1
|
Meng L, Zhao X, Sun Y, Cheng S, Bao L, Fang K, Yu Q, Zheng Y, Wang J, Luo M, Gunderman D, Vuckovic N, Sidhu AS, Li J, Li G, Wolfe JW, Liu Z, Adams DC. Characteristics associated with effectiveness in postoperative delirium research: a systematic review of randomised controlled trials with meta-regression and meta-analysis. Br J Anaesth 2024; 133:565-583. [PMID: 38969535 DOI: 10.1016/j.bja.2024.05.033] [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: 09/15/2023] [Revised: 05/28/2024] [Accepted: 05/30/2024] [Indexed: 07/07/2024] Open
Abstract
BACKGROUND Postoperative delirium remains prevalent despite extensive research through randomised trials aimed at reducing its incidence. Understanding trial characteristics associated with interventions' effectiveness facilitates data interpretation. METHODS Trial characteristics were extracted from eligible trials identified through two systematic literature searches. Multivariable meta-regression was used to investigate trial characteristics associated with effectiveness estimated using odds ratios. Meta-analysis was used to investigate pooled effectiveness. RESULTS We identified 201 eligible trials. Compared with China, trials from the USA/Canada (ratio of odds ratio, 1.89; 95% confidence interval, 1.45-2.45) and Europe/Australia/New Zealand (1.67; 1.29-2.18) had an 89% and 67% higher odds ratio, respectively, suggesting reduced effectiveness. The effectiveness was enhanced when the incidence of postoperative delirium increased (0.85; 0.79-0.92, per 10% increase). Trials with concerns related to deviations from intended interventions reported increased effectiveness compared with those at low risk (0.69; 0.53-0.90). Compared with usual care, certain interventions appeared to have reduced the incidence of postoperative delirium in low-risk trials with low-to-moderate certainty of evidence. However, these findings should be considered inconclusive because of challenges in grouping heterogeneous interventions, the limited number of eligible trials, the prevalence of small-scale studies, and potential publication bias. CONCLUSIONS The effectiveness of postoperative delirium trials varied based on the region of trial origin, the incidence of delirium, and the risk of bias. The limitations caution against drawing definitive conclusions from different bodies of evidence. These findings highlight the imperative need to improve the quality of research on a global scale. SYSTEMATIC REVIEW PROTOCOL PROSPERO (CRD42023413984).
Collapse
Affiliation(s)
- Lingzhong Meng
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Xu Zhao
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yanhua Sun
- Department of Anesthesiology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Shufen Cheng
- Department of Anesthesiology, The Fourth Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Lin Bao
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
| | - Kaiyun Fang
- Department of Anesthesiology, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China
| | - Qiong Yu
- Department of Anesthesiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Yueying Zheng
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jin Wang
- Department of Anesthesiology, The Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Mengqiang Luo
- Department of Anesthesiology, Huashan Hospital, Fudan University, Shanghai, China
| | - David Gunderman
- Indiana University School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Nikola Vuckovic
- Indiana University School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Angad S Sidhu
- Indiana University School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Jian Li
- Department of Anesthesiology, The Fourth Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Gang Li
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
| | - John W Wolfe
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ziyue Liu
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, USA
| | - David C Adams
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN, USA
| |
Collapse
|
2
|
Mei X, Liu YH, Han YQ, Zheng CY. Risk factors, preventive interventions, overlapping symptoms, and clinical measures of delirium in elderly patients. World J Psychiatry 2023; 13:973-984. [PMID: 38186721 PMCID: PMC10768493 DOI: 10.5498/wjp.v13.i12.973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/14/2023] [Accepted: 10/30/2023] [Indexed: 12/19/2023] Open
Abstract
Delirium is an acute reversible neuropsychiatric syndrome caused by multiple factors. It is associated with many adverse clinical outcomes including cognitive impairment, functional decline, prolonged hospitalization, and increased nursing service. The prevalence of delirium was high in department of cardiology, geriatric, and intensive care unit of hospital. With the increase in the aged population, further increases in delirium seem likely. However, it remains poorly recognized in the clinical practice. This article comprehensively discusses the latest research perspectives on the epidemiological data, risk factors, preventive interventions, overlapping symptoms, and clinical measures of delirium, including specific measures to manage delirium in clinical real-world situations. This article helps readers improve their knowledge and understanding of delirium and helps clinicians quickly identify and implement timely therapeutic measures to address various delirium subtypes that occur in the clinical settings to ensure patients are treated as aggressively as possible.
Collapse
Affiliation(s)
- Xi Mei
- Department of Psychiatry, Ningo Kangning Hospital, Ningbo 315201, Zhejiang Province, China
| | - Yue-Hong Liu
- Department of Psychiatry, Ningo Kangning Hospital, Ningbo 315201, Zhejiang Province, China
| | - Ya-Qing Han
- Department of Psychiatry, Ningo Kangning Hospital, Ningbo 315201, Zhejiang Province, China
| | - Cheng-Ying Zheng
- Department of Psychiatry, Ningo Kangning Hospital, Ningbo 315201, Zhejiang Province, China
| |
Collapse
|
3
|
Mattimore D, Fischl A, Christophides A, Cuenca J, Davidson S, Jin Z, Bergese S. Delirium after Cardiac Surgery-A Narrative Review. Brain Sci 2023; 13:1682. [PMID: 38137130 PMCID: PMC10741583 DOI: 10.3390/brainsci13121682] [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: 10/30/2023] [Revised: 12/04/2023] [Accepted: 12/05/2023] [Indexed: 12/24/2023] Open
Abstract
Postoperative delirium (POD) after cardiac surgery is a well-known phenomenon which carries a higher risk of morbidity and mortality. Multiple patient-specific risk factors and pathophysiologic mechanisms have been identified and therapies have been proposed to mitigate risk of delirium development postoperatively. Notably, cardiac surgery frequently involves the use of an intraoperative cardiopulmonary bypass (CPB), which may contribute to the mechanisms responsible for POD. Despite our greater understanding of these causative factors, a substantial reduction in the incidence of POD remains high among cardiac surgical patients. Multiple therapeutic interventions have been implemented intraoperatively and postoperatively, many with conflicting results. This review article will highlight the incidence and impact of POD in cardiac surgical patients. It will describe some of the primary risk factors associated with POD, as well as anesthetic management and therapies postoperatively that may help to reduce delirium.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Sergio Bergese
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (D.M.); (A.F.); (A.C.); (J.C.); (S.D.); (Z.J.)
| |
Collapse
|
4
|
Wang YP, Shen BB, Zhu CC, Li L, Lu S, Wang DJ, Jin H, Liu Q, Wang ZY, Ge M. Unveiling the nexus of postoperative fever and delirium in cardiac surgery: identifying predictors for enhanced patient care. Front Cardiovasc Med 2023; 10:1237055. [PMID: 38028495 PMCID: PMC10667695 DOI: 10.3389/fcvm.2023.1237055] [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: 06/08/2023] [Accepted: 10/25/2023] [Indexed: 12/01/2023] Open
Abstract
Background Postoperative delirium (POD) is a significant complication observed in cardiac surgery patients, characterized by acute cognitive decline, fluctuating mental status, consciousness impairment, and confusion. Despite its impact, POD often goes undiagnosed. Postoperative fever, a common occurrence after cardiac surgery, has not been comprehensively studied in relation to delirium. This study aims to identify perioperative period factors associated with POD in patients undergoing cardiopulmonary bypass, with the potential for implementing preventive interventions. Methods In a prospective observational study conducted between February 2023 and April 2023 at the Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Nanjing University Medical School, a total of 232 patients who underwent cardiac surgery were enrolled. POD assessment utilized the Confusion Assessment Method for the ICU (CAM-ICU), while high fever was defined as a bladder temperature exceeding 39°C. Statistical analysis included univariate and multivariate analyses, logistic regression, nomogram development, and internal validation. Result The overall incidence of postoperative delirium was found to be 12.1%. Multivariate analysis revealed that postoperative lactate levels [odds ratio (OR) = 1.787], maximum temperature (OR = 11.290), and cardiopulmonary bypass time (OR = 1.015) were independent predictors of POD. A predictive nomogram for POD was developed based on these three factors, demonstrating good discrimination and calibration. The prediction model exhibited a C-statistic value of 0.852 (95% CI, 0.763-0.941), demonstrating excellent discriminatory power. Sensitivity and specificity, based on the area under the receiver operating characteristic (AUROC) curve, were 91.2% and 67.9%, respectively. Conclusion This study underscores the high prevalence of POD in cardiac surgery patients and identifies postoperative lactate levels, cardiopulmonary bypass duration, and postoperative fever as independent predictors of delirium. The association between postoperative fever and POD warrants further investigation. These findings have implications for implementing preventive strategies in high-risk patients, aiming to mitigate postoperative complications and improve patient outcomes.
Collapse
Affiliation(s)
- Ya-peng Wang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, China
| | - Bei-bei Shen
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Afliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Cui-cui Zhu
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Afliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Li Li
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Afliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Shan Lu
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Afliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Dong-jin Wang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, China
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Afliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Hua Jin
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Afliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Qi Liu
- Department of Critical Care Medicine, Xiangya Hospital of Central South University, Changsha, China
| | - Zhe-yun Wang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Afliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Min Ge
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Afliated Hospital of Nanjing University Medical School, Nanjing, China
| |
Collapse
|
5
|
Nakamura R, Miyamoto K, Tsuji K, Ozaki K, Kunimoto H, Honda K, Nishimura Y, Kato S. The impact of a preoperative nurse-led orientation program on postoperative delirium after cardiovascular surgery: a retrospective single-center observational study. J Intensive Care 2023; 11:20. [PMID: 37198714 DOI: 10.1186/s40560-023-00666-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 04/28/2023] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND Postoperative delirium in intensive care is common and associated with mortality, cognitive impairment, prolonged hospital stays and high costs. We evaluate whether a nurse-led orientation program could reduce the incidence of delirium in the intensive care unit after cardiovascular surgery. METHODS In this retrospective cohort study, we enrolled patients admitted to the intensive care unit for planned cardiovascular surgery between January 2020 and December 2021. A nurse-led orientation program based on a preoperative visit was routinely introduced from January 2021. We assessed the association between these visits and postoperative delirium in the intensive care unit. We also assessed predictors of postoperative delirium with baseline and intraoperative characteristics. RESULTS Among 253 patients with planned cardiovascular surgery, 128 (50.6%) received preoperative visits. Valve surgery comprised 44.7%, coronary surgery 31.6%, and aortic surgery 20.9%. Cardiopulmonary bypass use and transcatheter surgery were 60.5% and 12.3%, respectively. Incidence of delirium was lower in patients that received preoperative visits, and median hospital stay was shorter than in those without visits (18 patients [14.1%] vs 34 patients [27.2%], P < 0.01; 14 days vs 17 days, P < 0.01). After adjusting predefined confounders, preoperative visits were independently associated with decreased incidence of delirium (adjusted odds ratio [aOR] 0.45; 95% confidence interval [95% CI] 0.22-0.84). Other predictors of delirium were higher European System for Cardiac Operative Risk Evaluation II score and lower minimum intraoperative cerebral oxygen saturation. CONCLUSIONS A preoperative nurse-led orientation program was associated with reduction of postoperative delirium and could be effective against postoperative delirium after cardiovascular surgery. Trial registration UMIN Clinical Trial Registry no. UMIN000048142. Registered 22, July, 2022, retrospectively registered, https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000054862 .
Collapse
Affiliation(s)
- Ryo Nakamura
- Department of Emergency and Critical Care Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8509, Japan.
- Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8509, Japan.
| | - Kyohei Miyamoto
- Department of Emergency and Critical Care Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8509, Japan
| | - Kaori Tsuji
- Department of Nursing, Wakayama Medical University Hospital, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8510, Japan
| | - Kana Ozaki
- Department of Nursing, Wakayama Medical University Hospital, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8510, Japan
| | - Hideki Kunimoto
- Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8509, Japan
| | - Kentaro Honda
- Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8509, Japan
| | - Yoshiharu Nishimura
- Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8509, Japan
| | - Seiya Kato
- Department of Emergency and Critical Care Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8509, Japan
| |
Collapse
|
6
|
Butris N, Tang E, He D, Wang DX, Chung F. Sleep disruption in older surgical patients and its important implications. Int Anesthesiol Clin 2023; 61:47-54. [PMID: 36727706 DOI: 10.1097/aia.0000000000000391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Nina Butris
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Ontario, Canada
| | - Evan Tang
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - David He
- Department of Anesthesia and Pain Management, Mount Sinai Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Dong-Xin Wang
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Frances Chung
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Ontario, Canada
| |
Collapse
|
7
|
Rengel KF, Boncyk CS, DiNizo D, Hughes CG. Perioperative Neurocognitive Disorders in Adults Requiring Cardiac Surgery: Screening, Prevention, and Management. Semin Cardiothorac Vasc Anesth 2023; 27:25-41. [PMID: 36137773 DOI: 10.1177/10892532221127812] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Neurocognitive changes are the most common complication after cardiac surgery, ranging from acute postoperative delirium to prolonged postoperative neurocognitive disorder. Changes in cognition are distressing to patients and families and associated with worse outcomes overall. This review outlines definitions and diagnostic criteria, risk factors for, and mechanisms of Perioperative Neurocognitive Disorders and offers strategies for preoperative screening and perioperative prevention and management of neurocognitive complications.
Collapse
Affiliation(s)
- Kimberly F Rengel
- Division of Anesthesia Critical Care Medicine, Department of Anesthesiology, 12328Vanderbilt University Medical Center, Nashville, TN, USA.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christina S Boncyk
- Division of Anesthesia Critical Care Medicine, Department of Anesthesiology, 12328Vanderbilt University Medical Center, Nashville, TN, USA.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Daniella DiNizo
- Scope Anesthesia of North Carolina, Charlotte, NC, USA.,Pulmonary and Critical Care Consultants, Carolinas Medical Center, 2351Atrium Health, Charlotte, NC, USA
| | - Christopher G Hughes
- Division of Anesthesia Critical Care Medicine, Department of Anesthesiology, 12328Vanderbilt University Medical Center, Nashville, TN, USA.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, 12328Vanderbilt University Medical Center, Nashville, TN, USA.,Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
| |
Collapse
|
8
|
Rengel KF, Wahl LA, Sharma A, Lee H, Hayhurst CJ. Delirium Prevention and Management in Frail Surgical Patients. Anesthesiol Clin 2023; 41:175-189. [PMID: 36871998 DOI: 10.1016/j.anclin.2022.10.011] [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] [Indexed: 03/07/2023]
Abstract
Delirium, an acute, fluctuating impairment in cognition and awareness, is one of the most common causes of postoperative brain dysfunction. It is associated with increased hospital length of stay, health care costs, and mortality. There is no FDA-approved treatment of delirium, and management relies on symptomatic control. Several preventative techniques have been proposed, including the choice of anesthetic agent, preoperative testing, and intraoperative monitoring. Frailty, a state of increased vulnerability to adverse events, is an independent and potentially modifiable risk factor for the development of delirium. Diligent preoperative screening techniques and implementation of prevention strategies could help improve outcomes in high-risk patients.
Collapse
Affiliation(s)
- Kimberly F Rengel
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, 1211 21st Avenue South, 422 MAB, Nashville, TN 37212, USA
| | - Lindsay A Wahl
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital, 251 East Huron, Suite 5-704, Chicago, IL 60611, USA
| | - Archit Sharma
- Division of Cardiothoracic Anesthesia, Solid Organ Transplant, and Critical Care, Department of Anesthesia, University of Iowa Carver College of Medicine, 200 Hawkins Drive, 6512 JCP, Iowa City, IA 52242, USA
| | - Howard Lee
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital, 251 East Huron, Suite 5-704, Chicago, IL 60611, USA
| | - Christina J Hayhurst
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, 1211 21st Avenue South, 422 MAB, Nashville, TN 37212, USA.
| |
Collapse
|
9
|
Pharmacological prevention of postoperative delirium in patients undergoing cardiac surgery: a bayesian network meta-analysis. J Anesth 2023; 37:294-310. [PMID: 36788134 DOI: 10.1007/s00540-023-03170-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 02/02/2023] [Indexed: 02/16/2023]
Abstract
The incidence of postoperative delirium in patients undergoing cardiac surgery is very high and increases morbidity and mortality. The possibility of pharmacological means to reduce its incidence is very attractive. At present, there is still no clear demonstration that any drug can prevent postoperative delirium in these patients. The aim of this Bayesian network meta-analysis (NMA) was to evaluate whether there is evidence that a drug is effective in reducing the incidence of POD in cardiac surgical patients. Our NMA showed that preoperative ketamine at subanesthetic doses can significantly reduce the incidence of POD. Risperidone also decreases the incidence of POD, but not significantly.
Collapse
|
10
|
[Delirium in the context of intensive care medicine-Part 2: diagnosis, prevention and treatment]. DER NERVENARZT 2023; 94:99-105. [PMID: 36269366 DOI: 10.1007/s00115-022-01399-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/05/2022] [Indexed: 02/04/2023]
Abstract
Despite the high prevalence and the enormous medical and health economic impact, delirium syndromes are often underdiagnosed, which is mainly attributable to the high frequency of hypoactive delirium and to the frequently subtle and fluctuating psychopathology in the initial phase of delirium. These aspects also justify the need for a consequent and continuous application of standardized screening tools to detect delirium as early as possible. A multidimensional, nonpharmacological prevention of delirium is effective and still underutilized in the clinical practice. So far, there are no consensus recommendations regarding the pharmacological prevention of delirium. From a therapeutic perspective a causal approach is prioritized. Pharmacological treatment of delirium can only be considered under strict observance of specific indicators. When treating non-withdrawal-related delirium benzodiazepines should be avoided.
Collapse
|
11
|
Malik J. Animal-Assisted Interventions in Intensive Care Delirium: A Literature Review. AACN Adv Crit Care 2021; 32:391-397. [PMID: 34879136 DOI: 10.4037/aacnacc2021708] [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: 11/01/2022]
Abstract
Critical illness has lasting consequences on the mind and the body. Acute sequelae include a decline in cognitive function known as delirium. Increased interest in improving outcomes for intensive care unit survivors without a high incidence of delirium has initiated a focus on an array of nonpharmacologic interventions in many countries. One such intervention is animalassisted intervention. As the role of animals in human healing is being recognized by clinicians, need is increasing for formal and professionally directed therapies. This review ascertains the effect of interaction with animals on critically ill patients. Emerging evidence indicates that animal-assisted intervention improves the efficacy of critical care regarding primary symptoms and secondary factors of delirium.
Collapse
Affiliation(s)
- Jahanzeb Malik
- Jahanzeb Malik is the Senior Registrar, Emergency and Critical Care, Rawalpindi Institute of Cardiology, Rawal Road, Rawalpindi, 46000, Pakistan
| |
Collapse
|
12
|
Effects of Intraoperative Dexmedetomidine Infusion on Postoperative Delirium in Elderly Patients Undergoing Total Hip Arthroplasty. Int Surg 2021. [DOI: 10.9738/intsurg-d-17-00029.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective
To investigate the effects of dexmedetomidine on postoperative delirium in elderly patients undergoing total hip arthroplasty.
Methods
A total of 100 patients, 42 male and 58 female, ages 60 to 85 years, American Society of Anesthesiologists grade I or II, who were undergoing total hip arthroplasty were randomly divided into 2 groups: a dexmedetomidine group (group D; n = 50) and a control group (group C; n = 50). Group D patients were infused with 0.3 μg · kg−1 · h−1 of dexmedetomidine from 5 minutes prior to anesthesia induction until the end of surgery. Group C patients received an equal volume of saline. Heart rate and mean arterial pressure (MAP) were recorded before anesthesia induction (T0), 1 minute before extubation (T1), and 30 minutes after extubation (T2). The Visual Analog Score (VAS) at 1, 2, and 3 days after surgery, the incidence and duration of postoperative delirium, and the length of hospital stay were recorded. Adverse reactions, such as nausea, vomiting, and lethargy, were also recorded.
Results
The Visual Analog Scores in the 2 groups were similar. In group D, there was no significant difference in heart rate (P = 0.232) and MAP (P = 0.056) between T0 and T1. However, in group C, heart rate significantly increased by 15.3 bpm (P = 0.000) and MAP significantly increased by 10.7 mmHg (P = 0.001) at T1 compared with those at T0. The incidence of postoperative delirium in group D (10%) was significantly lower than that in group C (26%; P = 0.037). The duration of delirium in group D (1.3 ± 0.6 days) was shorter than that in group C (3.0 ± 0.5 days; P = 0.000). The length of hospital stay in group D (13.2 ± 0.9 days) was shorter than that in group C (16.1 ± 0.7 days; P = 0.000). No significant differences were observed in adverse effects between the 2 groups.
Conclusion
Intravenous infusion of dexmedetomidine can not only reduce the incidence and duration of postoperative delirium, but also shorten the length of hospital stay in elderly patients undergoing total hip arthroplasty.
Collapse
|
13
|
Palakshappa JA, Hough CL. How We Prevent and Treat Delirium in the ICU. Chest 2021; 160:1326-1334. [PMID: 34102141 PMCID: PMC8727852 DOI: 10.1016/j.chest.2021.06.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/10/2021] [Accepted: 06/02/2021] [Indexed: 11/30/2022] Open
Abstract
Delirium is a serious and complex problem facing critically ill patients, their families, and the health care system. When delirium develops, it is associated with prolonged hospital stays, increased costs, and long-term cognitive impairment in many patients. This article uses a clinical case to discuss our approach to delirium prevention and treatment in the ICU. We believe that an effective strategy to combat delirium requires implementation and adherence to a pain and sedation protocol as part of bundled care, use of a validated tool to detect delirium when present, and a focus on nonpharmacologic care strategies, including reorientation, early mobility, and incorporating family into care when possible. At present, the evidence does not support the routine administration of medications to prevent or treat delirium. A pharmacologic approach may be needed for agitated delirium, and we discuss our evaluation of the evidence for and against particular medications. Although delirium can be a distressing problem, there is evidence that it can be addressed through careful attention to prevention, detection, and minimizing the long-term impact on patients and their families.
Collapse
|
14
|
Stollings JL, Kotfis K, Chanques G, Pun BT, Pandharipande PP, Ely EW. Delirium in critical illness: clinical manifestations, outcomes, and management. Intensive Care Med 2021; 47:1089-1103. [PMID: 34401939 PMCID: PMC8366492 DOI: 10.1007/s00134-021-06503-1] [Citation(s) in RCA: 116] [Impact Index Per Article: 38.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 07/29/2021] [Indexed: 12/22/2022]
Abstract
Delirium is the most common manifestation of brain dysfunction in critically ill patients. In the intensive care unit (ICU), duration of delirium is independently predictive of excess death, length of stay, cost of care, and acquired dementia. There are numerous neurotransmitter/functional and/or injury-causing hypotheses rather than a unifying mechanism for delirium. Without using a validated delirium instrument, delirium can be misdiagnosed (under, but also overdiagnosed and trivialized), supporting the recommendation to use a monitoring instrument routinely. The best-validated ICU bedside instruments are CAM-ICU and ICDSC, both of which also detect subsyndromal delirium. Both tools have some inherent limitations in the neurologically injured patients, yet still provide valuable information about delirium once the sequelae of the primary injury settle into a new post-injury baseline. Now it is known that antipsychotics and other psychoactive medications do not reliably improve brain function in critically ill delirious patients. ICU teams should systematically screen for predisposing and precipitating factors. These include exacerbations of cardiac/respiratory failure or sepsis, metabolic disturbances (hypoglycemia, dysnatremia, uremia and ammonemia) receipt of psychoactive medications, and sensory deprivation through prolonged immobilization, uncorrected vision and hearing deficits, poor sleep hygiene, and isolation from loved ones so common during COVID-19 pandemic. The ABCDEF (A2F) bundle is a means to facilitate implementation of the 2018 Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (PADIS) Guidelines. In over 25,000 patients across nearly 100 institutions, the A2F bundle has been shown in a dose-response fashion (i.e., greater bundle compliance) to yield improved survival, length of stay, coma and delirium duration, cost, and less ICU bounce-backs and discharge to nursing homes.
Collapse
Affiliation(s)
- Joanna L Stollings
- Critical Illness Brain Dysfunction Survivorship Center, Nashville, Vanderbilt University Medical Center, 1211 Medical Center Drive, B-131 VUH, Nashville, TN, 37232-7610, USA.
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Katarzyna Kotfis
- Department Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, Szczecin, Poland
| | - Gerald Chanques
- Department of Anaesthesia and Critical Care Medicine, Saint Eloi Hospital, Montpellier University Hospital Center, and PhyMedExp, University of Montpellier, INSERM, CNRS, Montpellier, France
| | - Brenda T Pun
- Critical Illness Brain Dysfunction Survivorship Center, Nashville, Vanderbilt University Medical Center, 1211 Medical Center Drive, B-131 VUH, Nashville, TN, 37232-7610, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Pratik P Pandharipande
- Critical Illness Brain Dysfunction Survivorship Center, Nashville, Vanderbilt University Medical Center, 1211 Medical Center Drive, B-131 VUH, Nashville, TN, 37232-7610, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - E Wesley Ely
- Critical Illness Brain Dysfunction Survivorship Center, Nashville, Vanderbilt University Medical Center, 1211 Medical Center Drive, B-131 VUH, Nashville, TN, 37232-7610, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA
- Geriatric Research, Education and Clinical Center Service, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care System, Nashville, TN, USA
| |
Collapse
|
15
|
Egi M, Ogura H, Yatabe T, Atagi K, Inoue S, Iba T, Kakihana Y, Kawasaki T, Kushimoto S, Kuroda Y, Kotani J, Shime N, Taniguchi T, Tsuruta R, Doi K, Doi M, Nakada TA, Nakane M, Fujishima S, Hosokawa N, Masuda Y, Matsushima A, Matsuda N, Yamakawa K, Hara Y, Sakuraya M, Ohshimo S, Aoki Y, Inada M, Umemura Y, Kawai Y, Kondo Y, Saito H, Taito S, Takeda C, Terayama T, Tohira H, Hashimoto H, Hayashida K, Hifumi T, Hirose T, Fukuda T, Fujii T, Miura S, Yasuda H, Abe T, Andoh K, Iida Y, Ishihara T, Ide K, Ito K, Ito Y, Inata Y, Utsunomiya A, Unoki T, Endo K, Ouchi A, Ozaki M, Ono S, Katsura M, Kawaguchi A, Kawamura Y, Kudo D, Kubo K, Kurahashi K, Sakuramoto H, Shimoyama A, Suzuki T, Sekine S, Sekino M, Takahashi N, Takahashi S, Takahashi H, Tagami T, Tajima G, Tatsumi H, Tani M, Tsuchiya A, Tsutsumi Y, Naito T, Nagae M, Nagasawa I, Nakamura K, Nishimura T, Nunomiya S, Norisue Y, Hashimoto S, Hasegawa D, Hatakeyama J, Hara N, Higashibeppu N, Furushima N, Furusono H, Matsuishi Y, Matsuyama T, Minematsu Y, Miyashita R, Miyatake Y, Moriyasu M, Yamada T, Yamada H, Yamamoto R, Yoshida T, Yoshida Y, Yoshimura J, Yotsumoto R, Yonekura H, Wada T, Watanabe E, Aoki M, Asai H, Abe T, Igarashi Y, Iguchi N, Ishikawa M, Ishimaru G, Isokawa S, Itakura R, Imahase H, Imura H, Irinoda T, Uehara K, Ushio N, Umegaki T, Egawa Y, Enomoto Y, Ota K, Ohchi Y, Ohno T, Ohbe H, Oka K, Okada N, Okada Y, Okano H, Okamoto J, Okuda H, Ogura T, Onodera Y, Oyama Y, Kainuma M, Kako E, Kashiura M, Kato H, Kanaya A, Kaneko T, Kanehata K, Kano KI, Kawano H, Kikutani K, Kikuchi H, Kido T, Kimura S, Koami H, Kobashi D, Saiki I, Sakai M, Sakamoto A, Sato T, Shiga Y, Shimoto M, Shimoyama S, Shoko T, Sugawara Y, Sugita A, Suzuki S, Suzuki Y, Suhara T, Sonota K, Takauji S, Takashima K, Takahashi S, Takahashi Y, Takeshita J, Tanaka Y, Tampo A, Tsunoyama T, Tetsuhara K, Tokunaga K, Tomioka Y, Tomita K, Tominaga N, Toyosaki M, Toyoda Y, Naito H, Nagata I, Nagato T, Nakamura Y, Nakamori Y, Nahara I, Naraba H, Narita C, Nishioka N, Nishimura T, Nishiyama K, Nomura T, Haga T, Hagiwara Y, Hashimoto K, Hatachi T, Hamasaki T, Hayashi T, Hayashi M, Hayamizu A, Haraguchi G, Hirano Y, Fujii R, Fujita M, Fujimura N, Funakoshi H, Horiguchi M, Maki J, Masunaga N, Matsumura Y, Mayumi T, Minami K, Miyazaki Y, Miyamoto K, Murata T, Yanai M, Yano T, Yamada K, Yamada N, Yamamoto T, Yoshihiro S, Tanaka H, Nishida O. The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020). J Intensive Care 2021; 9:53. [PMID: 34433491 PMCID: PMC8384927 DOI: 10.1186/s40560-021-00555-7] [Citation(s) in RCA: 90] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 05/10/2021] [Indexed: 02/08/2023] Open
Abstract
The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members.As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.
Collapse
Affiliation(s)
- Moritoki Egi
- Department of Surgery Related, Division of Anesthesiology, Kobe University Graduate School of Medicine, Kusunoki-cho 7-5-2, Chuo-ku, Kobe, Hyogo, Japan.
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Medical School, Yamadaoka 2-15, Suita, Osaka, Japan.
| | - Tomoaki Yatabe
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Toyoake, Japan
| | - Kazuaki Atagi
- Department of Intensive Care Unit, Nara Prefectural General Medical Center, Nara, Japan
| | - Shigeaki Inoue
- Department of Disaster and Emergency Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University, Tokyo, Japan
| | - Yasuyuki Kakihana
- Department of Emergency and Intensive Care Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Tatsuya Kawasaki
- Department of Pediatric Critical Care, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yasuhiro Kuroda
- Department of Emergency, Disaster, and Critical Care Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Joji Kotani
- Department of Surgery Related, Division of Disaster and Emergency Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Takumi Taniguchi
- Department of Anesthesiology and Intensive Care Medicine, Kanazawa University, Kanazawa, Japan
| | - Ryosuke Tsuruta
- Acute and General Medicine, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Kent Doi
- Department of Acute Medicine, The University of Tokyo, Tokyo, Japan
| | - Matsuyuki Doi
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Taka-Aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Masaki Nakane
- Department of Emergency and Critical Care Medicine, Yamagata University Hospital, Yamagata, Japan
| | - Seitaro Fujishima
- Center for General Medicine Education, Keio University School of Medicine, Tokyo, Japan
| | - Naoto Hosokawa
- Department of Infectious Diseases, Kameda Medical Center, Kamogawa, Japan
| | - Yoshiki Masuda
- Department of Intensive Care Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Asako Matsushima
- Department of Advancing Acute Medicine, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
| | - Naoyuki Matsuda
- Department of Emergency and Critical Care Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuma Yamakawa
- Department of Emergency Medicine, Osaka Medical College, Osaka, Japan
| | - Yoshitaka Hara
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Toyoake, Japan
| | - Masaaki Sakuraya
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Hatsukaichi, Japan
| | - Shinichiro Ohshimo
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yoshitaka Aoki
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Mai Inada
- Member of Japanese Association for Acute Medicine, Tokyo, Japan
| | - Yutaka Umemura
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Yusuke Kawai
- Department of Nursing, Fujita Health University Hospital, Toyoake, Japan
| | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Hiroki Saito
- Department of Emergency and Critical Care Medicine, St. Marianna University School of Medicine, Yokohama City Seibu Hospital, Yokohama, Japan
| | - Shunsuke Taito
- Division of Rehabilitation, Department of Clinical Support and Practice, Hiroshima University Hospital, Hiroshima, Japan
| | - Chikashi Takeda
- Department of Anesthesia, Kyoto University Hospital, Kyoto, Japan
| | - Takero Terayama
- Department of Psychiatry, School of Medicine, National Defense Medical College, Tokorozawa, Japan
| | | | - Hideki Hashimoto
- Department of Emergency and Critical Care Medicine/Infectious Disease, Hitachi General Hospital, Hitachi, Japan
| | - Kei Hayashida
- The Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Tomoya Hirose
- Emergency and Critical Care Medical Center, Osaka Police Hospital, Osaka, Japan
| | - Tatsuma Fukuda
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Tomoko Fujii
- Intensive Care Unit, Jikei University Hospital, Tokyo, Japan
| | - Shinya Miura
- The Royal Children's Hospital Melbourne, Melbourne, Australia
| | - Hideto Yasuda
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Toshikazu Abe
- Department of Emergency and Critical Care Medicine, Tsukuba Memorial Hospital, Tsukuba, Japan
| | - Kohkichi Andoh
- Division of Anesthesiology, Division of Intensive Care, Division of Emergency and Critical Care, Sendai City Hospital, Sendai, Japan
| | - Yuki Iida
- Department of Physical Therapy, School of Health Sciences, Toyohashi Sozo University, Toyohashi, Japan
| | - Tadashi Ishihara
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Kentaro Ide
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Kenta Ito
- Department of General Pediatrics, Aichi Children's Health and Medical Center, Obu, Japan
| | - Yusuke Ito
- Department of Infectious Disease, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Yu Inata
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Akemi Utsunomiya
- Human Health Science, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeshi Unoki
- Department of Acute and Critical Care Nursing, School of Nursing, Sapporo City University, Sapporo, Japan
| | - Koji Endo
- Department of Pharmacoepidemiology, Kyoto University Graduate School of Medicine and Public Health, Kyoto, Japan
| | - Akira Ouchi
- College of Nursing, Ibaraki Christian University, Hitachi, Japan
| | - Masayuki Ozaki
- Department of Emergency and Critical Care Medicine, Komaki City Hospital, Komaki, Japan
| | - Satoshi Ono
- Gastroenterological Center, Shinkuki General Hospital, Kuki, Japan
| | | | | | - Yusuke Kawamura
- Department of Rehabilitation, Showa General Hospital, Tokyo, Japan
| | - Daisuke Kudo
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kenji Kubo
- Department of Emergency Medicine and Department of Infectious Diseases, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Kiyoyasu Kurahashi
- Department of Anesthesiology and Intensive Care Medicine, International University of Health and Welfare School of Medicine, Narita, Japan
| | | | - Akira Shimoyama
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Takeshi Suzuki
- Department of Anesthesiology, Tokai University School of Medicine, Isehara, Japan
| | - Shusuke Sekine
- Department of Anesthesiology, Tokyo Medical University, Tokyo, Japan
| | - Motohiro Sekino
- Division of Intensive Care, Nagasaki University Hospital, Nagasaki, Japan
| | - Nozomi Takahashi
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Sei Takahashi
- Center for Innovative Research for Communities and Clinical Excellence (CiRC2LE), Fukushima Medical University, Fukushima, Japan
| | - Hiroshi Takahashi
- Department of Cardiology, Steel Memorial Muroran Hospital, Muroran, Japan
| | - Takashi Tagami
- Department of Emergency and Critical Care Medicine, Nippon Medical School Musashi Kosugi Hospital, Kawasaki, Japan
| | - Goro Tajima
- Nagasaki University Hospital Acute and Critical Care Center, Nagasaki, Japan
| | - Hiroomi Tatsumi
- Department of Intensive Care Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Masanori Tani
- Division of Critical Care Medicine, Saitama Children's Medical Center, Saitama, Japan
| | - Asuka Tsuchiya
- Department of Emergency and Critical Care Medicine, National Hospital Organization Mito Medical Center, Ibaraki, Japan
| | - Yusuke Tsutsumi
- Department of Emergency and Critical Care Medicine, National Hospital Organization Mito Medical Center, Ibaraki, Japan
| | - Takaki Naito
- Department of Emergency and Critical Care Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Masaharu Nagae
- Department of Intensive Care Medicine, Kobe University Hospital, Kobe, Japan
| | | | - Kensuke Nakamura
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Japan
| | - Tetsuro Nishimura
- Department of Traumatology and Critical Care Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Shin Nunomiya
- Department of Anesthesiology and Intensive Care Medicine, Division of Intensive Care, Jichi Medical University School of Medicine, Shimotsuke, Japan
| | - Yasuhiro Norisue
- Department of Emergency and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Japan
| | - Satoru Hashimoto
- Department of Anesthesiology and Intensive Care Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Daisuke Hasegawa
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Toyoake, Japan
| | - Junji Hatakeyama
- Department of Emergency and Critical Care Medicine, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Naoki Hara
- Department of Pharmacy, Yokohama Rosai Hospital, Yokohama, Japan
| | - Naoki Higashibeppu
- Department of Anesthesiology and Nutrition Support Team, Kobe City Medical Center General Hospital, Kobe City Hospital Organization, Kobe, Japan
| | - Nana Furushima
- Department of Anesthesiology, Kobe University Hospital, Kobe, Japan
| | - Hirotaka Furusono
- Department of Rehabilitation, University of Tsukuba Hospital/Exult Co., Ltd., Tsukuba, Japan
| | - Yujiro Matsuishi
- Doctoral program in Clinical Sciences. Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yusuke Minematsu
- Department of Clinical Engineering, Osaka University Hospital, Suita, Japan
| | - Ryoichi Miyashita
- Department of Intensive Care Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Yuji Miyatake
- Department of Clinical Engineering, Kakogawa Central City Hospital, Kakogawa, Japan
| | - Megumi Moriyasu
- Division of Respiratory Care and Rapid Response System, Intensive Care Center, Kitasato University Hospital, Sagamihara, Japan
| | - Toru Yamada
- Department of Nursing, Toho University Omori Medical Center, Tokyo, Japan
| | - Hiroyuki Yamada
- Department of Primary Care and Emergency Medicine, Kyoto University Hospital, Kyoto, Japan
| | - Ryo Yamamoto
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Takeshi Yoshida
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yuhei Yoshida
- Nursing Department, Osaka General Medical Center, Osaka, Japan
| | - Jumpei Yoshimura
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | | | - Hiroshi Yonekura
- Department of Clinical Anesthesiology, Mie University Hospital, Tsu, Japan
| | - Takeshi Wada
- Department of Anesthesiology and Critical Care Medicine, Division of Acute and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Eizo Watanabe
- Department of Emergency and Critical Care Medicine, Eastern Chiba Medical Center, Togane, Japan
| | - Makoto Aoki
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Hideki Asai
- Department of Emergency and Critical Care Medicine, Nara Medical University, Kashihara, Japan
| | - Takakuni Abe
- Department of Anesthesiology and Intensive Care, Oita University Hospital, Yufu, Japan
| | - Yutaka Igarashi
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, Tokyo, Japan
| | - Naoya Iguchi
- Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Masami Ishikawa
- Department of Anesthesiology, Emergency and Critical Care Medicine, Kure Kyosai Hospital, Kure, Japan
| | - Go Ishimaru
- Department of General Internal Medicine, Soka Municipal Hospital, Soka, Japan
| | - Shutaro Isokawa
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Ryuta Itakura
- Department of Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Hisashi Imahase
- Department of Biomedical Ethics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Haruki Imura
- Department of Infectious Diseases, Rakuwakai Otowa Hospital, Kyoto, Japan
- Department of Health Informatics, School of Public Health, Kyoto University, Kyoto, Japan
| | | | - Kenji Uehara
- Department of Anesthesiology, National Hospital Organization Iwakuni Clinical Center, Iwakuni, Japan
| | - Noritaka Ushio
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Maebashi, Japan
| | - Takeshi Umegaki
- Department of Anesthesiology, Kansai Medical University, Hirakata, Japan
| | - Yuko Egawa
- Advanced Emergency and Critical Care Center, Saitama Red Cross Hospital, Saitama, Japan
| | - Yuki Enomoto
- Department of Emergency and Critical Care Medicine, University of Tsukuba, Tsukuba, Japan
| | - Kohei Ota
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yoshifumi Ohchi
- Department of Anesthesiology and Intensive Care, Oita University Hospital, Yufu, Japan
| | - Takanori Ohno
- Department of Emergency and Critical Medicine, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Hiroyuki Ohbe
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | | | - Nobunaga Okada
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yohei Okada
- Department of Primary care and Emergency medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hiromu Okano
- Department of Anesthesiology, Kyorin University School of Medicine, Tokyo, Japan
| | - Jun Okamoto
- Department of ER, Hashimoto Municipal Hospital, Hashimoto, Japan
| | - Hiroshi Okuda
- Department of Community Medical Supports, Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
| | - Takayuki Ogura
- Tochigi prefectural Emergency and Critical Care Center, Imperial Gift Foundation Saiseikai, Utsunomiya Hospital, Utsunomiya, Japan
| | - Yu Onodera
- Department of Anesthesiology, Faculty of Medicine, Yamagata University, Yamagata, Japan
| | - Yuhta Oyama
- Department of Internal Medicine, Dialysis Center, Kichijoji Asahi Hospital, Tokyo, Japan
| | - Motoshi Kainuma
- Anesthesiology, Emergency Medicine, and Intensive Care Division, Inazawa Municipal Hospital, Inazawa, Japan
| | - Eisuke Kako
- Department of Anesthesiology and Intensive Care Medicine, Nagoya-City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Masahiro Kashiura
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Hiromi Kato
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Akihiro Kanaya
- Department of Anesthesiology, Sendai Medical Center, Sendai, Japan
| | - Tadashi Kaneko
- Emergency and Critical Care Center, Mie University Hospital, Tsu, Japan
| | - Keita Kanehata
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Maebashi, Japan
| | - Ken-Ichi Kano
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
| | - Hiroyuki Kawano
- Department of Gastroenterological Surgery, Onga Hospital, Fukuoka, Japan
| | - Kazuya Kikutani
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hitoshi Kikuchi
- Department of Emergency and Critical Care Medicine, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Takahiro Kido
- Department of Pediatrics, University of Tsukuba Hospital, Tsukuba, Japan
| | - Sho Kimura
- Division of Critical Care Medicine, Saitama Children's Medical Center, Saitama, Japan
| | - Hiroyuki Koami
- Center for Translational Injury Research, University of Texas Health Science Center at Houston, Houston, USA
| | - Daisuke Kobashi
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Maebashi, Japan
| | - Iwao Saiki
- Department of Anesthesiology, Tokyo Medical University, Tokyo, Japan
| | - Masahito Sakai
- Department of General Medicine Shintakeo Hospital, Takeo, Japan
| | - Ayaka Sakamoto
- Department of Emergency and Critical Care Medicine, University of Tsukuba Hospital, Tsukuba, Japan
| | - Tetsuya Sato
- Tohoku University Hospital Emergency Center, Sendai, Japan
| | - Yasuhiro Shiga
- Department of Orthopaedic Surgery, Center for Advanced Joint Function and Reconstructive Spine Surgery, Graduate school of Medicine, Chiba University, Chiba, Japan
| | - Manabu Shimoto
- Department of Primary care and Emergency medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shinya Shimoyama
- Department of Pediatric Cardiology and Intensive Care, Gunma Children's Medical Center, Shibukawa, Japan
| | - Tomohisa Shoko
- Department of Emergency and Critical Care Medicine, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - Yoh Sugawara
- Department of Anesthesiology, Yokohama City University, Yokohama, Japan
| | - Atsunori Sugita
- Department of Acute Medicine, Division of Emergency and Critical Care Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Satoshi Suzuki
- Department of Intensive Care, Okayama University Hospital, Okayama, Japan
| | - Yuji Suzuki
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Tomohiro Suhara
- Department of Anesthesiology, Keio University School of Medicine, Tokyo, Japan
| | - Kenji Sonota
- Department of Intensive Care Medicine, Miyagi Children's Hospital, Sendai, Japan
| | - Shuhei Takauji
- Department of Emergency Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Kohei Takashima
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Sho Takahashi
- Department of Cardiology, Fukuyama City Hospital, Fukuyama, Japan
| | - Yoko Takahashi
- Department of General Internal Medicine, Koga General Hospital, Koga, Japan
| | - Jun Takeshita
- Department of Anesthesiology, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Yuuki Tanaka
- Fukuoka Prefectural Psychiatric Center, Dazaifu Hospital, Dazaifu, Japan
| | - Akihito Tampo
- Department of Emergency Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Taichiro Tsunoyama
- Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Kenichi Tetsuhara
- Emergency and Critical Care Center, Kyushu University Hospital, Fukuoka, Japan
| | - Kentaro Tokunaga
- Department of Intensive Care Medicine, Kumamoto University Hospital, Kumamoto, Japan
| | - Yoshihiro Tomioka
- Department of Anesthesiology and Intensive Care Unit, Todachuo General Hospital, Toda, Japan
| | - Kentaro Tomita
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Naoki Tominaga
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, Tokyo, Japan
| | - Mitsunobu Toyosaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yukitoshi Toyoda
- Department of Emergency and Critical Care Medicine, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Hiromichi Naito
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Isao Nagata
- Intensive Care Unit, Yokohama City Minato Red Cross Hospital, Yokohama, Japan
| | - Tadashi Nagato
- Department of Respiratory Medicine, Tokyo Yamate Medical Center, Tokyo, Japan
| | - Yoshimi Nakamura
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Kyoto Daini Hospital, Kyoto, Japan
| | - Yuki Nakamori
- Department of Clinical Anesthesiology, Mie University Hospital, Tsu, Japan
| | - Isao Nahara
- Department of Anesthesiology and Critical Care Medicine, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Hiromu Naraba
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Japan
| | - Chihiro Narita
- Department of Emergency Medicine and Intensive Care Medicine, Shizuoka General Hospital, Shizuoka, Japan
| | - Norihiro Nishioka
- Department of Preventive Services, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Tomoya Nishimura
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Maebashi, Japan
| | - Kei Nishiyama
- Division of Emergency and Critical Care Medicine Niigata University Graduate School of Medical and Dental Science, Niigata, Japan
| | - Tomohisa Nomura
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Taiki Haga
- Department of Pediatric Critical Care Medicine, Osaka City General Hospital, Osaka, Japan
| | - Yoshihiro Hagiwara
- Department of Emergency and Critical Care Medicine, Saiseikai Utsunomiya Hospital, Utsunomiya, Japan
| | - Katsuhiko Hashimoto
- Research Associate of Minimally Invasive Surgical and Medical Oncology, Fukushima Medical University, Fukushima, Japan
| | - Takeshi Hatachi
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Toshiaki Hamasaki
- Department of Emergency Medicine, Japanese Red Cross Society Wakayama Medical Center, Wakayama, Japan
| | - Takuya Hayashi
- Division of Critical Care Medicine, Saitama Children's Medical Center, Saitama, Japan
| | - Minoru Hayashi
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
| | - Atsuki Hayamizu
- Department of Emergency Medicine, Saitama Saiseikai Kurihashi Hospital, Kuki, Japan
| | - Go Haraguchi
- Division of Intensive Care Unit, Sakakibara Heart Institute, Tokyo, Japan
| | - Yohei Hirano
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Ryo Fujii
- Department of Emergency Medicine and Critical Care Medicine, Tochigi Prefectural Emergency and Critical Care Center, Imperial Foundation Saiseikai Utsunomiya Hospital, Utsunomiya, Japan
| | - Motoki Fujita
- Acute and General Medicine, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Naoyuki Fujimura
- Department of Anesthesiology, St. Mary's Hospital, Our Lady of the Snow Social Medical Corporation, Kurume, Japan
| | - Hiraku Funakoshi
- Department of Emergency and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Japan
| | - Masahito Horiguchi
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Jun Maki
- Department of Critical Care Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Naohisa Masunaga
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yosuke Matsumura
- Department of Intensive Care, Chiba Emergency Medical Center, Chiba, Japan
| | - Takuya Mayumi
- Department of Internal Medicine, Kanazawa Municipal Hospital, Kanazawa, Japan
| | - Keisuke Minami
- Ishikawa Prefectual Central Hospital Emergency and Critical Care Center, Kanazawa, Japan
| | - Yuya Miyazaki
- Department of Emergency and General Internal Medicine, Saiseikai Kawaguchi General Hospital, Kawaguchi, Japan
| | - Kazuyuki Miyamoto
- Department of Emergency and Disaster Medicine, Showa University, Tokyo, Japan
| | - Teppei Murata
- Department of Cardiology, Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, Tokyo, Japan
| | - Machi Yanai
- Department of Emergency Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Takao Yano
- Department of Critical Care and Emergency Medicine, Miyazaki Prefectural Nobeoka Hospital, Nobeoka, Japan
| | - Kohei Yamada
- Department of Traumatology and Critical Care Medicine, National Defense Medical College, Tokorozawa, Japan
| | - Naoki Yamada
- Department of Emergency Medicine, University of Fukui Hospital, Fukui, Japan
| | - Tomonori Yamamoto
- Department of Intensive Care Unit, Nara Prefectural General Medical Center, Nara, Japan
| | - Shodai Yoshihiro
- Pharmaceutical Department, JA Hiroshima General Hospital, Hatsukaichi, Japan
| | - Hiroshi Tanaka
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Osamu Nishida
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Toyoake, Japan
| |
Collapse
|
16
|
Abstract
This review provides an overview for health care teams involved in the perioperative care of cardiac surgery patients. The intention is to summarize key determinants of delirium, its impact on short- and long-term outcomes as well as to discuss effective management strategies. The first component of this review examines the prevalence and the factors associated with an increased risk of postoperative delirium. A multitude of predisposing (eg, baseline vulnerability and comorbidities) and precipitating (eg, type of cardiac surgery and postoperative care) factors that contribute to the occurrence of delirium are discussed.
Collapse
|
17
|
Enomoto K, Kosaka S, Kimura T, Matsubara M, Kitada Y, Mieno M, Okamura H. Prevention of postoperative delirium after cardiovascular surgery: A team-based approach. J Thorac Cardiovasc Surg 2021; 165:1873-1881.e2. [PMID: 34417049 DOI: 10.1016/j.jtcvs.2021.07.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 06/29/2021] [Accepted: 07/15/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE We investigated the efficacy of the Delirium Team Approach program for delirium prevention after cardiovascular surgery. METHODS We retrospectively investigated 256 patients who underwent cardiac or thoracic vascular surgery between May 2017 and May 2020. We compared the outcomes before and after implementation of the Delirium Team Approach program in December 2018. The program included the following components: (a) educational sessions for the medical team regarding delirium and its management, (b) review of preprinted physician orders for insomnia and agitation, and (c) routine screening for delirium. We investigated the early outcomes and effects of the Delirium Team Approach program on postoperative delirium. RESULTS The incidence of postoperative delirium significantly decreased from 53.3% to 37.0% after implementation of the Delirium Team Approach program (P = .008). Although no intergroup differences were observed in the rates of stroke and reexploration for bleeding, the length of intensive care unit stay and the overall length of postoperative hospital stay were shorter in the postintervention group. Hospital costs, excluding surgery, and the cost during intensive care unit stay were lower in the postintervention group. Multivariable analysis showed that the Delirium Team Approach program was associated with a reduction in postoperative delirium (odds ratio, 0.38; 95% confidence interval, 0.21-0.67; P = .001). Other predictors of delirium included age, dementia, chronic kidney disease, and intubation time. After risk adjustment using propensity score matching, the rate of postoperative delirium was lower in the postintervention group. CONCLUSIONS Implementation of the Delirium Team Approach program was associated with a lower incidence of postoperative delirium in patients who underwent cardiovascular surgery.
Collapse
Affiliation(s)
- Kiichi Enomoto
- Department of Pharmacy, Nerima Hikarigaoka Hospital, Tokyo, Japan
| | - Shintaro Kosaka
- Department of Internal Medicine, Nerima Hikarigaoka Hospital, Tokyo, Japan
| | - Toru Kimura
- Department of Rehabilitation, Nerima Hikarigaoka Hospital, Tokyo, Japan
| | - Mikako Matsubara
- Department of Rehabilitation, Nerima Hikarigaoka Hospital, Tokyo, Japan
| | - Yuichiro Kitada
- Department of Cardiovascular Surgery, Nerima Hikarigaoka Hospital, Tokyo, Japan
| | - Makiko Mieno
- Department of Medical Informatics, Center for Information, Jichi Medical University, Tochigi, Japan
| | - Homare Okamura
- Department of Cardiovascular Surgery, Nerima Hikarigaoka Hospital, Tokyo, Japan.
| |
Collapse
|
18
|
Li X, Wang Y, Liu J, Xiong Y, Chen S, Han J, Xie W, Wu Q. Effects of perioperative interventions for preventing postoperative delirium: A protocol for systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore) 2021; 100:e26662. [PMID: 34398027 PMCID: PMC8294881 DOI: 10.1097/md.0000000000026662] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 06/24/2021] [Accepted: 06/28/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Postoperative delirium (POD) not only increases the medical burden but also adversely affects patient prognosis. Although some cases of delirium can be avoided by early intervention, there is no clear evidence indicating whether any of these measures can effectively prevent POD in specific patient groups. OBJECTIVE The aim of this meta-analysis was to compare the efficacy and safety of the existing preventive measures for managing POD. METHODS The PubMed, OVID (Embase and MEDLINE), Web of Science, and the Cochrane Library databases were searched for articles published before January 2020. The relevant randomized controlled trials (RCTs) were selected based on the inclusion and exclusion criteria. Data extraction and methodological quality assessment were performed according to a predesigned data extraction form and scoring system, respectively. The interventions were compared on the basis of the primary outcome like incidence of POD, and secondary outcomes like duration of delirium and the length of intensive care unit and hospital stay. RESULTS Sixty-three RCTs were included in the study, covering interventions like surgery, anesthesia, analgesics, intraoperative blood glucose control, cholinesterase inhibitors, anticonvulsant drugs, antipsychotic drugs, sleep rhythmic regulation, and multi-modal nursing. The occurrence of POD was low in 4 trials that monitored the depth of anesthesia with bispectral index during the operation (P < .0001). Two studies showed that supplementary analgesia was useful for delirium prevention (P = .002). Seventeen studies showed that perioperative sedation with α2-adrenergic receptor agonists prevented POD (P = .0006). Six studies showed that both typical and atypical antipsychotic drugs can reduce the incidence of POD (P = .002). Multimodal nursing during the perioperative period effectively reduced POD in 6 studies (P < .00001). Furthermore, these preventive measures can reduce the duration of delirium, as well as the total and postoperative length of hospitalized stay for non-cardiac surgery patients. For patients undergoing cardiac surgery, effective prevention can only reduce the length of intensive care unit stay. CONCLUSION Measures including intraoperative monitoring of bispectral index, supplemental analgesia, α2-adrenergic receptor agonists, antipsychotic drugs, and multimodal care are helpful to prevent POD effectively. However, larger, high-quality RCTs are needed to verify these findings and develop more interventions and drugs for preventing postoperative delirium.
Collapse
|
19
|
Nakamura ZM, Deal AM, Park EM, Quillen LJ, Chien SA, Stanton KE, McCabe SD, Heiling HM, Wood WA, Shea TC, Rosenstein DL. A randomized double-blind placebo-controlled trial of intravenous thiamine for prevention of delirium following allogeneic hematopoietic stem cell transplantation. J Psychosom Res 2021; 146:110503. [PMID: 33945982 PMCID: PMC8172461 DOI: 10.1016/j.jpsychores.2021.110503] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/22/2021] [Accepted: 04/23/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To determine if high dose intravenous (IV) thiamine can prevent delirium during hospitalization following allogeneic HSCT. Secondarily, we evaluated the effects of high dose IV thiamine on thiamine levels and explored risk factors for delirium. METHODS Randomized, double-blind, placebo-controlled trial in patients undergoing allogeneic HSCT at a U.S. academic medical center between October 2017 and March 2020. 64 participants were randomized 1:1 to thiamine 200 mg IV three times daily for 7 days or placebo. We used the Delirium Rating Scale to assess for delirium. Delirium incidence was compared between groups using the chi-square test. Group differences in time to onset and duration of delirium were compared using the Kaplan-Meier method. Fisher's Exact and Wilcoxon Rank Sum tests were used to examine associations between pre-transplantation variables and delirium. RESULTS 61 participants were analyzed. Delirium incidence (25% vs. 21%, Chi-square (df = 1) = 0.12, p = 0.73), time to onset, duration, and severity were not different between study arms. Immediately following the intervention, thiamine levels were higher in the thiamine arm (275 vs. 73 nmol/L, t-test (df = 57) = 13.63, p < 0.0001), but not predictive of delirium. Variables associated with delirium in our sample included disease severity, corticosteroid exposure, infection, and pre-transplantation markers of nutrition. CONCLUSION High dose IV thiamine did not prevent delirium in patients receiving allogeneic HSCT. Given the multiple contributors to delirium in this population, further research regarding the efficacy of multicomponent interventions may be needed. TRIAL REGISTRATION Clinical Trials NCT03263442. FUNDING Rising Tide Foundation for Clinical Cancer Research.
Collapse
Affiliation(s)
- Zev M Nakamura
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Allison M Deal
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Eliza M Park
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Laura J Quillen
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Stephanie A Chien
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kate E Stanton
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sean D McCabe
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Hillary M Heiling
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - William A Wood
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Thomas C Shea
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Donald L Rosenstein
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| |
Collapse
|
20
|
Park SK, Lim T, Cho H, Yoon HK, Lee HJ, Lee JH, Yoo S, Kim JT, Kim WH. Comparative effectiveness of pharmacological interventions to prevent postoperative delirium: a network meta-analysis. Sci Rep 2021; 11:11922. [PMID: 34099790 PMCID: PMC8184858 DOI: 10.1038/s41598-021-91314-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 05/24/2021] [Indexed: 12/30/2022] Open
Abstract
Many pharmacologic agents were investigated for the effect to prevent delirium. We aimed to comprehensively compare the effect of the pharmacological interventions to prevent postoperative delirium. A Bayesian network meta-analysis of randomized trials was performed using random effects model. PubMed, the Cochrane Central Register of Controlled Trials, and Embase were searched on 20 January 2021. Randomized trials comparing the effect of a drug to prevent postoperative delirium with another drug or placebo in adult patients undergoing any kind of surgery were included. Primary outcome was the postoperative incidence of delirium. Eighty-six trials with 26,992 participants were included. Dexmedetomidine, haloperidol, and atypical antipsychotics significantly decreased the incidence of delirium than placebo [dexmedetomidine: odds ratio 0.51, 95% credible interval (CrI) 0.40-0.66, moderate quality of evidence (QOE); haloperidol: odds ratio 0.59, 95% CrI 0.37-0.95, moderate QOE; atypical antipsychotics: odds ratio 0.27, 95% CrI 0.14-0.51, moderate QOE]. Dexmedetomidine and atypical antipsychotics had the highest-ranking probabilities to be the best. However, significant heterogeneity regarding diagnostic time window as well as small study effects precludes firm conclusion.
Collapse
Affiliation(s)
- Sun-Kyung Park
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Taeyoon Lim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Hyeyeon Cho
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Hyun-Kyu Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Ho-Jin Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Ji-Hyun Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Seokha Yoo
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jin-Tae Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Won Ho Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
| |
Collapse
|
21
|
Breit H, Bleck TP, Koffman L. Delirium in Cardiac and Cardiovascular Surgical Intensive Care Units. Semin Neurol 2021; 41:453-462. [PMID: 33851391 DOI: 10.1055/s-0041-1726283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Delirium is a common occurrence in cardiac and cardiovascular surgical intensive care units. Due to multiple confounding factors, this diagnosis remains challenging for medical professionals. Multiple theories exist regarding the pathophysiology of delirium, which include disruption of neurotransmitters as well as inflammation. Delirium has been associated with prolonged hospitalizations and an increase in mortality. Although there are widely used screening tools for delirium, none have been validated in this particular patient population. Limited treatments exist for delirium, so: both pharmacologic and nonpharmacologic preventative measures should be employed in this patient population.
Collapse
Affiliation(s)
- Hannah Breit
- Section of Neurocritical Care, Rush University Medical Center, Chicago, Illinois
| | - Thomas P Bleck
- Department of Neurology, Northwestern Memorial Hospital, Chicago, Illinois
| | - Lauren Koffman
- Section of Neurocritical Care, Rush University Medical Center, Chicago, Illinois
| |
Collapse
|
22
|
Lee JM, Cho YJ, Ahn EJ, Choi GJ, Kang H. Pharmacological strategies to prevent postoperative delirium: a systematic review and network meta-analysis. Anesth Pain Med (Seoul) 2021; 16:28-48. [PMID: 33445233 PMCID: PMC7861905 DOI: 10.17085/apm.20079] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 10/16/2020] [Indexed: 12/11/2022] Open
Abstract
Background Postoperative delirium (POD) is a condition of cerebral dysfunction and a common complication after surgery. This study aimed to compare and determine the relative efficacy of pharmacological interventions for preventing POD using a network meta-analysis. Methods We performed a systematic and comprehensive search to identify and analyze all randomized controlled trials until June 29, 2020, comparing two or more pharmacological interventions, including placebo, to prevent or reduce POD. The primary outcome was the incidence of POD. We performed a network meta-analysis and used the surface under the cumulative ranking curve (SUCRA) values and rankograms to present the hierarchy of the pharmacological interventions evaluated. Results According to the SUCRA value, the incidence of POD decreased in the following order: the combination of propofol and acetaminophen (86.1%), combination of ketamine and dexmedetomidine (86.0%), combination of diazepam, flunitrazepam, and pethidine (84.8%), and olanzapine (75.6%) after all types of anesthesia; combination of propofol and acetaminophen (85.9%), combination of ketamine and dexmedetomidine (83.2%), gabapentin (82.2%), and combination of diazepam, flunitrazepam, and pethidine (79.7%) after general anesthesia; and ketamine (87.1%), combination of propofol and acetaminophen (86.0%), and combination of dexmedetomidine and acetaminophen (66.3%) after cardiac surgery. However, only the dexmedetomidine group showed a lower incidence of POD than the control group after all types of anesthesia and after general anesthesia. Conclusions Dexmedetomidine reduced POD compared with the control group. The combination of propofol and acetaminophen and the combination of ketamine and dexmedetomidine seemed to be effective in preventing POD. However, further studies are needed to determine the optimal pharmacological intervention to prevent POD.
Collapse
Affiliation(s)
- Jun Mo Lee
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Ye Jin Cho
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Eun Jin Ahn
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Geun Joo Choi
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea.,The Institute of Evidence Based Clinical Medicine, Chung-Ang University, Seoul, Korea
| | - Hyun Kang
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea.,The Institute of Evidence Based Clinical Medicine, Chung-Ang University, Seoul, Korea
| |
Collapse
|
23
|
Egi M, Ogura H, Yatabe T, Atagi K, Inoue S, Iba T, Kakihana Y, Kawasaki T, Kushimoto S, Kuroda Y, Kotani J, Shime N, Taniguchi T, Tsuruta R, Doi K, Doi M, Nakada T, Nakane M, Fujishima S, Hosokawa N, Masuda Y, Matsushima A, Matsuda N, Yamakawa K, Hara Y, Sakuraya M, Ohshimo S, Aoki Y, Inada M, Umemura Y, Kawai Y, Kondo Y, Saito H, Taito S, Takeda C, Terayama T, Tohira H, Hashimoto H, Hayashida K, Hifumi T, Hirose T, Fukuda T, Fujii T, Miura S, Yasuda H, Abe T, Andoh K, Iida Y, Ishihara T, Ide K, Ito K, Ito Y, Inata Y, Utsunomiya A, Unoki T, Endo K, Ouchi A, Ozaki M, Ono S, Katsura M, Kawaguchi A, Kawamura Y, Kudo D, Kubo K, Kurahashi K, Sakuramoto H, Shimoyama A, Suzuki T, Sekine S, Sekino M, Takahashi N, Takahashi S, Takahashi H, Tagami T, Tajima G, Tatsumi H, Tani M, Tsuchiya A, Tsutsumi Y, Naito T, Nagae M, Nagasawa I, Nakamura K, Nishimura T, Nunomiya S, Norisue Y, Hashimoto S, Hasegawa D, Hatakeyama J, Hara N, Higashibeppu N, Furushima N, Furusono H, Matsuishi Y, Matsuyama T, Minematsu Y, Miyashita R, Miyatake Y, Moriyasu M, Yamada T, Yamada H, Yamamoto R, Yoshida T, Yoshida Y, Yoshimura J, Yotsumoto R, Yonekura H, Wada T, Watanabe E, Aoki M, Asai H, Abe T, Igarashi Y, Iguchi N, Ishikawa M, Ishimaru G, Isokawa S, Itakura R, Imahase H, Imura H, Irinoda T, Uehara K, Ushio N, Umegaki T, Egawa Y, Enomoto Y, Ota K, Ohchi Y, Ohno T, Ohbe H, Oka K, Okada N, Okada Y, Okano H, Okamoto J, Okuda H, Ogura T, Onodera Y, Oyama Y, Kainuma M, Kako E, Kashiura M, Kato H, Kanaya A, Kaneko T, Kanehata K, Kano K, Kawano H, Kikutani K, Kikuchi H, Kido T, Kimura S, Koami H, Kobashi D, Saiki I, Sakai M, Sakamoto A, Sato T, Shiga Y, Shimoto M, Shimoyama S, Shoko T, Sugawara Y, Sugita A, Suzuki S, Suzuki Y, Suhara T, Sonota K, Takauji S, Takashima K, Takahashi S, Takahashi Y, Takeshita J, Tanaka Y, Tampo A, Tsunoyama T, Tetsuhara K, Tokunaga K, Tomioka Y, Tomita K, Tominaga N, Toyosaki M, Toyoda Y, Naito H, Nagata I, Nagato T, Nakamura Y, Nakamori Y, Nahara I, Naraba H, Narita C, Nishioka N, Nishimura T, Nishiyama K, Nomura T, Haga T, Hagiwara Y, Hashimoto K, Hatachi T, Hamasaki T, Hayashi T, Hayashi M, Hayamizu A, Haraguchi G, Hirano Y, Fujii R, Fujita M, Fujimura N, Funakoshi H, Horiguchi M, Maki J, Masunaga N, Matsumura Y, Mayumi T, Minami K, Miyazaki Y, Miyamoto K, Murata T, Yanai M, Yano T, Yamada K, Yamada N, Yamamoto T, Yoshihiro S, Tanaka H, Nishida O. The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020). Acute Med Surg 2021; 8:e659. [PMID: 34484801 PMCID: PMC8390911 DOI: 10.1002/ams2.659] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members. As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.
Collapse
|
24
|
Burry LD, Cheng W, Williamson DR, Adhikari NK, Egerod I, Kanji S, Martin CM, Hutton B, Rose L. Pharmacological and non-pharmacological interventions to prevent delirium in critically ill patients: a systematic review and network meta-analysis. Intensive Care Med 2021; 47:943-960. [PMID: 34379152 PMCID: PMC8356549 DOI: 10.1007/s00134-021-06490-3] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 07/19/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE To compare the effects of prevention interventions on delirium occurrence in critically ill adults. METHODS MEDLINE, Embase, PsychINFO, CINAHL, Web of Science, Cochrane Library, Prospero, and WHO international clinical trial registry were searched from inception to April 8, 2021. Randomized controlled trials of pharmacological, sedation, non-pharmacological, and multi-component interventions enrolling adult critically ill patients were included. We performed conventional pairwise meta-analyses, NMA within Bayesian random effects modeling, and determined surface under the cumulative ranking curve values and mean rank. Reviewer pairs independently extracted data, assessed bias using Cochrane Risk of Bias tool and evidence certainty with GRADE. The primary outcome was delirium occurrence; secondary outcomes were durations of delirium and mechanical ventilation, length of stay, mortality, and adverse effects. RESULTS Eighty trials met eligibility criteria: 67.5% pharmacological, 31.3% non-pharmacological and 1.2% mixed pharmacological and non-pharmacological interventions. For delirium occurrence, 11 pharmacological interventions (38 trials, N = 11,993) connected to the evidence network. Compared to placebo, only dexmedetomidine (21/22 alpha2 agonist trials were dexmedetomidine) probably reduces delirium occurrence (odds ratio (OR) 0.43, 95% Credible Interval (CrI) 0.21-0.85; moderate certainty). Compared to benzodiazepines, dexmedetomidine (OR 0.21, 95% CrI 0.08-0.51; low certainty), sedation interruption (OR 0.21, 95% CrI 0.06-0.69; very low certainty), opioid plus benzodiazepine (OR 0.27, 95% CrI 0.10-0.76; very low certainty), and protocolized sedation (OR 0.27, 95% CrI 0.09-0.80; very low certainty) may reduce delirium occurrence but the evidence is very uncertain. Dexmedetomidine probably reduces ICU length of stay compared to placebo (Ratio of Means (RoM) 0.78, CrI 0.64-0.95; moderate certainty) and compared to antipsychotics (RoM 0.76, CrI 0.61-0.98; low certainty). Sedative interruption, protocolized sedation and opioids may reduce hospital length of stay compared to placebo, but the evidence is very uncertain. No intervention influenced mechanical ventilation duration, mortality, or arrhythmia. Single and multi-component non-pharmacological interventions did not connect to any evidence networks to allow for ranking and comparisons as planned; pairwise comparisons did not detect differences compared to standard care. CONCLUSION Compared to placebo and benzodiazepines, we found dexmedetomidine likely reduced the occurrence of delirium in critically ill adults. Compared to benzodiazepines, sedation-minimization strategies may also reduce delirium occurrence, but the evidence is uncertain.
Collapse
Affiliation(s)
- Lisa D. Burry
- grid.416166.20000 0004 0473 9881Department of Pharmacy, Mount Sinai Hospital, Room 18-377, 600 University Avenue, Toronto, ON M5G 1X5 Canada ,grid.416166.20000 0004 0473 9881Department Medicine, Mount Sinai Hospital, Toronto, Canada ,grid.17063.330000 0001 2157 2938Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Wei Cheng
- grid.47100.320000000419368710Department of Biostatistics, Yale School of Public Health, New Haven, CT USA
| | - David R. Williamson
- grid.14848.310000 0001 2292 3357Pharmacy Department, Université de Montréal, Montréal, Canada ,grid.414056.20000 0001 2160 7387Pharmacy Department and Research Centre, CIUSSS-NIM Hôpital du Sacré-Cœur de Montréal, Montréal, Canada
| | - Neill K. Adhikari
- grid.413104.30000 0000 9743 1587Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada ,grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada
| | - Ingrid Egerod
- grid.475435.4Intensive Care Unit 4131, Rigshospitalet, University of Copenhagen, Copenhagen Ø, Denmark
| | - Salmaan Kanji
- grid.412687.e0000 0000 9606 5108Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada ,grid.412687.e0000 0000 9606 5108Department of Pharmacy, The Ottawa Hospital, Ottawa, Canada
| | - Claudio M. Martin
- grid.412745.10000 0000 9132 1600Division of Critical Care, London Health Sciences Centre, London, Canada ,grid.39381.300000 0004 1936 8884Department of Medicine, The University of Western Ontario, London, Canada
| | - Brian Hutton
- grid.412687.e0000 0000 9606 5108Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada ,grid.28046.380000 0001 2182 2255School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Louise Rose
- grid.13097.3c0000 0001 2322 6764Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King’s College London, London, UK
| |
Collapse
|
25
|
Antipsychotic Drugs in Prevention of Postoperative Delirium-What Is Known in 2020? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17176069. [PMID: 32825428 PMCID: PMC7503241 DOI: 10.3390/ijerph17176069] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 08/11/2020] [Accepted: 08/18/2020] [Indexed: 12/14/2022]
Abstract
Delirium is one of the most frequently reported neuropsychiatric complications in the perioperative period, especially in the population of elderly patients who often suffer from numerous comorbidities undergoing extensive or urgent surgery. It can affect up to 80% of patients who require hospitalization in an intensive care setting postoperatively. Delirium increases mortality, morbidity, length of hospital stay, and cost of treatment. An episode of delirium in the acute phase may lower the general quality of life and increases the risk of cognitive decline long-term. Since pharmacological treatment of delirium is not highly effective, focus of research has shifted towards developing preventive strategies. We aimed to perform a review of the topic based on the most recent literature. We conclude that, based on the available data, it seems impossible to make strong recommendations for using antipsychotic drugs in prophylaxis. Further research should answer the question what, if any, benefit patients receive from the pharmacological prevention of delirium, and which agents should be used.
Collapse
|
26
|
Nakamura ZM, Deal AM, Rosenstein DL, Quillen LJ, Chien SA, Wood WA, Shea TC, Park EM. Design of a randomized placebo controlled trial of high dose intravenous thiamine for the prevention of delirium in allogeneic hematopoietic stem cell transplantation. Contemp Clin Trials 2020; 95:106076. [PMID: 32619524 DOI: 10.1016/j.cct.2020.106076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 06/15/2020] [Accepted: 06/18/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Delirium is a highly prevalent and preventable neuropsychiatric condition with major health consequences. Thiamine deficiency is a well-established cause of delirium in those with chronic, severe alcoholism, but there remains an underappreciation of its significance in non-alcoholic populations, including patients with cancer. Treatment of suspected thiamine-related mental status changes with high dose intravenous (IV) thiamine has preliminary evidence for improving a variety of cognitive symptoms in oncology inpatient settings but has never been studied for the prevention of delirium in any population. OBJECTIVES The primary objective of this clinical trial is to determine if high dose IV thiamine can prevent delirium in patients receiving allogeneic hematopoietic stem cell transplantation (HSCT) for treatment of cancer. Secondary objectives are to determine if thiamine status is predictive of delirium onset and if high dose IV thiamine can attenuate the deleterious impact of delirium on health-related quality of life (HRQOL), functional status, and long-term neuropsychiatric outcomes. METHODS In this phase II study, we are recruiting 60 patients undergoing allogeneic HSCT, randomizing them to treatment with high dose IV thiamine (n = 30) versus placebo (n = 30), and systematically evaluating all participants for delirium and related comorbidities. We use the Delirium Rating Scale to measure the severity and duration of delirium during hospitalization for HSCT. We obtain thiamine levels weekly during the transplantation hospitalization. We assess HRQOL, functional status, depression, post-traumatic stress symptoms, and cognitive function prior to and at one, three, and six months after transplantation.
Collapse
Affiliation(s)
- Zev M Nakamura
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Allison M Deal
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Donald L Rosenstein
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Laura J Quillen
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Stephanie A Chien
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - William A Wood
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Thomas C Shea
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Eliza M Park
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| |
Collapse
|
27
|
Hughes CG, Boncyk CS, Culley DJ, Fleisher LA, Leung JM, McDonagh DL, Gan TJ, McEvoy MD, Miller TE. American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Postoperative Delirium Prevention. Anesth Analg 2020; 130:1572-1590. [PMID: 32022748 DOI: 10.1213/ane.0000000000004641] [Citation(s) in RCA: 153] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Postoperative delirium is a geriatric syndrome that manifests as changes in cognition, attention, and levels of consciousness after surgery. It occurs in up to 50% of patients after major surgery and is associated with adverse outcomes, including increased hospital length of stay, higher cost of care, higher rates of institutionalization after discharge, and higher rates of readmission. Furthermore, it is associated with functional decline and cognitive impairments after surgery. As the age and medical complexity of our surgical population increases, practitioners need the skills to identify and prevent delirium in this high-risk population. Because delirium is a common and consequential postoperative complication, there has been an abundance of recent research focused on delirium, conducted by clinicians from a variety of specialties. There have also been several reviews and recommendation statements; however, these have not been based on robust evidence. The Sixth Perioperative Quality Initiative (POQI-6) consensus conference brought together a team of multidisciplinary experts to formally survey and evaluate the literature on postoperative delirium prevention and provide evidence-based recommendations using an iterative Delphi process and Grading of Recommendations Assessment, Development and Evaluation (GRADE) Criteria for evaluating biomedical literature.
Collapse
Affiliation(s)
- Christopher G Hughes
- From the Department of Anesthesiology, Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christina S Boncyk
- From the Department of Anesthesiology, Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Deborah J Culley
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lee A Fleisher
- Department of Anesthesiology & Critical Care, Penn Center for Perioperative Outcomes Research and Transformation, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jacqueline M Leung
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California
| | - David L McDonagh
- Departments of Anesthesiology and Pain Management, Neurological Surgery, and Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Tong J Gan
- Department of Anesthesiology, Stony Brook University Renaissance School of Medicine, Stony Brook, New York
| | - Matthew D McEvoy
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | |
Collapse
|
28
|
Pieri M, De Simone A, Rose S, De Domenico P, Lembo R, Denaro G, Landoni G, Monaco F. Trials Focusing on Prevention and Treatment of Delirium After Cardiac Surgery: A systematic Review of Randomized Evidence. J Cardiothorac Vasc Anesth 2020; 34:1641-1654. [DOI: 10.1053/j.jvca.2019.09.028] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 09/15/2019] [Accepted: 09/17/2019] [Indexed: 11/11/2022]
|
29
|
Scicutella A. The pharmacotherapeutic management of postoperative delirium: an expert update. Expert Opin Pharmacother 2020; 21:905-916. [PMID: 32156151 DOI: 10.1080/14656566.2020.1738388] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Postoperative delirium is a common sequela in older adults in the peri-operative period leading to poor outcomes with a complex pathophysiology which has led to a variety of different pharmacologic agents employed in attempts to prevent and treat this syndrome. No pharmacologic agent has been approved to treat this disorder, but this review discusses the pharmacologic strategies which have been tried based on the hypotheses of the causation of the syndrome including neurotransmitter imbalance, inflammation, and oxidative stress. AREAS COVERED Systematic reviews and meta-analyses of randomized clinical trials (RCTs) were included via search of electronic databases specifically for the terms postoperative delirium and pharmacologic treatments. With this approach, the recurrent topics of analgesia and sedation, antipsychotics, acetylcholinesterase inhibitors (AchE-Is), inflammation, and melatonin were emphasized and provided the outline for this review. EXPERT OPINION Research evidence does not support any particular agent in any of the pharmacologic classes reviewed. However, there is some potential benefit with dexmedetomidine, melatonin, and the monitoring of anesthetic agents all of which need further clinical trials to validate these conclusions. Exploration of ways to improve studies and the application of novel pharmacologic agents may offer future benefit.
Collapse
Affiliation(s)
- Angela Scicutella
- Department of Psychiatry, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell , Hempstead, NY, USA.,Psychiatry, SUNY Health Science Center at Brooklyn - Behavioral Health , Brooklyn, NY, USA
| |
Collapse
|
30
|
Abstract
PURPOSE OF REVIEW The present review aims to describe the clinical impact and assessment tools capable of identifying delirium in cardiac arrest survivors and providing strategies aimed at preventing and treating delirium. RECENT FINDINGS Patient factors leading to a cardiac arrest, initial resuscitation efforts, and postresuscitation management all influence the potential for recovery and the risk for development of delirium. Data suggest that delirium in cardiac arrest survivors is an independent risk factor for morbidity and mortality. Recognizing delirium in postcardiac arrest patients can be challenging; however, detection is not only achievable, but important as it may aid in predicting adverse outcomes. Serial neurologic examinations and delirium assessments, targeting light sedation when possible, limiting psychoactive medications, and initiating patient care bundles are important care aspects for not only allowing early identification of primary and secondary brain injury, but in improving patient morbidity and mortality. SUMMARY Developing delirium after cardiac arrest is associated with increased morbidity and mortality. The importance of addressing modifiable risk factors, recognizing symptoms early, and initiating coordinated treatment strategies can help to improve outcomes within this high risk population.
Collapse
|
31
|
Aripiprazole for prevention of delirium in the neurosurgical intensive care unit: a double-blind, randomized, placebo-controlled study. Eur J Clin Pharmacol 2020; 76:491-499. [PMID: 31900543 DOI: 10.1007/s00228-019-02802-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 11/20/2019] [Indexed: 01/15/2023]
Abstract
PURPOSE Delirium is reported in over 50% of critically ill ICU patients, and is associated with increased mortality and long-term cognitive consequences. Prevention and early management of delirium are essential components of ICU care. However, pharmacological interventions have not been effective in delirium prevention. This study investigated the effect of aripiprazole in the prevention of delirium in a neurosurgical intensive care unit. METHODS In this prospective, randomized placebo-controlled small clinical trial, 53 patients, 18 to 80 years old, were randomized to receive enteric aripiprazole (15 mg) or placebo for up to 7 days. Delirium, detected by the Confusion Assessment Method-ICU, ICU events, laboratory studies, aripiprazole safety, time to delirium onset, delirium-free days, delirium prevalence during follow-up and ICU length of stay were recorded. RESULTS Forty patients with similar baseline characteristics, including age, sex, neurosurgery types and APACHE II scores, completed the study. Delirium incidence and the mean days to its onset were 20% vs. 55% (p = 0.022) and 2.17 ± 0.41 vs. 2.09 ± 0.30 (p = 0.076) in the aripiprazole and placebo groups, respectively. The mean number of delirium-free days were: 5.6 (95%CI, 4.6-6.5) and 4.3 (95%CI, 3.2-5.4), in aripiprazole and placebo groups, respectively (p = 0.111). The prevalence of delirium during the follow-up was significantly lower in the aripiprazole group (p = 0.018). Serious aripiprazole adverse reactions were not observed. CONCLUSIONS Aripiprazole can reduce the incidence of delirium in the neurosurgical ICU. Studies with larger sample size in diverse ICU settings and longer follow-up are needed to confirm our findings.
Collapse
|
32
|
Kim Y, Kim HS, Park JS, Cho YJ, Yoon HI, Lee SM, Lee JH, Lee CT, Lee YJ. Efficacy of Low-Dose Prophylactic Quetiapine on Delirium Prevention in Critically Ill Patients: A Prospective, Randomized, Double-Blind, Placebo-Controlled Study. J Clin Med 2019; 9:jcm9010069. [PMID: 31892105 PMCID: PMC7019813 DOI: 10.3390/jcm9010069] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 12/19/2019] [Accepted: 12/25/2019] [Indexed: 12/02/2022] Open
Abstract
Purpose: To evaluate the efficacy of short-term low-dose quetiapine for delirium prevention in critically ill patients. Methods: In this prospective, a single-center, randomized, double-blind, placebo-controlled trial, adult patients who were admitted from July 2015 to July 2017 to a medical intensive care unit (ICU) of a tertiary teaching hospital affiliated to Seoul National University were included. Quetiapine (12.5 mg or 25 mg oral at night; N = 16) or placebo (N = 21) was administered according to randomization until ICU discharge or the 10th ICU day. The primary endpoint was the incidence of delirium within the first 10 ICU days. Secondary endpoints included the rate of positive Confusion Assessment Method for the ICU (CAM-ICU) (the number of positive CAM-ICU counts/the number of total CAM-ICU counts), delirium duration, successful extubation, and overall mortality. Result: The incidence of delirium during the 10 days after ICU admission was 46.7% (7/15) in the quetiapine group and 55.0% (11/20) in the placebo group (p = 0.442). In the quetiapine group, the rate of positive CAM-ICU was significantly lower than in the placebo group (14.4% vs. 37.4%, p = 0.048), delirium duration during the study period was significantly shorter (0.28 day vs. 1.83 days, p = 0.018), and more patients in the quetiapine than in the placebo group were weaned from mechanical ventilation successfully (84.6% vs. 47.1%, p = 0.040). Conclusions: Our study suggests that prophylactic use of low-dose quetiapine could be helpful for preventing delirium in critically ill patients. A further large-scale prospective study is needed.
Collapse
Affiliation(s)
- Youlim Kim
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Chuncheon Sacred Heart Hospital, Chuncheon-si 24253, Gangwon-Do, Korea;
| | - Hyung-Sook Kim
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam-si 13620, Gyeonggi-Do, Korea;
| | - Jong Sun Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-Si 13620, Gyeonggi-Do, Korea; (J.S.P.); (Y.-J.C.); (H.I.Y.); (J.H.L.); (C.-T.L.)
| | - Young-Jae Cho
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-Si 13620, Gyeonggi-Do, Korea; (J.S.P.); (Y.-J.C.); (H.I.Y.); (J.H.L.); (C.-T.L.)
| | - Ho Il Yoon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-Si 13620, Gyeonggi-Do, Korea; (J.S.P.); (Y.-J.C.); (H.I.Y.); (J.H.L.); (C.-T.L.)
| | - Sang-Min Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul 03080, Korea;
| | - Jae Ho Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-Si 13620, Gyeonggi-Do, Korea; (J.S.P.); (Y.-J.C.); (H.I.Y.); (J.H.L.); (C.-T.L.)
| | - Choon-Taek Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-Si 13620, Gyeonggi-Do, Korea; (J.S.P.); (Y.-J.C.); (H.I.Y.); (J.H.L.); (C.-T.L.)
| | - Yeon Joo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-Si 13620, Gyeonggi-Do, Korea; (J.S.P.); (Y.-J.C.); (H.I.Y.); (J.H.L.); (C.-T.L.)
- Correspondence: ; Tel.: +82-031-787-7082; Fax: +82-031-787-6137
| |
Collapse
|
33
|
Stollings JL, Devlin JW, Pun BT, Puntillo KA, Kelly T, Hargett KD, Morse A, Esbrook CL, Engel HJ, Perme C, Barnes-Daly MA, Posa PJ, Aldrich JM, Barr J, Carson SS, Schweickert WD, Byrum DG, Harmon L, Ely EW, Balas MC. Implementing the ABCDEF Bundle: Top 8 Questions Asked During the ICU Liberation ABCDEF Bundle Improvement Collaborative. Crit Care Nurse 2019; 39:36-45. [PMID: 30710035 DOI: 10.4037/ccn2019981] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
The ABCDEF bundle (A, assess, prevent, and manage pain; B, both spontaneous awakening and spontaneous breathing trials; C, choice of analgesic and sedation; D, delirium: assess, prevent, and manage; E, early mobility and exercise; and F, family engagement and empowerment) improves intensive care unit patient-centered outcomes and promotes interprofessional teamwork and collaboration. The Society of Critical Care Medicine recently completed the ICU Liberation ABCDEF Bundle Improvement Collaborative, a 20-month, multicenter, national quality improvement initiative that formalized dissemination and implementation strategies to promote effective adoption of the ABCDEF bundle. The purpose of this article is to describe 8 of the most frequently asked questions during the Collaborative and to provide practical advice from leading experts to other institutions implementing the ABCDEF bundle.
Collapse
Affiliation(s)
- Joanna L Stollings
- Joanna Stollings is a clinical pharmacist, Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - John W Devlin
- John Devlin is Professor of Pharmacy, Northeastern University, and a clinical scientist, Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Brenda T Pun
- Joanna Stollings is a clinical pharmacist, Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kathleen A Puntillo
- Kathleen Puntillo is a professor of nursing emeritus, Department of Physiological Nursing, School of Nursing, University of California, San Francisco
| | - Tamra Kelly
- Tamra Kelly is a respiratory therapist, Sutter Health, Sacramento, California
| | - Ken D Hargett
- Ken Hargett is a respiratory therapist, Houston Methodist Hospital, Houston, Texas
| | | | - Cheryl L Esbrook
- Cheryl Esbrook is an occupational therapist, University of Chicago Medicine, Chicago, Illinois
| | - Heidi J Engel
- Heidi Engel is a physical therapist, Department of Rehabilitative Services, University of California, San Francisco
| | - Christiane Perme
- Christiane Perme is a physical therapist, Houston Methodist Hospital
| | - Mary Ann Barnes-Daly
- Mary Ann Barnes-Daly is a clinical performance improvement consultant, Sutter Health
| | - Patricia J Posa
- Patricia Posa is a population health clinical integration leader, Saint Joseph Mercy Health System, Ann Arbor, Michigan
| | - J Matthew Aldrich
- J. Matthew Aldrich is the Medical Director of Critical Care Medicine and an associate clinical professor, University of San Francisco, San Francisco
| | - Juliana Barr
- Juliana Barr is a staff intensivist and anesthesiologist, VA Palo Alto Health Care System, Palo Alto, California, and an associate professor, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Shannon S Carson
- Shannon Carson is a critical care pulmonologist, University of North Carolina School of Medicine, Chapel Hill
| | - William D Schweickert
- William Schweickert is an associate professor of clinical medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Diane G Byrum
- Diane Byrum is a quality implementation consultant, Innovative Solutions for Healthcare Education, LLC, Charlotte, North Carolina
| | - Lori Harmon
- Lori Harmon is director of quality, Society of Critical Care Medicine, Mount Prospect, Illinois
| | - E Wesley Ely
- E. Wesley Ely is a professor of medicine, Vanderbilt University School of Medicine, and associate director, VA Tennessee Valley Geriatric Research Education Clinical Center, Nashville, Tennessee
| | - Michele C Balas
- Michele Balas is an associate professor, Center of Excellence in Critical and Complex Care, College of Nursing, and a nurse scientist, Wexner Medical Center, The Ohio State University, Columbus
| |
Collapse
|
34
|
Affiliation(s)
- Robyn P Thom
- The Department of Psychiatry, Brigham and Women's Hospital, Boston
| | | | - Melissa Bui
- The Department of Psychiatry, Brigham and Women's Hospital, Boston
| | | |
Collapse
|
35
|
Oh ES, Needham DM, Nikooie R, Wilson LM, Zhang A, Robinson KA, Neufeld KJ. Antipsychotics for Preventing Delirium in Hospitalized Adults: A Systematic Review. Ann Intern Med 2019; 171:474-484. [PMID: 31476766 DOI: 10.7326/m19-1859] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Delirium is an acute disorder marked by impairments in attention and cognition, caused by an underlying medical problem. Antipsychotics are used to prevent delirium, but their benefits and harms are unclear. PURPOSE To conduct a systematic review evaluating the benefits and harms of antipsychotics for prevention of delirium in adults. DATA SOURCES PubMed, Embase, CENTRAL, CINAHL, and PsycINFO from inception through July 2019, without restrictions based on study setting, language of publication, or length of follow-up. STUDY SELECTION Randomized, controlled trials (RCTs) that compared an antipsychotic with placebo or another antipsychotic, and prospective observational studies with a comparison group. DATA EXTRACTION One reviewer extracted data and graded the strength of the evidence, and a second reviewer confirmed the data. Two reviewers independently assessed the risk of bias. DATA SYNTHESIS A total of 14 RCTs were included. There were no differences in delirium incidence or duration, hospital length of stay (high strength of evidence [SOE]), and mortality between haloperidol and placebo used for delirium prevention. Little to no evidence was found to determine the effect of haloperidol on cognitive function, delirium severity (insufficient SOE), inappropriate continuation, and sedation (insufficient SOE). There is limited evidence that second-generation antipsychotics may lower delirium incidence in the postoperative setting. There is little evidence that short-term use of antipsychotics was associated with neurologic harms. In some of the trials, potentially harmful cardiac effects occurred more frequently with antipsychotic use. LIMITATIONS There was significant heterogeneity in antipsychotic dosing, route of antipsychotic administration, assessment of outcomes, and adverse events. There were insufficient or no data available to draw conclusions for many of the outcomes. CONCLUSION Current evidence does not support routine use of haloperidol or second-generation antipsychotics for prevention of delirium. There is limited evidence that second-generation antipsychotics may lower the incidence of delirium in postoperative patients, but more research is needed. Future trials should use standardized outcome measures. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality. (PROSPERO: CRD42018109552).
Collapse
Affiliation(s)
- Esther S Oh
- Johns Hopkins University School of Medicine, Baltimore, Maryland (E.S.O., D.M.N., R.N., K.A.R., K.J.N.)
| | - Dale M Needham
- Johns Hopkins University School of Medicine, Baltimore, Maryland (E.S.O., D.M.N., R.N., K.A.R., K.J.N.)
| | - Roozbeh Nikooie
- Johns Hopkins University School of Medicine, Baltimore, Maryland (E.S.O., D.M.N., R.N., K.A.R., K.J.N.)
| | - Lisa M Wilson
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (L.M.W., A.Z.)
| | - Allen Zhang
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (L.M.W., A.Z.)
| | - Karen A Robinson
- Johns Hopkins University School of Medicine, Baltimore, Maryland (E.S.O., D.M.N., R.N., K.A.R., K.J.N.)
| | - Karin J Neufeld
- Johns Hopkins University School of Medicine, Baltimore, Maryland (E.S.O., D.M.N., R.N., K.A.R., K.J.N.)
| |
Collapse
|
36
|
Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Crit Care Med 2019; 46:e825-e873. [PMID: 30113379 DOI: 10.1097/ccm.0000000000003299] [Citation(s) in RCA: 1802] [Impact Index Per Article: 360.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To update and expand the 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU. DESIGN Thirty-two international experts, four methodologists, and four critical illness survivors met virtually at least monthly. All section groups gathered face-to-face at annual Society of Critical Care Medicine congresses; virtual connections included those unable to attend. A formal conflict of interest policy was developed a priori and enforced throughout the process. Teleconferences and electronic discussions among subgroups and whole panel were part of the guidelines' development. A general content review was completed face-to-face by all panel members in January 2017. METHODS Content experts, methodologists, and ICU survivors were represented in each of the five sections of the guidelines: Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption). Each section created Population, Intervention, Comparison, and Outcome, and nonactionable, descriptive questions based on perceived clinical relevance. The guideline group then voted their ranking, and patients prioritized their importance. For each Population, Intervention, Comparison, and Outcome question, sections searched the best available evidence, determined its quality, and formulated recommendations as "strong," "conditional," or "good" practice statements based on Grading of Recommendations Assessment, Development and Evaluation principles. In addition, evidence gaps and clinical caveats were explicitly identified. RESULTS The Pain, Agitation/Sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) panel issued 37 recommendations (three strong and 34 conditional), two good practice statements, and 32 ungraded, nonactionable statements. Three questions from the patient-centered prioritized question list remained without recommendation. CONCLUSIONS We found substantial agreement among a large, interdisciplinary cohort of international experts regarding evidence supporting recommendations, and the remaining literature gaps in the assessment, prevention, and treatment of Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) in critically ill adults. Highlighting this evidence and the research needs will improve Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) management and provide the foundation for improved outcomes and science in this vulnerable population.
Collapse
|
37
|
Smithburger PL, Patel MK. Pharmacologic Considerations Surrounding Sedation, Delirium, and Sleep in Critically Ill Adults: A Narrative Review. J Pharm Pract 2019; 32:271-291. [PMID: 30955461 DOI: 10.1177/0897190019840120] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Agitation, delirium, and sleep dysfunction in the intensive care unit (ICU) are common occurrences that result in negative patient outcomes. With the recent publication of the 2018 Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (PAD-IS), several areas are of particular interest due to emerging literature or conflicting results of research. OBJECTIVE To highlight areas where emerging literature or variable study results exist and to provide the clinician with recommendations regarding patient management. METHODS The 2018 PAD-IS guidelines were reviewed, and areas of emerging literature or lack of consensus of included investigations surrounding pharmacologic management of sedation, delirium, and sleep in the ICU were identified. A review and appraisal of the literature was conducted specifically to address the identified areas. Prospective, randomized trials were included in this narrative review. RESULTS Four areas with emerging data or conflicting evidence were identified and included: use of propofol or dexmedetomidine for sedation, pharmacologic prevention of delirium, treatment of delirium, and pharmacologic strategies to improve sleep. CONCLUSION A comprehensive approach to the prevention and management of delirium, sedation, and sleep in the ICU is necessary to optimize patient outcomes.
Collapse
Affiliation(s)
- Pamela L Smithburger
- 1 Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Mona K Patel
- 2 Department of Pharmacy, Surgical Intensive Care Unit, New York-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| |
Collapse
|
38
|
Zayed Y, Barbarawi M, Kheiri B, Banifadel M, Haykal T, Chahine A, Rashdan L, Aburahma A, Bachuwa G, Seedahmed E. Haloperidol for the management of delirium in adult intensive care unit patients: A systematic review and meta-analysis of randomized controlled trials. J Crit Care 2019; 50:280-286. [DOI: 10.1016/j.jcrc.2019.01.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Revised: 12/10/2018] [Accepted: 01/11/2019] [Indexed: 12/23/2022]
|
39
|
Pharmacological Prevention of Postoperative Delirium: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2019; 2019:9607129. [PMID: 31001357 PMCID: PMC6437723 DOI: 10.1155/2019/9607129] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 03/04/2019] [Indexed: 02/05/2023]
Abstract
Background The high prevalence of delirium among postoperative patients has increased morbidity and mortality. The kind of drug that can effectively reduce the incidence of delirium has become the focus of discussion in recent years. However, a consensus in this respect has yet to be reached. Methods Randomized controlled trials (RCTs) were retrieved from the PubMed, Cochrane Library, ClinicalTrials.gov, and Embase databases from their inception through October 12, 2018. We included RCTs of pharmacological prevention for postoperative delirium in adults (at least 18 years), and the Cochrane risk of bias tool was used to evaluate the methodological quality of trials. The primary outcomes were the risk ratios (RRs) of incidence of postoperative delirium, and the secondary outcomes were the RRs of mortality and adverse events in the intervention and control groups. Results Thirty-eight trials, which comprised 20302 patients and 18 different drugs, were included in the analysis. Of the 38 studies, 17 were rated as low risk with respect to methodological quality. Dexmedetomidine administration (RR 0.58, 95%CI 0.44-0.76, P<0.01) was associated with a significantly lower incidence of postoperative delirium than the control conditions. However, the findings from the studies with a low risk of bias did not show a significant difference in this beneficial effect (RR 0.64, 95%CI 0.39-1.04, P=0.07). The antipsychotic drugs olanzapine (RR 0.44, 95%CI 0.30- 0.65, P<0.01) and risperidone (RR 0.42, 95%CI 0.19-0.92, P=0.03) had promising effects, but there was a lack of sufficient evidence to obtain a definitive conclusion. The beneficial effect of other drugs, including haloperidol, methylprednisolone, dexamethasone, gabapentin, ketamine, cyproheptadine, donepezil, hypertonic saline, melatonin, nimodipine, ondansetron, pregabalin, rivastigmine, TJ-54, and tryptophan, was not proven on the basis of present evidence. Conclusion Among the pharmacological prophylactic measures for postoperative delirium, dexmedetomidine, olanzapine, and risperidone showed higher efficacy than other drugs. However, more high-quality evidence is needed to confirm these results.
Collapse
|
40
|
Tao R, Wang XW, Pang LJ, Cheng J, Wang YM, Gao GQ, Liu Y, Wang C. Pharmacologic prevention of postoperative delirium after on-pump cardiac surgery: A meta-analysis of randomized trials. Medicine (Baltimore) 2018; 97:e12771. [PMID: 30412068 PMCID: PMC6221693 DOI: 10.1097/md.0000000000012771] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Postoperative delirium is a prevalent and disabling mental disorder in patients undergoing on-pump cardiac surgery. There is some evidence that the use of pharmacological interventions may reduce the risk of developing of postoperative delirium. Therefore, the aim of this meta-analysis was to determine the effect of pharmacologic agents for the prevention postoperative delirium after cardiac surgery. METHODS Randomized controlled trials (RCTs) were identified through a systematic literature search of electronic databases and article references up to October 2016. End points included incidence of postoperative delirium, severity of postoperative delirium, cognitive disturbances of postoperative delirium, duration of postoperative delirium, length of stay in intensive care unit (ICU) and hospital, and short-term mortality. RESULTS A total of 14 RCTs with an aggregate of 14,139 patients were included. The results of the present meta-analysis show that pharmacologic agents significantly decrease postoperative delirium [relative risk (RR), 0.83; 95% confidence interval (95% CI), 0.75-0.91, P < .00001] and duration of postoperative delirium (RR = -0.37, 95% CI = -0.47 to -0.27, P < .00001) after on-pump cardiac surgery. In addition, subgroup analysis shows that dexamethasone and dexamethasone were associated with a trend toward a reduction in postoperative delirium (RR, 0.45; 95% CI, 0.30-0.66, P < .0001; RR, 0.80; 95% CI, 0.68-0.93, P = .003, respectively). However, our results fail to support the assumption that pharmacologic prophylaxis is associated with a positively reduction in short-term mortality, length of ICU, or hospital stay. CONCLUSION This meta-analysis suggests that the perioperative use of pharmacologic agents can prevent postoperative delirium development in patients undergoing cardiac surgery. However, there remain important gaps in the evidence base on a few small studies with multiple limitations. Further large-scale, high-quality RCTs are needed in this area.
Collapse
Affiliation(s)
- Rui Tao
- Department of Substance-Related Disorders, Division of Psychiatry, Hefei No.4 People's Hospital, Anhui Mental Health Center
- Mental Health Clinical College of Anhui Medical University, Hefei
| | - Xiao-Wen Wang
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Liang-Jun Pang
- Department of Substance-Related Disorders, Division of Psychiatry, Hefei No.4 People's Hospital, Anhui Mental Health Center
- Mental Health Clinical College of Anhui Medical University, Hefei
| | - Jun Cheng
- Department of Substance-Related Disorders, Division of Psychiatry, Hefei No.4 People's Hospital, Anhui Mental Health Center
- Mental Health Clinical College of Anhui Medical University, Hefei
| | - Yong-Mei Wang
- Department of Substance-Related Disorders, Division of Psychiatry, Hefei No.4 People's Hospital, Anhui Mental Health Center
- Mental Health Clinical College of Anhui Medical University, Hefei
| | - Guo-Qing Gao
- Department of Substance-Related Disorders, Division of Psychiatry, Hefei No.4 People's Hospital, Anhui Mental Health Center
| | - Yu Liu
- Department of Substance-Related Disorders, Division of Psychiatry, Hefei No.4 People's Hospital, Anhui Mental Health Center
| | - Chao Wang
- Department of Substance-Related Disorders, Division of Psychiatry, Hefei No.4 People's Hospital, Anhui Mental Health Center
- Mental Health Clinical College of Anhui Medical University, Hefei
| |
Collapse
|
41
|
Mechanistically, How Does Postoperative Delirium Differ From Critical Illness Delirium? Crit Care Med 2018; 44:e1019-20. [PMID: 27635520 DOI: 10.1097/ccm.0000000000001890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
42
|
Ogawa A, Okumura Y, Fujisawa D, Takei H, Sasaki C, Hirai K, Kanno Y, Higa K, Ichida Y, Sekimoto A, Asanuma C. Quality of care in hospitalized cancer patients before and after implementation of a systematic prevention program for delirium: the DELTA exploratory trial. Support Care Cancer 2018; 27:557-565. [DOI: 10.1007/s00520-018-4341-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 07/04/2018] [Indexed: 10/28/2022]
|
43
|
Safavynia SA, Arora S, Pryor KO, García PS. An Update on Postoperative Delirium: Clinical Features,
Neuropathogenesis, and Perioperative Management. CURRENT ANESTHESIOLOGY REPORTS 2018. [DOI: 10.1007/s40140-018-0282-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
|
44
|
|
45
|
Torbic H, Duggal A. Antipsychotics, Delirium, and Acute Respiratory Distress Syndrome: What Is the Link? Pharmacotherapy 2018; 38:462-469. [PMID: 29444340 DOI: 10.1002/phar.2093] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Acute respiratory distress syndrome (ARDS) is an acute inflammatory process that impairs the ability of the lungs to oxygenate and ultimately leads to respiratory failure. Patients who develop ARDS often have prolonged and complicated hospital courses putting them at risk for intensive care unit (ICU) delirium. Patients with ICU delirium often need chemical sedation, mechanical ventilation, prolonged duration of ICU and hospital stays, and they experience long-term cognitive impairment and increased mortality. In a patient with ARDS, ICU delirium further complicates the hospital course and increases the risk of morbidity and mortality. Antipsychotics are prescribed to decrease the severity and duration of ICU delirium, thus potentially decreasing their risk of morbidity and mortality. However, antipsychotics are associated with many adverse effects including respiratory failure. Given the long-term sequelae associated with the development of ICU delirium and the risks associated with antipsychotic use, clinicians must weigh the risks and benefits of antipsychotic use. This review investigates the interrelationship between ARDS, delirium, and antipsychotic use. In addition to discussing relevant studies evaluating antipsychotics for the prevention and treatment of delirium, we investigate safety concerns with the use of antipsychotics, especially as they relate to ARDS. Using the data compiled in this review, clinicians can make an informed decision about the use of antipsychotics for the prevention or treatment of delirium, with special consideration for their patients with ARDS. Future studies are needed to critically evaluate antipsychotic timing, dose, and duration for the prevention and treatment of ICU delirium and specifically evaluate the impact in special populations, particularly patients with ARDS.
Collapse
Affiliation(s)
- Heather Torbic
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio
| | - Abhijit Duggal
- Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
46
|
Intensive Care Unit Delirium: A Review of Diagnosis, Prevention, and Treatment. Anesthesiology 2018; 125:1229-1241. [PMID: 27748656 DOI: 10.1097/aln.0000000000001378] [Citation(s) in RCA: 107] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
|
47
|
|
48
|
Maldonado JR. Acute Brain Failure: Pathophysiology, Diagnosis, Management, and Sequelae of Delirium. Crit Care Clin 2017; 33:461-519. [PMID: 28601132 DOI: 10.1016/j.ccc.2017.03.013] [Citation(s) in RCA: 172] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Delirium is the most common psychiatric syndrome found in the general hospital setting, with an incidence as high as 87% in the acute care setting. Delirium is a neurobehavioral syndrome caused by the transient disruption of normal neuronal activity secondary to systemic disturbances. The development of delirium is associated with increased morbidity, mortality, cost of care, hospital-acquired complications, placement in specialized intermediate and long-term care facilities, slower rate of recovery, poor functional and cognitive recovery, decreased quality of life, and prolonged hospital stays. This article discusses the epidemiology, known etiological factors, presentation and characteristics, prevention, management, and impact of delirium.
Collapse
Affiliation(s)
- José R Maldonado
- Psychosomatic Medicine Service, Emergency Psychiatry Service, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Suite 2317, Stanford, CA 94305-5718, USA.
| |
Collapse
|
49
|
Hawkins WA, Phan SV, Campbell SL. Effect of various antipsychotic regimens on incidence of delirium in critically ill adults. J Crit Care 2017; 44:289-293. [PMID: 29223744 DOI: 10.1016/j.jcrc.2017.11.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 11/24/2017] [Accepted: 11/27/2017] [Indexed: 11/19/2022]
Abstract
PURPOSE Delirium is common during critical illness but it is unknown whether the choice of antipsychotic or dosing strategy impacts delirium outcomes. We evaluated the incidence of delirium in critically ill adults receiving different antipsychotic regimens. MATERIALS AND METHODS Single center retrospective cohort study of adult patients admitted to the intensive care unit (ICU). Patients who received haloperidol or quetiapine and scored negative on the Confusion Assessment Method for the ICU (CAM-ICU) prior to initiation were included. Patients were divided into four groups based on dosing schedule of the antipsychotic. The primary outcomes were the incidence and duration of delirium. RESULTS Eighty patients were included in the study. Patients received scheduled quetiapine (35%), PRN haloperidol (55%), and PRN quetiapine (10%). The overall incidence of delirium in patients receiving antipsychotics was 39%. The incidence of delirium was similar between the scheduled quetiapine group, PRN haloperidol and PRN quetiapine groups, at 39%, 50% and 36%, respectively (p=0.79). The scheduled quetiapine group had a longer time to first episode of delirium, but this was not statistically significant (11days vs 4.8days vs 5.6days; p=0.20). CONCLUSIONS There was no difference in incidence or duration of delirium between quetiapine and haloperidol regimens.
Collapse
Affiliation(s)
- W Anthony Hawkins
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, 1000 Jefferson Street, Albany, GA, USA; Department of Pharmacology and Toxicology, Medical College of Georgia at Augusta University, 1000 Jefferson Street, Albany, GA, USA.
| | - Stephanie V Phan
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, 1000 Jefferson Street, Albany, GA, USA.
| | - Stacey L Campbell
- Department of Pharmaceutical Services, Emory University Hospital, 1364 Clifton Road NE, Atlanta, GA, United States; Department of Pharmacy Practice, Mercer University College of Pharmacy, 3001 Mercer University Drive, Atlanta, GA, USA.
| |
Collapse
|
50
|
Gaudry S, Sztrymf B, Sonneville R, Megarbane B, Van Der Meersch G, Vodovar D, Cohen Y, Ricard JD, Hajage D, Salomon L, Dreyfuss D. Loxapine to control agitation during weaning from mechanical ventilation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:235. [PMID: 28877705 PMCID: PMC5586048 DOI: 10.1186/s13054-017-1822-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 08/22/2017] [Indexed: 02/07/2023]
Abstract
Background Weaning from mechanical ventilation (MV) may be impeded by the occurrence of agitation. Loxapine has the ability to control agitation without affecting spontaneous ventilation. The aim of this study was to establish whether loxapine would reduce MV weaning duration in agitated patients. Methods We performed a multicentre, double-blind, placebo-controlled, parallel group, randomised trial. Patients who were potential candidates for weaning but exhibited agitation (Richmond Agitation-Sedation Scale score ≥ 2) after sedation withdrawal were randomly assigned to receive either loxapine or placebo. In case of severe agitation, conventional sedation was immediately resumed. The primary endpoint was the time between first administration of loxapine or placebo and successful extubation. Results The trial was discontinued after 102 patients were enrolled because of an insufficient inclusion rate. Median times to successful extubation were 3.2 days in the loxapine group and 5 days in the placebo group (relative risk 1.2, 95% CI 0.75–1.88, p = 0.45). During the first 24 h, sedation was more frequently resumed in the placebo group (44% vs 17%, p = 0.01). Conclusions In this prematurely stopped trial, loxapine did not significantly shorten weaning from MV. However, loxapine reduced the need for resuming sedation. Trial registration Clinicaltrials.gov, NCT01193816. Registered on 26 August 2010.
Collapse
Affiliation(s)
- Stéphane Gaudry
- Service de Réanimation Médico-Chirurgicale, Hôpital Louis Mourier, Assistance Publique - Hôpitaux de Paris, F-92700, Colombes, France.,Epidémiologie Clinique et Évaluation Économique Appliqué aux Populations Vulnérables (ECEVE), UMR 1123, Université Paris Diderot, Sorbonne Paris Cité, F-75018, Paris, France
| | - Benjamin Sztrymf
- Service de Réanimation Polyvalente et surveillance continue, Hôpital Antoine Béclère, Assistance Publique - Hôpitaux de Paris, F-92140, Clamart, France.,INSERM U999, Université Paris Sud, F-92060, Le Plessis Robinson, France
| | - Romain Sonneville
- Service de Réanimation Médicale et maladies infectieuses, Hôpital Bichat, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Bruno Megarbane
- Service de Réanimation Médicale, Hôpital Lariboisière, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Guillaume Van Der Meersch
- Service de Réanimation Médico-Chirurgicale, Hôpital Avicenne, Assistance Publique - Hôpitaux de Paris, Bobigny, France
| | - Dominique Vodovar
- Service de Réanimation Médicale, Hôpital Lariboisière, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Yves Cohen
- Service de Réanimation Médico-Chirurgicale, Hôpital Avicenne, Assistance Publique - Hôpitaux de Paris, Bobigny, France
| | - Jean-Damien Ricard
- Service de Réanimation Médico-Chirurgicale, Hôpital Louis Mourier, Assistance Publique - Hôpitaux de Paris, F-92700, Colombes, France.,Infection, Antimicrobials, Modelling, Evolution (IAME), UMR 1137, Université Paris Diderot, Sorbonne Paris Cité, F-75018, Paris, France
| | - David Hajage
- Epidémiologie Clinique et Évaluation Économique Appliqué aux Populations Vulnérables (ECEVE), UMR 1123, Université Paris Diderot, Sorbonne Paris Cité, F-75018, Paris, France.,Département d'Epidémiologie et Recherche Clinique, Hôpital Louis Mourier, Assistance Publique - Hôpitaux de Paris, 178 rue des Renouillers, F-92700, Colombes, France
| | - Laurence Salomon
- Département d'Epidémiologie et Recherche Clinique, Hôpital Louis Mourier, Assistance Publique - Hôpitaux de Paris, 178 rue des Renouillers, F-92700, Colombes, France
| | - Didier Dreyfuss
- Service de Réanimation Médico-Chirurgicale, Hôpital Louis Mourier, Assistance Publique - Hôpitaux de Paris, F-92700, Colombes, France. .,Infection, Antimicrobials, Modelling, Evolution (IAME), UMR 1137, Université Paris Diderot, Sorbonne Paris Cité, F-75018, Paris, France. .,Present address: Intensive Care Unit, Hôpital Louis Mourier, 178 rue des Renouillers, 92110, Colombes, France.
| |
Collapse
|