a previous proposal of cancer treatment (chemotherapy, target therapy, hormone therapy, immunotherapy, radiotherapy, oncologic surgery, and bone marrow transplantation). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We considered delirium present if Confusion Assessment Method for the ICU was positive. We assessed the association between delirium and modification of the treatment after discharge. We also performed a mediation analysis to assess both the direct and indirect (i.e., mediated by the development of functional dependence after discharge) of delirium on modification of cancer treatment and whether the modification of cancer treatment was associated with mortality at 1 year. We included 1,134 patients, of whom, 189 (16.7%) had delirium. Delirium was associated with the change in cancer treatment (adjusted odds ratio [OR], 3.80; 95% CI, 2.72-5.35). The association between delirium in ICU and change of treatment was both direct and mediated by the development of functional dependence after discharge. The proportion of the total effect of delirium on change of treatment mediated by the development of functional dependence after discharge was 33.0% (95% CI, 21.7-46.0%). Change in treatment was associated with increased mortality at 1 year (adjusted OR, 2.68; 95% CI, 2.01-3.60). CONCLUSIONS Patients who had delirium during ICU stay had a higher rate of modification of cancer treatment after discharge. The effect of delirium on change in cancer treatment was only partially mediated by the development of functional dependence after discharge. Change in cancer treatment was associated with increased 1-year mortality.
Collapse
Affiliation(s)
- Bárbara A Vizzacchi
- Rehabilitation and Palliative Care Supervision, A.C. Camargo Cancer Center, São Paulo, Brazil
| | - Aldo L A Dettino
- Department of Clinical Oncology. A.C. Camargo Cancer Center, São Paulo, Brazil
| | - Bruno A M P Besen
- Department of Critical Care, Intensive Care Unit, A. C. Camargo Cancer Center, São Paulo, Brazil
- Medical ICU, Internal Medicine Division, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Pedro Caruso
- Department of Critical Care, Intensive Care Unit, A. C. Camargo Cancer Center, São Paulo, Brazil
- Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Antonio P Nassar
- Department of Critical Care, Intensive Care Unit, A. C. Camargo Cancer Center, São Paulo, Brazil
| |
Collapse
|
18
|
Zorko Garbajs N, Valencia Morales DJ, Singh TD, Herasevich V, Hanson AC, Schroeder DR, Weingarten TN, Gajic O, Sprung J, Rabinstein AA. Association of Blood Pressure Variability with Delirium in Patients with Critical Illness. Neurocrit Care 2023; 39:646-654. [PMID: 36526945 PMCID: PMC9757627 DOI: 10.1007/s12028-022-01661-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 11/28/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND The objective was to examine the association of blood pressure variability (BPV) during the first 24 h after intensive care unit admission with the likelihood of delirium and depressed alertness without delirium ("depressed alertness"). METHODS This retrospective, observational, cohort study included all consecutive adult patients admitted to an intensive care unit at Mayo Clinic, Rochester, Minnesota, from July 1, 2004, through October 31, 2015. The primary outcomes were delirium and delirium-free days, and the secondary outcomes included depressed alertness and depressed alertness-free days. Logistic regression was performed to determine the association of BPV with delirium and depressed alertness. Proportional odds regression was used to assess the association of BPV with delirium-free days and depressed alertness-free days. RESULTS Among 66,549 intensive care unit admissions, delirium was documented in 20.2% and depressed alertness was documented in 24.4%. Preserved cognition was documented in 55.4% of intensive care unit admissions. Increased systolic and diastolic BPV was associated with an increased odds of delirium and depressed alertness. The magnitude of the association per 5-mm Hg increase in systolic average real variability (the average of absolute value of changes between consecutive systolic blood pressure readings) was greater for delirium (odds ratio 1.34; 95% confidence interval 1.29-1.40; P < 0.001) than for depressed alertness (odds ratio 1.06; 95% confidence interval 1.02-1.10; P = 0.004). Increased systolic and diastolic BPV was associated with fewer delirium-free days but not with depressed alertness-free days. CONCLUSIONS BPV in the first 24 h after intensive care unit admission is associated with an increased likelihood of delirium and fewer delirium-free days.
Collapse
Affiliation(s)
- Nika Zorko Garbajs
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA.
- Division of Neurology, Department of Vascular Neurology and Intensive Therapy, University Medical Centre, Ljubljana, Slovenia.
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia.
| | | | - Tarun D Singh
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Neurology and Neurological Surgery, University of Michigan Hospital, Ann Arbor, MI, USA
| | - Vitaly Herasevich
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Andrew C Hanson
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, USA
| | - Darrell R Schroeder
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, USA
| | - Toby N Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
- Critical Care Independent Multidisciplinary Program, Mayo Clinic, Rochester, MN, USA
| | - Juraj Sprung
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Alejandro A Rabinstein
- Critical Care Independent Multidisciplinary Program, Mayo Clinic, Rochester, MN, USA
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
19
|
Kodama L, Woldemariam S, Tang A, Li Y, Oskotsky T, Raphael E, Sirota M. Sex-stratified phenotyping of comorbidities associated with an inpatient delirium diagnosis using real world data. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.11.02.23297925. [PMID: 37961487 PMCID: PMC10635265 DOI: 10.1101/2023.11.02.23297925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
Delirium is a heterogeneous and detrimental mental condition often seen in older, hospitalized patients and is currently hard to predict. In this study, we leverage large-scale, real- world data using the electronic health records (EHR) to identify two cohorts comprised of 7,492 UCSF patients and 19,417 UC health system patients (excluding UCSF patients) with an inpatient delirium diagnosis and the same number of propensity score-matched control patients without delirium. We found significant associations between comorbidities or laboratory test values and an inpatient delirium diagnosis which were validated independently. Most of these associations were those previously-identified as risk factors for delirium, including metabolic abnormalities, mental health diagnoses, and infections. Some of the associations were sex- specific, including those related to dementia subtypes and infections. We further explored the diagnostic associations with anemia and bipolar disorder by conducting longitudinal analyses from the time of first diagnosis of the risk factor to development of delirium demonstrating a significant relationship across time. Finally, we show that an inpatient delirium diagnosis leads to dramatic increases in mortality outcome across both cohorts. These results demonstrate the powerful application of leveraging EHR data to shed insights into prior diagnoses and laboratory test values that could help predict development of inpatient delirium and emphasize the importance of considering patient demographic characteristics including documented sex when making these assessments. One Sentence Summary Longitudinal analysis of electronic health record data reveals associations between inpatient delirium, comorbidities, and mortality.
Collapse
|
20
|
Vizzacchi BA, Pezzini TR, de Souza JM, Caruso P, Nassar AP. Long-term mortality of critically ill patients with cancer and delirium who survived to discharge: a retrospective cohort study. Can J Anaesth 2023; 70:1789-1796. [PMID: 37610551 DOI: 10.1007/s12630-023-02538-8] [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: 11/21/2022] [Revised: 03/20/2023] [Accepted: 03/20/2023] [Indexed: 08/24/2023] Open
Abstract
PURPOSE Delirium is common in critically ill patients and has been associated with lower short-term survival; however, its association with long-term survival has been scarcely evaluated and few studies have shown divergent results. METHODS We conducted a retrospective cohort study of adult patients with cancer admitted to the intensive care unit (ICU) and discharged from hospital from January 2015 to December 2018. We considered delirium present if the Confusion Assessment Method for Intensive Care Unit (CAM-ICU) result was positive. We assessed the association between delirium during ICU stay and long-term mortality (up to three years after discharge). We also assessed the association between delirium type (hypoactive, hyperactive, and mixed) with long-term mortality. RESULTS We included 3,079 patients. Of these, 430 (14%) were considered delirious at some point during their ICU stay. Delirium was associated with one-year mortality after hospital discharge (hazard ratio [HR], 1.58; 95% confidence interval [CI], 1.36 to 1.83) after adjustment for potential confounders, but not with one to three year-mortality (HR, 0.92; 95% CI, 0.61 to 1.39). Hypoactive and mixed delirium were associated with one-year mortality (HR, 1.77; 95% CI, 1.46 to 2.14 and HR, 1.56; 95% CI, 1.21 to 2.00, respectively), but none of the delirium motor types was associated with one to three-year mortality. CONCLUSIONS We observed that delirium during ICU stay was associated with increased one-year mortality, but was not with mortality after one year. This association was observed in hypoactive and mixed delirium types but not with hyperactive delirium.
Collapse
Affiliation(s)
- Barbara A Vizzacchi
- Rehabilitation and Palliative Care Supervision, A. C. Camargo Cancer Center, São Paulo, SP, Brazil
| | - Tainara R Pezzini
- Scientific Research Program for Undergraduates, A. C. Camargo Cancer Center, São Paulo, SP, Brazil
| | - Jessica M de Souza
- Scientific Research Program for Undergraduates, A. C. Camargo Cancer Center, São Paulo, SP, Brazil
| | - Pedro Caruso
- Intensive Care Unit, A. C. Camargo Cancer Center, São Paulo, SP, Brazil
- Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Antonio Paulo Nassar
- Intensive Care Unit, A. C. Camargo Cancer Center, São Paulo, SP, Brazil.
- Program to Support Institutional Development of the Brazil's Unified Health System, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
- , Rua Professor Antonio Prudente, 211, 6th Floor, São Paulo, CEP 01509-001, Brazil.
| |
Collapse
|
21
|
To-Adithep P, Chittawatanarat K, Mueankwan S, Morakul S, Luetrakool P, Dilokpattanamongkol P, Thanakiattiwibun C, Chaiwat O. Long-term outcomes of delirium in critically ill surgical patients: A multicenter prospective cohort study. J Psychosom Res 2023; 172:111427. [PMID: 37413796 DOI: 10.1016/j.jpsychores.2023.111427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 06/20/2023] [Accepted: 06/23/2023] [Indexed: 07/08/2023]
Abstract
OBJECTIVE To identify the mortality rates and dependency rate (functional outcomes) of delirious patients at 12-months after surgical intensive care unit (SICU) admission and to determine the independent risk factors of 12-months mortality and dependency rate in a cohort of SICU patients. METHODS A prospective, multi-center study was conducted in 3 university-based hospitals. Critically-ill surgical patients who were admitted to SICU and followed-up at 12-months after ICU admission were enrolled. RESULTS A total of 630 eligible patients were recruited. 170 patients (27%) had postoperative delirium (POD). The overall 12-months mortality rate in this cohort was 25.2%. Delirium group showed significantly higher mortality rates than non-delirium group at 12-months after ICU admission (44.1% vs 18.3%, P < 0.001). Independent risk factors of 12-months mortality were age, diabetes mellitus, preoperative dementia, high Sequential Organ Failure Assessment (SOFA) score and POD. POD was associated with 12-months mortality (adjusted hazard ratio, 1.49; 95% confidence interval 1.04-2.15; P = 0.032). The dependency rate defined as the Basic Activities Daily Living (B-ADL) ≤70 was 52%. Independent risk factors of B-ADL were age ≥ 75 years, cardiac disease, preoperative dementia, intraoperative hypotension, on mechanical ventilator and POD. POD was associated with dependency rate at 12-months. (adjusted risk ratio, 1.26; 95%CI 1.04-1.53; P = 0.018). CONCLUSIONS Postoperative delirium was an independent risk factor of death and was also associated with dependent state at 12 months after a surgical intensive care unit admission in critically ill surgical patients.
Collapse
Affiliation(s)
- Puriwat To-Adithep
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
| | - Kaweesak Chittawatanarat
- Department of Surgery, Faculty of Medicine Chiang Mai Hospital, Chiang Mai University, Bangkok, Thailand; Clinical Surgical Research Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
| | - Sirirat Mueankwan
- Surgical Critical Care Unit, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
| | - Sunthiti Morakul
- Department of Anesthesiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Punchika Luetrakool
- Department of Anesthesiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
| | | | - Chayanan Thanakiattiwibun
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
| | - Onuma Chaiwat
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand; Integrated Perioperative Geriatric Excellent Research Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
| |
Collapse
|
22
|
Martinez FE, Tee R, Poulter AL, Jordan L, Bell L, Balogh ZJ. Delirium Screening and Pharmacotherapy in the ICU: The Patients Are Not the Only Ones Confused. J Clin Med 2023; 12:5671. [PMID: 37685738 PMCID: PMC10488395 DOI: 10.3390/jcm12175671] [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: 08/04/2023] [Revised: 08/22/2023] [Accepted: 08/29/2023] [Indexed: 09/10/2023] Open
Abstract
Background: Delirium is difficult to measure in the Intensive Care Unit (ICU). It is possible that by considering the rate of screening, incidence, and rate of treatment with antipsychotic medications (APMs) for suspected delirium, a clearer picture can emerge. Methods: A retrospective, observational study was conducted at two ICUs in Australia, between April and June of 2020. All adult ICU patients were screened; those who spoke English and did not have previous neurocognitive pathology or intracranial pathology were included in the analysis. Data were collected from the hospitals' electronic medical records. The primary outcome was incidence of delirium based on the use of the Confusion Assessment Method for ICU (CAM-ICU). Secondary outcomes included measures of screening for delirium, treatment of suspected delirium with APMs, and identifying clinical factors associated with both delirium and the use of APMs. Results: From 736 patients that were screened, 665 were included in the analysis. The incidence of delirium was 11.3% (75/665); on average, the Richmond Agitation and Sedation Scale (RASS) was performed every 2.9 h and CAM-ICU every 40 h. RASS was not performed in 8.4% (56/665) of patients and CAM-ICU was not performed in 40.6% (270/665) of patients. A total of 17% (113/665) of patients were prescribed an APM, with quetiapine being the most used. ICU length of stay (LOS), APACHE-III score, and the use of alpha-2 agonists were associated with the presence of delirium, while ICU LOS, the use of alpha-2 agonists, and the presence of delirium were associated with patients receiving APMs. Conclusions: The incidence of delirium was lower than previously reported, at 11.3%. The rate of screening for delirium was low, while the use of APMs for delirium was higher than the incidence of delirium. It is possible that the true incidence is higher than what was measured. Critical prospective assessment is required to optimize APM indications in the ICU.
Collapse
Affiliation(s)
- F. Eduardo Martinez
- Intensive Care Unit, John Hunter Hospital, Lookout Road, New Lambton Heights, Newcastle, NSW 2305, Australia; (F.E.M.); (R.T.); (A.-L.P.); (L.J.); (L.B.)
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW 2308, Australia
| | - Rebecca Tee
- Intensive Care Unit, John Hunter Hospital, Lookout Road, New Lambton Heights, Newcastle, NSW 2305, Australia; (F.E.M.); (R.T.); (A.-L.P.); (L.J.); (L.B.)
| | - Amber-Louise Poulter
- Intensive Care Unit, John Hunter Hospital, Lookout Road, New Lambton Heights, Newcastle, NSW 2305, Australia; (F.E.M.); (R.T.); (A.-L.P.); (L.J.); (L.B.)
| | - Leah Jordan
- Intensive Care Unit, John Hunter Hospital, Lookout Road, New Lambton Heights, Newcastle, NSW 2305, Australia; (F.E.M.); (R.T.); (A.-L.P.); (L.J.); (L.B.)
| | - Liam Bell
- Intensive Care Unit, John Hunter Hospital, Lookout Road, New Lambton Heights, Newcastle, NSW 2305, Australia; (F.E.M.); (R.T.); (A.-L.P.); (L.J.); (L.B.)
| | - Zsolt J. Balogh
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW 2308, Australia
- Department of Traumatology, John Hunter Hospital, Lookout Road, New Lambton Heights, Newcastle, NSW 2305, Australia
- Injury and Trauma Research Program, Hunter Medical Research Institute, Newcastle, NSW 2305, Australia
| |
Collapse
|
23
|
Al Huraizi AR, Al-Maqbali JS, Al Farsi RS, Al Zeedy K, Al-Saadi T, Al-Hamadani N, Al Alawi AM. Delirium and Its Association with Short- and Long-Term Health Outcomes in Medically Admitted Patients: A Prospective Study. J Clin Med 2023; 12:5346. [PMID: 37629388 PMCID: PMC10455146 DOI: 10.3390/jcm12165346] [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: 06/26/2023] [Revised: 08/11/2023] [Accepted: 08/16/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Delirium is highly prevalent among elderly hospitalized patients in various healthcare settings. This study aimed to assess the impact of delirium on short- and long-term health outcomes. METHODS A prospective cohort included medically ill patients (≥65 years) admitted to a tertiary healthcare facility. Delirium was screened using the 3-Minute Diagnostic confusion assessment method (3D-CAM). RESULTS During hospitalization, 53.8% (n = 153/284) had delirium. Patients with delirium had a longer length of hospital stay (LOS) (7 vs. 5 days; p < 0.01) compared to patients without delirium. Delirium caused a higher frequency of high-dependency unit (HDU) or intensive care unit (ICU) admission (p < 0.01) and an increased incidence of hospital-acquired complications, including infections (p = 0.03), pressure injuries (p = 0.01), and upper gastrointestinal bleeding (p < 0.01). Inpatient all-cause mortality was higher in patients with delirium than those without delirium (16.3% vs. 1.5%; p < 0.01). Patients with delirium had higher rates of 90-day all-cause mortality (25.4% vs. 8.4%; p < 0.01) and 1-year all-cause mortality (35.9% vs. 16%; p < 0.01) compared to patients without delirium. Patients with delirium exhibited shorter survival periods at 90 days and 1 year compared to patients without delirium with a hazard ratio (HR) = 3.41, 95% CI: 1.75-6.66, p < 0.01 and HR = 2.64, 95% CI: 1.59-4.37, p < 0.01, respectively. CONCLUSIONS Delirium is associated with serious short-term and long-term clinical consequences. Early recognition, prevention, and targeted interventions addressing reversible risk factors are crucial. Further research is warranted to explore effective strategies for delirium management in general medical wards.
Collapse
Affiliation(s)
- Aisha Ramadhan Al Huraizi
- Department of Medicine, Sultan Qaboos University Hospital, Muscat 123, Oman; (A.R.A.H.); (K.A.Z.); (A.M.A.A.)
| | - Juhaina Salim Al-Maqbali
- Department of Pharmacy, Sultan Qaboos University Hospital, Muscat 123, Oman
- Department of Pharmacology and Clinical Pharmacy, College of Medicine and Health Science, Sultan Qaboos University, Muscat 123, Oman
| | - Rajaa Saleh Al Farsi
- Internal Medicine Residency Training Program, Oman Medical Specialty Board, Muscat 130, Oman;
| | - Khalfan Al Zeedy
- Department of Medicine, Sultan Qaboos University Hospital, Muscat 123, Oman; (A.R.A.H.); (K.A.Z.); (A.M.A.A.)
- Internal Medicine Residency Training Program, Oman Medical Specialty Board, Muscat 130, Oman;
| | - Taif Al-Saadi
- College of Medicine, Royal College of Surgeons, D02 YN77 Dublin, Ireland
| | - Noof Al-Hamadani
- College of Medicine, Royal College of Surgeons, D02 YN77 Dublin, Ireland
| | - Abdullah M. Al Alawi
- Department of Medicine, Sultan Qaboos University Hospital, Muscat 123, Oman; (A.R.A.H.); (K.A.Z.); (A.M.A.A.)
- Internal Medicine Residency Training Program, Oman Medical Specialty Board, Muscat 130, Oman;
| |
Collapse
|
24
|
Jaworska N, Soo A, Stelfox HT, Burry LD, Fiest KM. Impacts of antipsychotic medication prescribing practices in critically ill adult patients on health resource utilization and new psychoactive medication prescriptions. PLoS One 2023; 18:e0287929. [PMID: 37384760 PMCID: PMC10310007 DOI: 10.1371/journal.pone.0287929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 06/15/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Antipsychotic medications are commonly prescribed to critically ill adult patients and initiation of new antipsychotic prescriptions in the intensive care unit (ICU) increases the proportion of patients discharged home on antipsychotics. Critically ill adult patients are also frequently exposed to multiple psychoactive medications during ICU admission and hospitalization including benzodiazepines and opioid medications which may increase the risk of psychoactive polypharmacy following hospital discharge. The associated impact on health resource utilization and risk of new benzodiazepine and opioid prescriptions is unknown. RESEARCH QUESTION What is the burden of health resource utilization and odds of new prescriptions of benzodiazepines and opioids up to 1-year post-hospital discharge in critically ill patients with new antipsychotic prescriptions at hospital discharge? STUDY DESIGN & METHODS We completed a multi-center, propensity-score matched retrospective cohort study of critically ill adult patients. The primary exposure was administration of ≥1 dose of an antipsychotic while the patient was admitted in the ICU and ward with continuation at hospital discharge and a filled outpatient prescription within 1-year following hospital discharge. The control group was defined as no doses of antipsychotics administered in the ICU and hospital ward and no filled outpatient prescriptions for antipsychotics within 1-year following hospital discharge. The primary outcome was health resource utilization (72-hour ICU readmission, 30-day hospital readmission, 30-day emergency room visitation, 30-day mortality). Secondary outcomes were administration of benzodiazepines and/or opioids in-hospital and following hospital discharge in patients receiving antipsychotics. RESULTS 1,388 propensity-score matched patients were included who did and did not receive antipsychotics in ICU and survived to hospital discharge. New antipsychotic prescriptions were not associated with increased health resource utilization or 30-day mortality following hospital discharge. There was increased odds of new prescriptions of benzodiazepines (adjusted odds ratio [aOR] 1.61 [95%CI 1.19-2.19]) and opioids (aOR 1.82 [95%CI 1.38-2.40]) up to 1-year following hospital discharge in patients continuing antipsychotics at hospital discharge. INTERPRETATION New antipsychotic prescriptions at hospital discharge are significantly associated with additional prescriptions of benzodiazepines and opioids in-hospital and up to 1-year following hospital discharge.
Collapse
Affiliation(s)
- Natalia Jaworska
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
| | - Andrea Soo
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Henry T. Stelfox
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Leslie Dan Faculty of Pharmacy, O’Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Lisa D. Burry
- Departments of Pharmacy and Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Kirsten M. Fiest
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Leslie Dan Faculty of Pharmacy, O’Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Psychiatry, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| |
Collapse
|
25
|
Gu WJ, Zhang LM, Wang CM, Zhao FZ, Yin HY, Lyu J. Pre-intensive care unit use of selective serotonin reuptake inhibitors and mortality in critically ill adults with mental disorders: analysis from the MIMIC-IV database. Transl Psychiatry 2023; 13:187. [PMID: 37277344 DOI: 10.1038/s41398-023-02487-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 05/12/2023] [Accepted: 05/26/2023] [Indexed: 06/07/2023] Open
Abstract
Selective serotonin reuptake inhibitors (SSRIs) are the most commonly prescribed drugs for mental disorders in critically ill patients. We performed a retrospective cohort study to investigate the association between pre-ICU use of SSRIs and mortality in critically ill adults with mental disorders. We identified critically ill adults with mental disorders based on the Medical Information Mart in Intensive Care-IV database. The exposure was the use of SSRIs during the period after hospital admission and before ICU admission. The outcome was in-hospital mortality. Time-dependent Cox proportional hazards regression models were used to estimate the adjusted hazard ratio (aHR) with 95% confidence interval (CI). To further test the robustness of the results, we performed propensity score matching and marginal structural Cox model estimated by inverse probability of treatment weighting. The original cohort identified 16601 patients. Of those, 2232 (13.4%) received pre-ICU SSRIs, and 14369 (86.6%) did not. Matched cohort obtained 4406 patients, with 2203 patients in each group (SSRIs users vs. non-users). In the original cohort, pre-ICU use of SSRIs was associated with a 24% increase in the hazard for in-hospital mortality (aHR, 1.24; 95% CI, 1.05-1.46; P = 0.010). The results were robust in the matched cohort (aHR, 1.26; 95% CI, 1.02-1.57; P = 0.032) and the weighted cohort (aHR, 1.43; 95% CI, 1.32-1.54; P < 0.001). Pre-ICU use of SSRIs is associated with an increase in the hazard for in-hospital mortality in critically ill adults with mental disorders.
Collapse
Affiliation(s)
- Wan-Jie Gu
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
| | - Lu-Ming Zhang
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
| | - Chun-Mei Wang
- Department of Critical Care Medicine, Affiliated Hospital of Weifang Medical University, Weifang, Shandong, China
| | - Feng-Zhi Zhao
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
| | - Hai-Yan Yin
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China.
| | - Jun Lyu
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China.
| |
Collapse
|
26
|
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
| |
Collapse
|
27
|
Sinha S, Bhattacharjee S. Prediction of Delirium in the Critically Ill Obstetric Patients: An Old Friend to the Rescue? Indian J Crit Care Med 2023; 27:301-302. [PMID: 37214116 PMCID: PMC10196641 DOI: 10.5005/jp-journals-10071-24453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 04/14/2023] [Indexed: 05/24/2023] Open
Abstract
How to cite this article: Sinha S, Bhattacharjee S. Prediction of Delirium in the Critically Ill Obstetric Patients: An Old Friend to the Rescue? Indian J Crit Care Med 2023;27(5):301-302.
Collapse
Affiliation(s)
- Sharmili Sinha
- Department of Critical Care Medicine, Apollo Hospitals, Bhubaneswar, Odisha, India
| | - Sulagna Bhattacharjee
- Department of Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
28
|
Mohsen ST, Stelfox HT, Fiest KM. The authors reply. Crit Care Med 2023; 51:e125-e126. [PMID: 37052447 DOI: 10.1097/ccm.0000000000005830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Affiliation(s)
- Samiha T Mohsen
- Department of Critical Care Medicine, Alberta Health Services & University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences & O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine, Alberta Health Services & University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences & O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Kirsten M Fiest
- Department of Critical Care Medicine, Alberta Health Services & University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences & O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
- Department of Psychiatry & Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| |
Collapse
|
29
|
Noda K, Koga M, Toyoda K. Recognition of Strokes in the ICU: A Narrative Review. J Cardiovasc Dev Dis 2023; 10:jcdd10040182. [PMID: 37103061 PMCID: PMC10145112 DOI: 10.3390/jcdd10040182] [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: 03/25/2023] [Revised: 04/14/2023] [Accepted: 04/17/2023] [Indexed: 04/28/2023] Open
Abstract
Despite the remarkable progress in acute treatment for stroke, in-hospital stroke is still devastating. The mortality and neurological sequelae are worse in patients with in-hospital stroke than in those with community-onset stroke. The leading cause of this tragic situation is the delay in emergent treatment. To achieve better outcomes, early stroke recognition and immediate treatment are crucial. In general, in-hospital stroke is initially witnessed by non-neurologists, but it is sometimes challenging for non-neurologists to diagnose a patient's state as a stroke and respond quickly. Therefore, understanding the risk and characteristics of in-hospital stroke would be helpful for early recognition. First, we need to know "the epicenter of in-hospital stroke". Critically ill patients and patients who undergo surgery or procedures are admitted to the intensive care unit, and they are potentially at high risk for stroke. Moreover, since they are often sedated and intubated, evaluating their neurological status concisely is difficult. The limited evidence demonstrated that the intensive care unit is the most common place for in-hospital strokes. This paper presents a review of the literature and clarifies the causes and risks of stroke in the intensive care unit.
Collapse
Affiliation(s)
- Kotaro Noda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita 564-8565, Japan
- Department of Neurology and Neurological Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo 113-8519, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita 564-8565, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita 564-8565, Japan
| |
Collapse
|
30
|
Pilowsky JK, Elliott R, Roche MA. Association Between Preexisting Mental Health Disorders and Adverse Outcomes in Adult Intensive Care Patients: A Data Linkage Study. Crit Care Med 2023; 51:513-524. [PMID: 36752617 DOI: 10.1097/ccm.0000000000005792] [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: 02/09/2023]
Abstract
OBJECTIVES Mental illness is known to adversely affect the physical health of patients in primary and acute care settings; however, its impact on critically ill patients is less well studied. This study aimed to determine the prevalence, characteristics, and outcomes of patients admitted to the ICU with a preexisting mental health disorder. DESIGN A multicenter, retrospective cohort study using linked data from electronic ICU clinical progress notes and the Australia and New Zealand Intensive Care Society Adult Patient Database. SETTING/PATIENTS All patients admitted to eight Australian adult ICUs in the calendar year 2019. Readmissions within the same hospitalization were excluded. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Natural language processing techniques were used to classify preexisting mental health disorders in participants based on clinician documentation in electronic ICU clinical progress notes. Sixteen thousand two hundred twenty-eight patients (58% male) were included in the study, of which 5,044 (31.1%) had a documented preexisting mental health disorder. Affective disorders were the most common subtype occurring in 2,633 patients (16.2%), followed by anxiety disorders, occurring in 1,611 patients (9.9%). Mixed-effects regression modeling found patients with a preexisting mental health disorder stayed in ICU 13% longer than other patients (β-coefficient, 0.12; 95% CI, 0.10-0.15) and were more likely to experience invasive ventilation (odds ratio, 1.42; 95% CI, 1.30-1.56). Severity of illness and ICU mortality rates were similar in both groups. CONCLUSIONS Patients with preexisting mental health disorders form a significant subgroup within the ICU. The presence of a preexisting mental health disorder is associated with greater ICU length of stay and higher rates of invasive ventilation, suggesting these patients may have a different clinical trajectory to patients with no mental health history. Further research is needed to better understand the reasons for these adverse outcomes and to develop interventions to better support these patients during and after ICU admission.
Collapse
Affiliation(s)
- Julia K Pilowsky
- Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
- Department of Intensive Care, Royal North Shore Hospital, Northern Sydney Local Health District, Sydney, NSW, Australia
| | - Rosalind Elliott
- Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
- Department of Intensive Care, Royal North Shore Hospital, Northern Sydney Local Health District, Sydney, NSW, Australia
- Nursing and Midwifery Directorate, Northern Sydney Local Health District, Sydney, NSW, Australia
- University of Canberra and ACT Health Directorate, Canberra, ACT, Australia
| | - Michael A Roche
- Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
- University of Canberra and ACT Health Directorate, Canberra, ACT, Australia
| |
Collapse
|
31
|
Prone Positioning During Venovenous Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome-Better Together? Crit Care Med 2023; 51:143-145. [PMID: 36519989 DOI: 10.1097/ccm.0000000000005727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
|
32
|
Tachibana M, Inada T. Poor prognostic impact of delirium: especially on mortality and institutionalisation. Psychogeriatrics 2023; 23:187-195. [PMID: 36416212 DOI: 10.1111/psyg.12914] [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: 08/22/2022] [Revised: 10/19/2022] [Accepted: 11/04/2022] [Indexed: 11/24/2022]
Abstract
The course of delirium is associated with increased hospital costs, healthcare complications, increased mortality, and long-term poor outcomes. Despite delirium being long recognised as one of the most important prognostic components of patients with illnesses, delirium remains poorly understood, effective management options are limited, and no effective treatment has yet been established. This review evaluated the effects of delirium on mortality, institutionalisation, and dementia in various situations to clarify its prognostic seriousness to elucidate important areas for clinical practice and future research. The effect of delirium on mortality in COVID-19 patients was similar to that in other diseases. The effect of delirium on mortality in patients with delirium between the ages of 18 and 65 may be higher than in those with delirium aged over 65, but studies are scarce. Promoting recognition of delirium at all ages is needed. With careful attention to the specific factors in younger patients that contribute to delirium, healthcare providers may be able to decrease the poor impact of delirium on clinical outcomes. Evaluation of the association between interventions for delirium such as sedation in present clinical practice and the prognosis of delirium is lacking, and further clinical studies are essential.
Collapse
Affiliation(s)
- Masako Tachibana
- Department of Psychiatry, Nagoya University Hospital, Nagoya-shi, Japan.,Department of Psychiatry, Nagoya Ekisaikai Hospital, Nagoya-shi, Japan
| | - Toshiya Inada
- Department of Psychiatry, Nagoya University Graduate School of Medicine, Nagoya-shi, Japan
| |
Collapse
|
33
|
Zaaqoq AM, Lorusso R. "Awake" extracorporeal membrane oxygenation: A challenge worth taking. J Card Surg 2022; 37:4543-4544. [PMID: 36321710 DOI: 10.1111/jocs.17078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 10/17/2022] [Indexed: 12/31/2022]
Affiliation(s)
- Akram M Zaaqoq
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Georgetown University, Washington DC, USA
| | - Roberto Lorusso
- Department and Cardio-Thoracic Surgery, Heart & Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| |
Collapse
|
34
|
Poikajärvi S, Rauta S, Salanterä S, Junttila K. Delirium in a surgical context from a nursing perspective: A hybrid concept analysis. INTERNATIONAL JOURNAL OF NURSING STUDIES ADVANCES 2022; 4:100103. [PMID: 38745600 PMCID: PMC11080469 DOI: 10.1016/j.ijnsa.2022.100103] [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: 12/10/2021] [Revised: 09/12/2022] [Accepted: 09/26/2022] [Indexed: 10/14/2022] Open
Abstract
Background The term delirium has been defined in medical diagnosis criteria as a multidimensional disorder, and the term acute confusion is included in nursing classifications. Delirium can be a serious complication assessed in a patient after a surgical procedure. Still, the patient's delirium frequently remains unrecognised. Care of patients with delirium after surgical procedure is complex, and it challenges nursing expertise. From the nurses' viewpoint, delirium is associated with ambiguity of concepts and lack of knowledge. Therefore, reseach on how nurses perceive patients with delirium in a surgical context is needed. Objective The aim of this study was to describe the concepts of delirium and acute confusion, as well as the associated dimensions, in adult patients in a surgical context from the nursing perspective. Design The study used Schwartz and Barcott's hybrid concept analysis with theoretical, fieldwork, and final analytical phases. Settings Surgical wards, surgical intensive care units, and post-anaesthesia care units. Data sources A systematic literature search was performed through Pubmed (Medline), Cinahl, PsycInfo, and Embase. Participants Registered nurses and licensed practical nurses (n = 105) participated in the fieldwork phase. Methods In the theoretical phase, the concepts' working definitions were formulated based on a systematic literature search with the year limitations from 2000 until February 2021. At the fieldwork phase, the nurses' descriptions of patients with delirium were analysed using the deductive content analysis method. At the final analytical phase, findings were combined and reported. Results The concepts of delirium, subsyndromal delirium, and acute confusion are well defined in the literature. From the perspective of the nurses in the study, concepts were seen as a continuum not as individual diagnoses. Nurses described the continuum of delirium as a process with acute onset, duration, and recovery with the associated dimensions of symptoms, symptom severity, risk factors, and early signs. The acute phase of delirium was emphasised, and preoperative or prolonged disturbance did not seem to be relevant in the surgical care context. Patients' compliance with care may be decreased with the continuum of delirium, which might challenge both patients' recovery from surgery and the quality of nursing care. Conclusions In clinical practice the nurses used term confusion inaccurately. The term acute confusion might be used when illustrating an early stage of delirium. Nurses could benefit from further education where the theoretical knowledge is combined with the clinical practice. The discussion about the delirium, which covers the time both before surgery and after the acute phase should be increased.
Collapse
Affiliation(s)
- Satu Poikajärvi
- Department of Nursing Science, Faculty of Medicine, University of Turku, Turku, Finland
- Department of Perioperative, Intensive Care, and Pain Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Satu Rauta
- Department of Perioperative, Intensive Care, and Pain Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Sanna Salanterä
- Department of Nursing Science, Faculty of Medicine, University of Turku, Turku, Finland
- Turku University Hospital, Turku, Finland
| | - Kristiina Junttila
- Department of Nursing Science, Faculty of Medicine, University of Turku, Turku, Finland
- Nursing Research Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| |
Collapse
|
35
|
|
36
|
Tiberio PJ, Prendergast NT, Girard TD. Pharmacologic Management of Delirium in the Intensive Care Unit. Clin Chest Med 2022; 43:411-424. [PMID: 36116811 DOI: 10.1016/j.ccm.2022.04.004] [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: 11/16/2022]
Abstract
Delirium, often underdiagnosed in the intensive care unit, is a common complication of critical illness that contributes to significant morbidity and mortality. Clinicians should be aware of common risk factors and triggers and should work to mitigate these as much as possible to reduce the occurrence of delirium. This review first provides an overview of the epidemiology, pathophysiology, evaluation, and consequences of delirium in critically ill patients. Presented next is the current evidence for the pharmacologic management of delirium, focusing on prevention and treatment of delirium in the intensive care unit. It concludes by outlining some emerging treatments of delirium.
Collapse
Affiliation(s)
- Perry J Tiberio
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, NW 628 UPMC Montefiore, 3459 Fifth Avenue, Pittsburgh, PA 15213, USA
| | - Niall T Prendergast
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, NW 628 UPMC Montefiore, 3459 Fifth Avenue, Pittsburgh, PA 15213, USA
| | - Timothy D Girard
- Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh, 3520 Fifth Avenue, 101 Keystone Building, Pittsburgh, PA, 15213, USA.
| |
Collapse
|
37
|
Rollo E, Brunetti V, Scala I, Callea A, Marotta J, Vollono C, Frisullo G, Broccolini A, Calabresi P, Della Marca G. Impact of delirium on the outcome of stroke: a prospective, observational, cohort study. J Neurol 2022; 269:6467-6475. [PMID: 35945396 PMCID: PMC9618551 DOI: 10.1007/s00415-022-11309-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/20/2022] [Accepted: 07/24/2022] [Indexed: 11/06/2022]
Abstract
Introduction Delirium is an acute fluctuating disorder of attention and awareness, which often complicates the clinical course of several conditions, including acute stroke. The aim of the present study was to determine whether delirium occurrence impacts the outcome of patients with acute stroke. Methods The study design is single center, prospective, observational. We consecutively enrolled patients admitted to the stroke unit from April to October 2020. Inclusion criteria were age ≥ 18 years and diagnosis of acute stroke. Exclusion criteria were stroke mimics, coma, and terminal conditions. All patients were screened for delirium upon admission, within 72 h, and whenever symptoms suggesting delirium occurred by means of the Confusion Assessment Method for Intensive Care Unit and the Richmond Agitation Sedation Scale. Outcomes were evaluated with the 90-days modified Rankin Scale (mRS) by telephone interview. Results The final study cohort consisted of 103 patients (62 men; median age 75 years, interquartile range 63–81). Thirty-one patients (30%) developed delirium. In the multivariate ordinal logistic regression, patients with delirium had higher mRS scores at 3 months (DLR + : mRS = 4 (3–6); DLR–: mRS = 1 (1–3); adjusted odds ratio = 4.83; CI = 1.88–12.35; p = 0.006). Delirium was a risk factor for death (mRS = 6) in the univariate logistic regression (OR 4.5, CI = 1.44–14.07; p = 0.010), but not in the adjusted analysis (OR 3.45; CI = 0.66–17.95; p = 0.142). Survival time during 90-days follow-up was shorter in the delirium group (Log Rank χ2 3.89; p = 0.048). Conclusion Delirium negatively impacts the prognosis of patients with acute stroke. Patients with post-stroke delirium have a worse functional outcome and a shorter survival.
Collapse
Affiliation(s)
- Eleonora Rollo
- Department of Neurosciences, Università Cattolica del Sacro Cuore, Rome, Italy. .,Department of Neurosciences, IRCCS Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy.
| | - Valerio Brunetti
- Department of Neurosciences, Università Cattolica del Sacro Cuore, Rome, Italy.,UOC Neurologia, Dipartimento Scienze dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, IRCCS Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Irene Scala
- Department of Neurosciences, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio Callea
- Department of Neurosciences, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Jessica Marotta
- Department of Neurosciences, Università Cattolica del Sacro Cuore, Rome, Italy.,UOC Neuroriabilitazione ad Alta Intensità, IRCCS Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Catello Vollono
- UOC Neurologia, Dipartimento Scienze dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, IRCCS Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Giovanni Frisullo
- UOC Neurologia, Dipartimento Scienze dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, IRCCS Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Aldobrando Broccolini
- Department of Neurosciences, Università Cattolica del Sacro Cuore, Rome, Italy.,UOC Neurologia, Dipartimento Scienze dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, IRCCS Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Paolo Calabresi
- Department of Neurosciences, Università Cattolica del Sacro Cuore, Rome, Italy.,UOC Neurologia, Dipartimento Scienze dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, IRCCS Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Giacomo Della Marca
- Department of Neurosciences, Università Cattolica del Sacro Cuore, Rome, Italy.,UOC Neurologia, Dipartimento Scienze dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, IRCCS Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| |
Collapse
|
38
|
Govil D, Pal D. Delirium Assessment in Intensive Care Unit: A Need for Higher Regard! Indian J Crit Care Med 2022; 26:661-662. [PMID: 35836639 PMCID: PMC9237158 DOI: 10.5005/jp-journals-10071-24247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
How to cite this article: Govil D, Pal D. Delirium Assessment in Intensive Care Unit: A Need for Higher Regard! Indian J Crit Care Med 2022;26(6):661–662.
Collapse
Affiliation(s)
- Deepak Govil
- Institute of Critical Care and Anesthesia, Medanta–The Medicity, Gurugram, Haryana, India
- Deepak Govil, Institute of Critical Care and Anesthesia, Medanta–The Medicity, Gurugram, Haryana, India, Phone: +91 11 26692531, e-mail:
| | - Divya Pal
- Department of Critical Care Medicine, Medanta–The Medicity, Gurugram, Haryana, India
| |
Collapse
|
39
|
Vollam S, Efstathiou N. Special issue: Rehabilitation in and after critical care. Nurs Crit Care 2022; 27:130-132. [PMID: 35179277 DOI: 10.1111/nicc.12755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 01/13/2022] [Indexed: 12/01/2022]
Affiliation(s)
- Sarah Vollam
- Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom of Great Britain and Northern Ireland
| | - Nikolaos Efstathiou
- School of Nursing, University of Birmingham, United Kingdom of Great Britain and Northern Ireland
| |
Collapse
|
40
|
Castro VM, Hart KL, Sacks CA, Murphy SN, Perlis RH, McCoy TH. Longitudinal validation of an electronic health record delirium prediction model applied at admission in COVID-19 patients. Gen Hosp Psychiatry 2022; 74:9-17. [PMID: 34798580 PMCID: PMC8562039 DOI: 10.1016/j.genhosppsych.2021.10.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/25/2021] [Accepted: 10/27/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To validate a previously published machine learning model of delirium risk in hospitalized patients with coronavirus disease 2019 (COVID-19). METHOD Using data from six hospitals across two academic medical networks covering care occurring after initial model development, we calculated the predicted risk of delirium using a previously developed risk model applied to diagnostic, medication, laboratory, and other clinical features available in the electronic health record (EHR) at time of hospital admission. We evaluated the accuracy of these predictions against subsequent delirium diagnoses during that admission. RESULTS Of the 5102 patients in this cohort, 716 (14%) developed delirium. The model's risk predictions produced a c-index of 0.75 (95% CI, 0.73-0.77) with 27.7% of cases occurring in the top decile of predicted risk scores. Model calibration was diminished compared to the initial COVID-19 wave. CONCLUSION This EHR delirium risk prediction model, developed during the initial surge of COVID-19 patients, produced consistent discrimination over subsequent larger waves; however, with changing cohort composition and delirium occurrence rates, model calibration decreased. These results underscore the importance of calibration, and the challenge of developing risk models for clinical contexts where standard of care and clinical populations may shift.
Collapse
Affiliation(s)
- Victor M. Castro
- Center for Quantitative Health, Massachusetts General Hospital, 185 Cambridge Street, Boston, MA 02114, USA,Research Information Science and Computing, Mass General Brigham, 399 Revolution Drive, Somerville, MA 02145, USA
| | - Kamber L. Hart
- Center for Quantitative Health, Massachusetts General Hospital, 185 Cambridge Street, Boston, MA 02114, USA
| | - Chana A. Sacks
- Department of Medicine, Massachusetts General Hospital, 100 Cambridge Street, Boston, MA 02114, USA
| | - Shawn N. Murphy
- Research Information Science and Computing, Mass General Brigham, 399 Revolution Drive, Somerville, MA 02145, USA,Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Roy H. Perlis
- Center for Quantitative Health, Massachusetts General Hospital, 185 Cambridge Street, Boston, MA 02114, USA
| | - Thomas H. McCoy
- Center for Quantitative Health, Massachusetts General Hospital, 185 Cambridge Street, Boston, MA 02114, USA,Corresponding author at: Simches Research Building, Massachusetts General Hospital, 185 Cambridge St, 6th Floor, Boston, MA 02114, USA
| |
Collapse
|
41
|
Delirium in Critically Ill Cancer Patients With COVID-19. J Acad Consult Liaison Psychiatry 2022; 63:539-547. [PMID: 35660676 PMCID: PMC9162788 DOI: 10.1016/j.jaclp.2022.05.005] [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: 02/13/2022] [Revised: 05/23/2022] [Accepted: 05/28/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND COVID-19 has been a devastating pandemic with little known of its neuropsychiatric complications. Delirium is one of the most common neuropsychiatric syndromes among hospitalized cancer patients with incidence ranging from 25% to 40% and rates of up to 85% in the terminally ill. Data on the incidence, risk factors, duration, and outcomes of delirium in critically ill cancer patients with COVID-19 are lacking. OBJECTIVE To report the incidence, risks and outcomes of critically ill cancer patients who developed COVID-19. METHODS This is a retrospective single-center study evaluating delirium frequency and outcomes in all critically ill cancer patients with COVID-19 admitted between March 1 and July 10, 2020. Delirium was assessed by Confusion Assessment Method for Intensive Care Unit, performed twice daily by trained intensive care unit (ICU) nursing staff. Patients were considered to have a delirium-positive day if Confusion Assessment Method for Intensive Care Unit was positive at least once per day. RESULTS A total of 70 patients were evaluated. Of those 70, 53 (75.7%) were found to be positive for delirium. Patients with delirium were significantly older than patients without delirium (median age 67.5 vs 60.3 y, P = 0.013). There were no significant differences in demographic characteristics, chronic medical conditions, neuropsychiatric history, cancer type, or application of prone positioning between the 2 groups. Delirium patients were less likely to receive cancer-directed therapies (58.5% vs 88.2%, P = 0.038) but more likely to receive antipsychotics (81.1% vs 41.2%, P = 0.004), dexmedetomidine (79.3% vs 11.8%, P < 0.001), steroids (84.9% vs 58.8%, P = 0.039), and vasopressors (90.6% vs 58.8%, P = 0.006). Delirium patients were more likely to be intubated (86.8% vs 41.2%, P < 0.001), and all tracheostomies (35.9%) occurred in patients with delirium. ICU length of stay (19 vs 8 d, P < 0.001) and hospital length of stay (37 vs 12 d, P < 0.001) were significantly longer in delirium patients, but there was no statistically significant difference in hospital mortality (43.4% vs 58.8%, P = 0.403) or ICU mortality (34.0% vs 58.8%, P = 0.090). CONCLUSIONS Delirium in critically ill cancer patients with COVID-19 was associated with less cancer-directed therapies and increased hospital and ICU length of stay. However, the presence of delirium was not associated with an increase in hospital or ICU mortality.
Collapse
|
42
|
Jaster JH. Gravity in the brain-how it may regulate skeletal muscle metabolism by balancing compressive ischemic changes in the weight-bearing pituitary and hypothalamus. Physiol Rep 2021; 9:e14878. [PMID: 34042300 PMCID: PMC8157765 DOI: 10.14814/phy2.14878] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 04/25/2021] [Accepted: 04/26/2021] [Indexed: 12/15/2022] Open
|