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Tomlinson EJ, Schnitker LM, Casey PA. Exploring Antipsychotic Use for Delirium Management in Adults in Hospital, Sub-Acute Rehabilitation and Aged Care Settings: A Systematic Literature Review. Drugs Aging 2024; 41:455-486. [PMID: 38856874 PMCID: PMC11193698 DOI: 10.1007/s40266-024-01122-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2024] [Indexed: 06/11/2024]
Abstract
BACKGROUND International guidelines discourage antipsychotic use for delirium; however, concerns persist about their continued use in clinical practice. OBJECTIVES We aimed to describe the prevalence and patterns of antipsychotic use in delirium management with regard to best-practice recommendations. Primary outcomes investigated were prevalence of use, antipsychotic type, dosage and clinical indication. METHODS Eligibility criteria: studies of any design that examined antipsychotic use to manage delirium in adults in critical care, acute care, palliative care, rehabilitation, and aged care were included. Studies of patients in acute psychiatric care, with psychiatric illness or pre-existing antipsychotic use were excluded. INFORMATION SOURCES we searched five health databases on 16 August, 2023 (PubMed, CINAHL, Embase, APA PsycInfo, ProQuest Health and Medical Collection) using MeSH terms and relevant keywords, including 'delirium' and 'antipsychotic'. Risk of bias: as no included studies were randomised controlled trials, all studies were assessed for methodological quality using the Mixed Methods Appraisal Tool. SYNTHESIS OF RESULTS descriptive data were extracted in Covidence and synthesised in Microsoft Excel. RESULTS Included studies: 39 studies published between March 2004 and August 2023 from 13 countries (n = 1,359,519 patients). Most study designs were retrospective medical record audits (n = 16). SYNTHESIS OF RESULTS in 18 studies, participants' mean age was ≥65 years (77.79, ±5.20). Palliative care had the highest average proportion of patients with delirium managed with antipsychotics (70.87%, ±33.81%); it was lower and varied little between intensive care unit (53.53%, ±19.73%) and non-intensive care unit settings [medical, surgical and any acute care wards] (56.93%, ±26.44%) and was lowest in in-patient rehabilitation (17.8%). Seventeen different antipsychotics were reported on. In patients aged ≥65 years, haloperidol was the most frequently used and at higher than recommended mean daily doses (2.75 mg, ±2.21 mg). Other antipsychotics commonly administered were olanzapine (mean 11 mg, ±8.54 mg), quetiapine (mean 64.23 mg, ±43.20 mg) and risperidone (mean 0.97 mg, ±0.64 mg). CONCLUSIONS The use of antipsychotics to manage delirium is strongly discouraged in international guidelines. Antipsychotic use in delirium care is a risk for adverse health outcomes and a longer duration of delirium, especially in older people. However, this study has provided evidence that clinicians continue to use antipsychotics for delirium management, the dose, frequency and duration of which are often outside evidence-based guideline recommendations. Clinicians continue to choose antipsychotics to manage delirium symptoms to settle agitation and maintain patient and staff safety, particularly in situations where workload pressures are high. Sustained efforts are needed at the individual, team and organisational levels to educate, train and support clinicians to prioritise non-pharmacological interventions early before deciding to use antipsychotics. This could prevent delirium and avert escalation in behavioural symptoms that often lead to antipsychotic use.
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Affiliation(s)
- Emily J Tomlinson
- Deakin University, Centre for Quality and Patient Safety Research in the Institute for Health Transformation, Geelong, Victoria, Australia.
- Deakin University, School of Nursing and Midwifery, Geelong, Victoria, Australia.
| | - Linda M Schnitker
- School of Nursing, Queensland University of Technology, Kelvin Grove, Brisbane, QLD, Australia
- Bolton Clarke Research Institute, Kelvin Grove, Brisbane, QLD, Australia
| | - Penelope A Casey
- Deakin University, School of Nursing and Midwifery, Geelong, Victoria, Australia
- Deakin University, Centre for Quality and Patient Safety Research-Eastern Health Partnership, Geelong, Victoria, Australia
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2
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Zhang Y, Xie J, Tang M. Attitudes, knowledge and practices concerning delirium among paediatric intensive care unit nurses: a multisite cross-sectional study in Sichuan, China. BMC Nurs 2024; 23:289. [PMID: 38684972 PMCID: PMC11057075 DOI: 10.1186/s12912-024-01956-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 04/21/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Delirium is an acute mental state associated with poor outcomes. The incidence of delirium is high, especially in the paediatric intensive care unit (PICU). It is important for staff, particularly nurses, to understand delirium and implement interventions to prevent it. We performed a survey with the aim of evaluating and analysing the factors influencing the knowledge, attitudes and behaviour of PICU nurses towards delirium. METHODS This cross-sectional descriptive study included 215 PICU nurses in 6 PICUs from five teaching hospitals in Sichuan Province, China. An online survey about the knowledge, attitudes and practices related to delirium care was conducted among PICU nurses used a self-made and validated questionnaire. The data were analysed using descriptive statistics; differences between groups were compared using t tests, ANOVA and rank-sum tests. Variables with a significance level of 0.05 in the univariate analysis were entered into the multivariable regression analysis to identify predictors. RESULTS Only 14.4% of the nurses had a good understanding of delirium, and 40.9% had received relevant training. The mean knowledge score was 9.01 ± 3.86, and the overall passing rate of knowledge was 49.8%. The mean attitude and behaviour scores were 40.95 ± 5.62 and 40.33 ± 8.01, respectively. Among the hospitals, different delirium assessments for children and specific training were performed, explaining approximately 10% of the variability in knowledge scores (F = 6.152), approximately 10% of the variability in attitude/belief scores (F = 5.908), and approximately 17% of the variability in practice scores (F = 10.767). CONCLUSIONS PICU nurses have poor knowledge of delirium, particularly regarding its clinical manifestations, influencing factors and medications used, and they have adequate attitudes and confidence and good behaviour regarding delirium in children. To better prevent delirium, we suggest that PICU departments routinely assess delirium and conduct delirium training for nurses. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- YueEr Zhang
- Department of Pain Management, West China Hospital ,Sichuan University/West China School of Nursing, Sichuan University, Chengdu, 610041, China
| | - JingYing Xie
- West China Hospital of Stomatology,Sichuan University, Chengdu, 610041, China
| | - MengLin Tang
- Department of cardiovascular surgery,West China Hospital,Sichuan University/West China School of Nursing, Sichuan University, Chengdu, 610041, China.
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Huang YL, Lei YQ, Xie WP, Cao H, Yu XR, Chen Q. Effect of music therapy on infants who underwent mechanical ventilation after cardiac surgery. J Card Surg 2021; 36:4460-4464. [PMID: 34477246 DOI: 10.1111/jocs.15976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 07/17/2021] [Accepted: 08/10/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To investigate the effect of music therapy on infants who underwent mechanical ventilation after cardiac surgery. METHODS A prospective randomized controlled study was conducted in a provincial hospital in southeast China. The subjects were randomly divided into the music therapy (MT) group and the control group. Both groups were given standardized sedation treatment and routine nursing. Infants in the MT group received 60 min of MT three times a day. The sedation medication, Richmond sedation agitation scale (RASS) score, incidence of delirium, mechanical ventilation duration, length of cardiac intensive care unit (CICU) stay, restraint belt use time, and successful ventilation withdrawal rate were collected. RESULTS Infants in the control group had a higher total amount of on-demand midazolam (p = .039). Infants in the MT group had a significantly lower incidence of delirium, shorter mechanical ventilation duration, and restraint band use time (p = .047, p = .046, and p = .038, respectively). Although infants in the MT group had a higher success rate of ventilation withdrawal, lower RASS scores, and shorter ICU stay, the difference was not statistically significant (p = .427, p = .585, and p = .068, respectively). CONCLUSION MT in the ICU can reduce the use of on-demand sedative drugs, shorten mechanical ventilation, and reduce the occurrence of delirium in infants who underwent mechanical ventilation after cardiac surgery. MT is a safe and reliable treatment and worthy of clinical application.
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Affiliation(s)
- Ya-Li Huang
- Department of Cardiac Surgery, Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China.,Fujian Children's Hospital, Fuzhou, China.,Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China
| | - Yu-Qing Lei
- Department of Cardiac Surgery, Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China.,Fujian Children's Hospital, Fuzhou, China.,Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China
| | - Wen-Peng Xie
- Department of Cardiac Surgery, Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China.,Fujian Children's Hospital, Fuzhou, China.,Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China
| | - Hua Cao
- Department of Cardiac Surgery, Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China.,Fujian Children's Hospital, Fuzhou, China.,Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China
| | - Xian-Rong Yu
- Department of Cardiac Surgery, Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China.,Fujian Children's Hospital, Fuzhou, China.,Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China
| | - Qiang Chen
- Department of Cardiac Surgery, Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China.,Fujian Children's Hospital, Fuzhou, China.,Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China
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Dixit D, Barbarello Andrews L, Radparvar S, Adams C, Kumar ST, Cardinale M. Descriptive analysis of the unwarranted continuation of antipsychotics for the management of ICU delirium during transitions of care: A multicenter evaluation across New Jersey. Am J Health Syst Pharm 2021; 78:1385-1394. [PMID: 33895793 DOI: 10.1093/ajhp/zxab180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Nearly half of intensive care unit (ICU) patients will develop delirium. Antipsychotics are used routinely for the management of ICU delirium despite limited reliable data supporting this approach. The unwarranted continuation of antipsychotics initiated for ICU delirium is an emerging transitions of care concern, especially considering the adverse event profile of these agents. We sought to evaluate the magnitude of this issue across 6 centers in New Jersey and describe risk factors for continuation. METHODS This multicenter, retrospective study examined adult ICU patients who developed ICU delirium from June 2016 to June 2018. Patients were included in the study if they received at least 3 doses of antipsychotics while in the ICU with presence of either a clinical diagnosis of delirium or a positive Confusion Assessment Method score. Patients were excluded if they were on an antipsychotic before ICU admission. RESULTS Of the 300 patients included and initiated on antipsychotics for ICU delirium, 157 (52.3%) were continued on therapy upon transfer from the ICU to another level of inpatient care. The number of patients continued on newly initiated antipsychotics further increased to 183 (61%) upon discharge from the hospital. CONCLUSION The continuation of antipsychotics for the management of delirium during transitions of care was a common practice across ICUs in New Jersey. Several risk factors for continuation of antipsychotics were identified. Efforts to reduce unnecessary continuation of antipsychotics at transitions of care are warranted.
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Affiliation(s)
- Deepali Dixit
- Ernest Mario School of Pharmacy, Rutgers,The State University of New Jersey, Piscataway, NJ,USA
| | - Liza Barbarello Andrews
- Ernest Mario School of Pharmacy, Rutgers,The State University of New Jersey, Piscataway, NJ,USA
| | | | - Christopher Adams
- Ernest Mario School of Pharmacy, Rutgers,The State University of New Jersey, Piscataway, NJ,USA
| | | | - Maria Cardinale
- Ernest Mario School of Pharmacy, Rutgers,The State University of New Jersey, Piscataway, NJ,USA
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MacLullich AM, Shenkin SD, Goodacre S, Godfrey M, Hanley J, Stíobhairt A, Lavender E, Boyd J, Stephen J, Weir C, MacRaild A, Steven J, Black P, Diernberger K, Hall P, Tieges Z, Fox C, Anand A, Young J, Siddiqi N, Gray A. The 4 'A's test for detecting delirium in acute medical patients: a diagnostic accuracy study. Health Technol Assess 2020; 23:1-194. [PMID: 31397263 DOI: 10.3310/hta23400] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Delirium is a common and serious neuropsychiatric syndrome, usually triggered by illness or drugs. It remains underdetected. One reason for this is a lack of brief, pragmatic assessment tools. The 4 'A's test (Arousal, Attention, Abbreviated Mental Test - 4, Acute change) (4AT) is a screening tool designed for routine use. This project evaluated its usability, diagnostic accuracy and cost. METHODS Phase 1 - the usability of the 4AT in routine practice was measured with two surveys and two qualitative studies of health-care professionals, and a review of current clinical use of the 4AT as well as its presence in guidelines and reports. Phase 2 - the 4AT's diagnostic accuracy was assessed in newly admitted acute medical patients aged ≥ 70 years. Its performance was compared with that of the Confusion Assessment Method (CAM; a longer screening tool). The performance of individual 4AT test items was related to cognitive status, length of stay, new institutionalisation, mortality at 12 weeks and outcomes. The method used was a prospective, double-blind diagnostic test accuracy study in emergency departments or in acute general medical wards in three UK sites. Each patient underwent a reference standard delirium assessment and was also randomised to receive an assessment with either the 4AT (n = 421) or the CAM (n = 420). A health economics analysis was also conducted. RESULTS Phase 1 found evidence that delirium awareness is increasing, but also that there is a need for education on delirium in general and on the 4AT in particular. Most users reported that the 4AT was useful, and it was in widespread use both in the UK and beyond. No changes to the 4AT were considered necessary. Phase 2 involved 785 individuals who had data for analysis; their mean age was 81.4 (standard deviation 6.4) years, 45% were male, 99% were white and 9% had a known dementia diagnosis. The 4AT (n = 392) had an area under the receiver operating characteristic curve of 0.90. A positive 4AT score (> 3) had a specificity of 95% [95% confidence interval (CI) 92% to 97%] and a sensitivity of 76% (95% CI 61% to 87%) for reference standard delirium. The CAM (n = 382) had a specificity of 100% (95% CI 98% to 100%) and a sensitivity of 40% (95% CI 26% to 57%) in the subset of participants whom it was possible to assess using this. Patients with positive 4AT scores had longer lengths of stay (median 5 days, interquartile range 2.0-14.0 days) than did those with negative 4AT scores (median 2 days, interquartile range 1.0-6.0 days), and they had a higher 12-week mortality rate (16.1% and 9.2%, respectively). The estimated 12-week costs of an initial inpatient stay for patients with delirium were more than double the costs of an inpatient stay for patients without delirium (e.g. in Scotland, £7559, 95% CI £7362 to £7755, vs. £4215, 95% CI £4175 to £4254). The estimated cost of false-positive cases was £4653, of false-negative cases was £8956, and of a missed diagnosis was £2067. LIMITATIONS Patients were aged ≥ 70 years and were assessed soon after they were admitted, limiting generalisability. The treatment of patients in accordance with reference standard diagnosis limited the ability to assess comparative cost-effectiveness. CONCLUSIONS These findings support the use of the 4AT as a rapid delirium assessment instrument. The 4AT has acceptable diagnostic accuracy for acute older patients aged > 70 years. FUTURE WORK Further research should address the real-world implementation of delirium assessment. The 4AT should be tested in other populations. TRIAL REGISTRATION Current Controlled Trials ISRCTN53388093. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 40. See the NIHR Journals Library website for further project information. The funder specified that any new delirium assessment tool should be compared against the CAM, but had no other role in the study design or conduct of the study.
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Affiliation(s)
| | - Susan D Shenkin
- Geriatric Medicine, Division of Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Steve Goodacre
- Emergency Medicine, University of Sheffield, Sheffield, UK
| | - Mary Godfrey
- Health and Social Care, Leeds Institute of Health Sciences, School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Janet Hanley
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Antaine Stíobhairt
- Geriatric Medicine, Division of Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Elizabeth Lavender
- Health and Social Care, Leeds Institute of Health Sciences, School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Julia Boyd
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Jacqueline Stephen
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK.,Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Christopher Weir
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK.,Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Allan MacRaild
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Jill Steven
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Polly Black
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Katharina Diernberger
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.,Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Peter Hall
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Zoë Tieges
- Geriatric Medicine, Division of Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Christopher Fox
- Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Atul Anand
- Geriatric Medicine, Division of Health Sciences, University of Edinburgh, Edinburgh, UK
| | - John Young
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford, UK
| | - Najma Siddiqi
- Psychiatry, University of York, York.,Hull York Medical School, York, UK.,Bradford District Care NHS Foundation Trust, Bradford, UK
| | - Alasdair Gray
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.,Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
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Chatterjee S, Engelman DT. Commentary: The need for better identification of postoperative delirium. J Thorac Cardiovasc Surg 2020; 163:735-736. [PMID: 32868061 DOI: 10.1016/j.jtcvs.2020.07.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 07/07/2020] [Accepted: 07/10/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Subhasis Chatterjee
- Divisions of General and Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex
| | - Daniel T Engelman
- Heart and Vascular Program, Baystate Health, University of Massachusetts Medical School-Baystate, Springfield, Mass.
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Bilotta F, Weiss B, Neuner B, Kramer S, Aldecoa C, Bettelli G, Sanders RD, Delp SM, Spies CD. Routine management of postoperative delirium outside the ICU: Results of an international survey among anaesthesiologists. Acta Anaesthesiol Scand 2020; 64:494-500. [PMID: 31883373 DOI: 10.1111/aas.13535] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Revised: 11/18/2019] [Accepted: 12/16/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Postoperative delirium (POD) is a severe brain dysfunction. Although data indicate a high relevance, no survey has investigated the routine practice to monitor delirium outside the ICU setting after surgery. Prior to publishing of the new European Society of Anaesthesiology (ESA) guidelines on POD, an international survey was conducted to assess current practice. METHODS European Society of Anaesthesiology-endorsed online survey; Trial Registration: NCT-identifier: 02513537. RESULTS In total, 566 respondents from 62 countries accessed, and 564 (99.6%) completed the survey (completion rate). Overall, 385 (68%) of the respondents reported that delirium is either "very relevant" or "relevant" for their daily clinical practice. In all, 38 (7%) of the respondents routinely monitor for delirium in >50% of all patients. Asked on the monitoring time point, more than half (n = 308, 55%) indicated to screen before or at recovery room discharge, 235 (42%) up to the first postoperative day, 143 (25%) up to 3 days, and 77 (14%) up to 5 postoperative days. Although there is a lack of long-term monitoring, nearly all respondents (n = 530, 94%) reported to treat delirium. Availability of EEG/EMG-based monitoring to assess the depth of anaesthesia was high in the study group (n = 547, 97%) and was used by more than one-third of the respondents to reduce risk of burst suppression (n = 189, 34%). CONCLUSION Although delirium is perceived as a relevant condition among anaesthesiologists, there is a high demand for implementing monitoring strategies after publishing of the POD Guideline. The survey shows that tools necessary for POD Guideline implementation are available in the centres represented by the respondents.
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Affiliation(s)
- Federico Bilotta
- Department of Anesthesiology Critical Care and Pain Medicine, "Sapienza" University of Rome Rome Italy
| | - Bjoern Weiss
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK) Charité – Universitätsmedizin Berlin corporate member of Freie Universität Berlin Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
| | - Bruno Neuner
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK) Charité – Universitätsmedizin Berlin corporate member of Freie Universität Berlin Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
| | - Sylvia Kramer
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK) Charité – Universitätsmedizin Berlin corporate member of Freie Universität Berlin Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
| | - César Aldecoa
- Department of Anaesthesiology & Intensive Care Hospital Universitario Rio Hortega Valladolid Spain
| | - Gabriella Bettelli
- Department of Geriatric Surgery Italian National Research Centres on Aging/IRCCS Ancona Italy
- Department of Anaesthesia, Analgesia and Intensive Care Italian National Research Centres on Aging/IRCCS Ancona Italy
| | | | - Simon M. Delp
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK) Charité – Universitätsmedizin Berlin corporate member of Freie Universität Berlin Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
| | - Claudia D. Spies
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK) Charité – Universitätsmedizin Berlin corporate member of Freie Universität Berlin Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
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Chiu JA, Shergill M, Dhingra V, Ronco JJ, LeBlanc A, Pamplin C, McKeown S, Dodek PM. Variation in the Management of Pain, Agitation, and Delirium in Intensive Care Units in British Columbia. Am J Crit Care 2020; 29:122-129. [PMID: 32114614 DOI: 10.4037/ajcc2020396] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Pain, agitation, and delirium are associated with negative outcomes in critically ill patients. Reducing variation in pain, agitation, and delirium management among institutions could improve care. OBJECTIVES To define opportunities to improve pain, agitation, and delirium management in intensive care units in British Columbia, Canada. METHODS A 13-item survey was developed to determine practices for assessing and managing pain, agitation, and delirium. Target participants were persons designated as the most informed about pain, agitation, and delirium management at each of the 30 intensive care units in British Columbia. Main measures were protocol use, assessment tool(s) used and frequency, and management approaches. RESULTS All 30 units responded; half of them had a unit-specific pain algorithm. The Behavioral Pain Scale and the numerical rating scale were the most common tools used to assess pain. Sites reported 15 different approaches to pain management: two-thirds used a sedation assessment tool, but some relied on physician diagnoses to identify sedation. Sites reported 18 different approaches to sedation management: most included an algorithm or order set for sedation management, but the most commonly used approach was individualized management by a clinician (17% for sedation and 30% for agitation). Sites reported 22 different approaches for delirium management: more than two-thirds used a delirium measurement instrument, but some relied on physician diagnoses to identify delirium. CONCLUSION Variation in assessment and management of pain, agitation, and delirium in British Columbia intensive care units highlights opportunities to improve care.
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Affiliation(s)
- Judy A. Chiu
- Judy A. Chiu is a project manager at the Centre for Health Evaluation & Outcome Sciences, Vancouver, British Columbia, Canada
| | - Meher Shergill
- Meher Shergill was a consultant at the BC Patient Safety and Quality Council, Vancouver
| | - Vinay Dhingra
- Vinay Dhingra was a physician consultant at the BC Patient Safety and Quality Council and are physicians at the Division of Critical Care Medicine, University of British Columbia, Vancouver
| | - Juan J. Ronco
- Juan J. Ronco was a physician consultant at the BC Patient Safety and Quality Council and are physicians at the Division of Critical Care Medicine, University of British Columbia, Vancouver
| | - Allana LeBlanc
- Allana LeBlanc is a nurse educator at the Vancouver Coastal Health Authority, Vancouver
| | - Chantale Pamplin
- Chantale Pamplin was a consultant at the BC Patient Safety and Quality Council
| | - Shari McKeown
- Shari McKeown was a leader at the BC Patient Safety and Quality Council and a faculty member at Thompson Rivers University, Kamloops, British Columbia
| | - Peter M. Dodek
- Peter M. Dodek is a scientist at the Centre for Health Evaluation and Outcome Sciences and a physician at the Division of Critical Care Medicine, University of British Columbia
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Lin P, Zhang J, Shi F, Liang ZA. Can haloperidol prophylaxis reduce the incidence of delirium in critically ill patients in intensive care units? A systematic review and meta-analysis. Heart Lung 2020; 49:265-272. [PMID: 32033776 DOI: 10.1016/j.hrtlng.2020.01.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 01/03/2020] [Accepted: 01/24/2020] [Indexed: 02/05/2023]
Abstract
INTRODUCTION The purpose of this study was to evaluate the efficacy and safety of haloperidol in the prevention of delirium in intensive care unit (ICU) patients. METHODS We systematically searched PubMed, Embase, and the Cochrane Library for eligible randomized controlled trials up to July 2019. No publication type or language restrictions were applied. RESULTS Compared to the placebo, haloperidol did not significantly reduce the incidence of delirium in all ICU patients (relative risk (RR), 0.83; 95% confidence interval (CI), 0.62-1.10, p = 0.20). However, haloperidol prophylaxis could reduce the incidence of delirium exclusively in postoperative patients admitted to an ICU (RR, 0.63; 95% CI, 0.47-0.86, p = 0.004). We observed no significant differences between the haloperidol and placebo groups in terms of length of ICU stay, all-cause mortality, and adverse events. CONCLUSIONS The use of prophylactic haloperidol might reduce the incidence of delirium in postoperative patients admitted to an ICU, but not in all ICU patients.
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Affiliation(s)
- Ping Lin
- Department of Respiratory and Critical Care Medicine, West China School of Medicine and West China Hospital, Sichuan University, Chengdu 610041, China
| | - Jiarui Zhang
- Department of Respiratory and Critical Care Medicine, West China School of Medicine and West China Hospital, Sichuan University, Chengdu 610041, China
| | - Fangyu Shi
- Department of Respiratory and Critical Care Medicine, West China School of Medicine and West China Hospital, Sichuan University, Chengdu 610041, China
| | - Zong-An Liang
- Department of Respiratory and Critical Care Medicine, West China School of Medicine and West China Hospital, Sichuan University, Chengdu 610041, China.
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10
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Barbateskovic M, Krauss SR, Collet MO, Andersen‐Ranberg NC, Mathiesen O, Jakobsen JC, Perner A, Wetterslev J. Haloperidol for the treatment of delirium in critically ill patients: A systematic review with meta-analysis and Trial Sequential Analysis. Acta Anaesthesiol Scand 2020; 64:254-266. [PMID: 31663112 DOI: 10.1111/aas.13501] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/02/2019] [Accepted: 10/04/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Haloperidol is the most frequently used drug to treat delirium in the critically ill patients. Yet, no systematic review has focussed on the effects of haloperidol in critically ill patients with delirium. METHODS We conducted a systematic review with meta-analysis and Trial Sequential Analysis of randomized clinical trials (RCTs) assessing the effects of haloperidol vs any intervention on all-cause mortality, serious adverse reactions/events, days alive without delirium, health-related quality of life (HRQoL), cognitive function and delirium severity in critically ill patients with delirium. We also report on QTc prolongation, delirium resolution and extrapyramidal symptoms. RESULTS We included 8 RCTs with 11 comparisons (n = 951). We adjudicated one trial as having overall low risk of bias. Three trials used rescue haloperidol; excluding these, we did not find an effect of haloperidol vs control on all-cause mortality (RR 1.01; 95% CI 0.33-3.06; I2 = 0%; 112 participants; 3 trials; 4 comparisons; very low certainty) or delirium severity (SMD -0.15; 95% CI -0.61-0.30; I2 = 27%; 134 participants; 3 trials; 4 comparisons; very low certainty). No trials reported adequately on serious adverse reactions/events. Only one trial reported on days alive without delirium, cognitive function and QTc prolongation, and no trials reported on HRQoL. Sensitivity analyses, including trials using rescue haloperidol, did not change the results. CONCLUSIONS The evidence for the use of haloperidol to treat critically ill patients with delirium is sparse, of low quality and inconclusive. We therefore have no certainty regarding any beneficial, harmful or neutral effects of haloperidol in these patients.
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Affiliation(s)
- Marija Barbateskovic
- Copenhagen Trial Unit Centre for Clinical Intervention Research Copenhagen Denmark
- Centre for Research in Intensive Care Rigshospitalet, Copenhagen University Hospital Copenhagen Denmark
| | - Sara R. Krauss
- Copenhagen Trial Unit Centre for Clinical Intervention Research Copenhagen Denmark
| | - Marie O. Collet
- Centre for Research in Intensive Care Rigshospitalet, Copenhagen University Hospital Copenhagen Denmark
- Department of Intensive Care Rigshospitalet, Copenhagen University Hospital Copenhagen Denmark
| | - Nina C. Andersen‐Ranberg
- Centre for Research in Intensive Care Rigshospitalet, Copenhagen University Hospital Copenhagen Denmark
- Centre for Anaesthesiological Research Department of Anaesthesiology and Intensive Care Zealand University Hospital Koege Denmark
| | - Ole Mathiesen
- Centre for Research in Intensive Care Rigshospitalet, Copenhagen University Hospital Copenhagen Denmark
- Centre for Anaesthesiological Research Department of Anaesthesiology and Intensive Care Zealand University Hospital Koege Denmark
- Department of Clinical Medicine Faculty of Health and Medical Sciences Copenhagen University Copenhagen Denmark
| | - Janus C. Jakobsen
- Copenhagen Trial Unit Centre for Clinical Intervention Research Copenhagen Denmark
- Centre for Research in Intensive Care Rigshospitalet, Copenhagen University Hospital Copenhagen Denmark
- Department of Cardiology Holbaek Hospital Holbaek Denmark
- Department of Regional Health Research The Faculty of Heath Sciences University of Southern Denmark Odense Denmark
| | - Anders Perner
- Centre for Research in Intensive Care Rigshospitalet, Copenhagen University Hospital Copenhagen Denmark
- Department of Intensive Care Rigshospitalet, Copenhagen University Hospital Copenhagen Denmark
| | - Jørn Wetterslev
- Copenhagen Trial Unit Centre for Clinical Intervention Research Copenhagen Denmark
- Centre for Research in Intensive Care Rigshospitalet, Copenhagen University Hospital Copenhagen Denmark
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11
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Collet M, Thomsen T, Egerod I. Nurses' and physicians' approaches to delirium management in the intensive care unit: A focus group investigation. Aust Crit Care 2019; 32:299-305. [DOI: 10.1016/j.aucc.2018.07.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 06/01/2018] [Accepted: 07/08/2018] [Indexed: 02/01/2023] Open
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12
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Cha S, Brown CH. Treating delirium in the intensive care unit: No easy answers. J Thorac Cardiovasc Surg 2019; 159:1895-1898. [PMID: 31303322 DOI: 10.1016/j.jtcvs.2019.02.143] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 02/21/2019] [Accepted: 02/21/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Stephanie Cha
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Md.
| | - Charles H Brown
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
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13
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Kovacic NL, Gagnon DJ, Riker RR, Wen S, Fraser GL. An Analysis of Psychoactive Medications Initiated in the ICU but Continued Beyond Discharge: A Pilot Study of Stewardship. J Pharm Pract 2019; 33:760-767. [PMID: 30813837 DOI: 10.1177/0897190019830518] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Psychoactive medications (PM) are frequently administered in the intensive care unit (ICU) to provide comfort. Interventions focused on preventing their continuation after the acute phase of illness are needed. OBJECTIVE To determine the frequency that patients with ICU-initiated PM are continued upon ICU and hospital discharge. METHODS This single-center, prospective, observational study assessed consecutive adult ICU patients who received scheduled PM. Frequency of PM continued at ICU and hospital discharge was recorded. The patient's primary treatment team was contacted by the pharmacist within 72 hours of ICU discharge to establish rationale for continued use or to suggest discontinuation. RESULTS Of the 60 patients included, 72% were continued on PM at ICU discharge and 30% at hospital discharge. The pharmacist contacted 40% of treatment teams after ICU discharge and intervention resulted in PM discontinued in 50% of patients. Post ICU discharge, the indication of 41% of patients' PM was unknown by the non-ICU care team or incorrect. Medical ICU patients or those transferred to an outside facility were more likely remain on PM at hospital discharge. CONCLUSION PM are frequently continued during transitions of care and often without knowledge of the initial indication. Future studies should establish effective PM stewardship methods.
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Affiliation(s)
- Nicole Lynn Kovacic
- WVU Medicine, Morgantown, WV, USA.,West Virginia University School of Pharmacy, Morgantown, WV, USA
| | - David J Gagnon
- 92602Maine Medical Center, Portland, ME, USA.,Tufts University School of Medicine, Boston, MA, USA
| | - Richard R Riker
- 92602Maine Medical Center, Portland, ME, USA.,Tufts University School of Medicine, Boston, MA, USA
| | - Sijin Wen
- Health Science Center, 24041West Virginia University, Morgantown, WV, USA
| | - Gilles L Fraser
- 92602Maine Medical Center, Portland, ME, USA.,Tufts University School of Medicine, Boston, MA, USA
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14
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Barbateskovic M, Krauss SR, Collet MO, Larsen LK, Jakobsen JC, Perner A, Wetterslev J. Pharmacological interventions for prevention and management of delirium in intensive care patients: a systematic overview of reviews and meta-analyses. BMJ Open 2019; 9:e024562. [PMID: 30782910 PMCID: PMC6377549 DOI: 10.1136/bmjopen-2018-024562] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES We assessed the evidence from reviews and meta-analyses of randomised clinical trials on the effects of pharmacological prevention and management of delirium in intensive care unit (ICU) patients. METHODS We searched for reviews in July 2017 in: Cochrane Library, MEDLINE, Embase, Science Citation Index, BIOSIS Previews, CINAHL and LILACS. We assessed whether reviews were systematic according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and assessed the methodological quality using ROBIS. OUTCOME MEASURES Primary outcomes: all-cause mortality, serious adverse events, prevention of delirium and management of delirium. SECONDARY OUTCOMES quality of life; non-serious adverse events and cognitive function. RESULTS We included 378 reviews: 369 narrative reviews, eight semisystematic reviews which failed on a maximum of two arbitrary PRISMA criteria and one systematic review fulfilling all 27 PRISMA criteria. For the prevention of delirium, we identified the one systematic review and eight semisystematic reviews all assessing the effects of alpha-2-agonists. None found evidence of a reduction of mortality (systematic review RR 0.99, 95% CI 0.79 to 1.24). The systematic review and three semisystematic reviews found no evidence of an effect for the prevention of delirium (systematic review RR 0.85, 0.63 to 1.14). Conversely, four semisystematic reviews found a beneficial effect. Serious adverse events, quality of life, non-serious adverse events and cognitive function were not assessed. We did not identify any systematic or semisystematic reviews addressing other pharmacological interventions for the prevention of delirium. For the management of manifest delirium, we did not identify any systematic or semisystematic review assessing any pharmacological agents. CONCLUSION Based on systematic reviews, the evidence for the use of pharmacological interventions for prevention or management of delirium is poor or sparse. A systematic review with low risk of bias assessing the effects of pharmacological prevention of delirium and management of manifest delirium in ICU patients is urgently needed. PROSPERO REGISTRATION NUMBER CRD42016046628.
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Affiliation(s)
- Marija Barbateskovic
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Sara Russo Krauss
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Marie Oxenboell Collet
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Laura Krone Larsen
- Department of of Neuroanaesthesiology, Rigshospitalet, Copenhagen University hospital, Copenhagen, Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Cardiology, Holbaek Hospital, Holbaek, Denmark
| | - Anders Perner
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jørn Wetterslev
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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15
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Bannon L, McGaughey J, Verghis R, Clarke M, McAuley DF, Blackwood B. The effectiveness of non-pharmacological interventions in reducing the incidence and duration of delirium in critically ill patients: a systematic review and meta-analysis. Intensive Care Med 2019; 45:1-12. [PMID: 30506354 DOI: 10.1007/s00134-018-5452-x] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 11/03/2018] [Indexed: 12/20/2022]
Abstract
PURPOSE To evaluate the effect of non-pharmacological interventions versus standard care on incidence and duration of delirium in critically ill patients. METHODS We searched electronic and grey literature for randomised clinical trials up to March 2018. Two reviewers independently screened, selected and extracted data. Meta-analysis was undertaken using random effects modelling. RESULTS We identified 15 trials (2812 participants). Eleven trials reported incidence of delirium. Pooled data from four trials of bright light therapy showed no significant effect between groups (n = 829 participants, RR 0.45, 99% CI 0.10-2.13, P = 0.19, very low quality evidence). Seven trials of various individual interventions also failed to report any significant effects. A total of eight trials reported duration of delirium. Pooled data from two trials of multicomponent physical therapy showed no significant effect [n = 404 participants, MD (days) - 0.65, 99% CI - 2.73 to 1.44, P = 0.42, low quality of evidence]. Four trials of various individual interventions also reported no significant effects. A trial of family voice reorientation showed a beneficial effect [n = 30, MD (days) - 1.30, 99% CI - 2.41 to - 0.19, P = 0.003, very low quality evidence]. CONCLUSIONS Current evidence does not support the use of non-pharmacological interventions in reducing incidence and duration of delirium in critically ill patients. Future research should consider well-designed and well-described multicomponent interventions and include adequately defined outcome measures.
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Affiliation(s)
- Leona Bannon
- School of Medicine, Dentistry and Biomedical Sciences, Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK.
| | - Jennifer McGaughey
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Rejina Verghis
- School of Medicine, Dentistry and Biomedical Sciences, Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Mike Clarke
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Science, Queen's University Belfast, Belfast, UK
| | - Daniel F McAuley
- School of Medicine, Dentistry and Biomedical Sciences, Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Bronagh Blackwood
- School of Medicine, Dentistry and Biomedical Sciences, Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
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16
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Meagher D, Agar MR, Teodorczuk A. Debate article: Antipsychotic medications are clinically useful for the treatment of delirium. Int J Geriatr Psychiatry 2018; 33:1420-1427. [PMID: 28758323 DOI: 10.1002/gps.4759] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 06/01/2017] [Indexed: 11/05/2022]
Abstract
Prescribing of antipsychotic medications for patients with delirium remains controversial. Concerns exist that these vulnerable and frail patients may be prescribed antipsychotics inappropriately as a substitute for non-pharmacological approaches when identifiable causes are not found or they challenge ward processes. Moreover, recent evidence suggests that antipsychotics may cause more harm than good in the palliative care patient group with delirium. On the other hand, guidelines in the United Kingdom and the Netherlands support prescribing of antipsychotics in certain circumstances, and a large European survey has revealed that antipsychotics tend to be prescribed first line for hyperactive delirium. Never before, therefore, is there a greater need to examine whether indeed these medications are clinically useful for the treatment of delirium. With this in mind, evidence-based arguments for and against prescribing antipsychotics for the treatment of delirium are presented in this debate article. The paper concludes with a moderation piece to help guide clinical practice.
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Affiliation(s)
- David Meagher
- Cognitive Impairment Research Group, Graduate Entry Medical School, University of Limerick, Ireland.,Department of Psychiatry, University Hospital Limerick, Ireland
| | - Meera R Agar
- Faculty of Health, University of Technology Sydney, New South Wales, Australia.,South West Sydney Clinical School, University of New South Wales, New South Wales, Australia.,Ingham Institute of Applied Medical Research, New South Wales, Australia.,Discipline, Palliative and Supportive Services, Flinders University, South Australia, Australia
| | - Andrew Teodorczuk
- School of Medicine, Griffith University, Gold Coast, Australia.,Health Institute for the Development of Education and Scholarship (Health IDEAS), Griffith University, Queensland, Australia
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17
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Heavner MS, Nguyen NK, Knauert MP, Verceles A, Pisani MA, Seung H, Gonzales JP. Survey of clinical pharmacist perceptions and practices in promoting sleep in intensive care unit patients. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2018. [DOI: 10.1002/jac5.1027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Mojdeh S. Heavner
- Department of Pharmacy Practice and Science; University of Maryland School of Pharmacy; Baltimore Maryland
| | - Nam K. Nguyen
- Master of Science in Regulatory Science Candidate; University of Maryland School of Pharmacy; Baltimore Maryland
| | - Melissa P. Knauert
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine; Yale University School of Medicine; New Haven Connecticut
| | - Avelino Verceles
- Division of Pulmonary and Critical Care; University of Maryland School of Medicine; Baltimore Maryland
| | - Margaret A. Pisani
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine; Yale University School of Medicine; New Haven Connecticut
| | - Hyunuk Seung
- Department of Pharmacy Practice and Science; University of Maryland School of Pharmacy; Baltimore Maryland
| | - Jeffrey P. Gonzales
- Department of Pharmacy Practice and Science; University of Maryland School of Pharmacy; Baltimore Maryland
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18
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Stewart C, Bench S. Evaluating the implementation of confusion assessment method-intensive care unit using a quality improvement approach. Nurs Crit Care 2018; 23:172-178. [PMID: 29766622 DOI: 10.1111/nicc.12354] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 02/22/2018] [Accepted: 03/21/2018] [Indexed: 02/01/2023]
Abstract
Quality improvement (QI) is a way through which health care delivery can be made safer and more effective. Various models of quality improvement methods exist in health care today. These models can help guide and manage the process of introducing changes into clinical practice. The aim of this project was to implement the use of a delirium assessment tool into three adult critical care units within the same hospital using a QI approach. The objective was to improve the identification and management of delirium. Using the Model for Improvement framework, a multidisciplinary working group was established. A delirium assessment tool was introduced via a series of educational initiatives. New local guidelines regarding the use of delirium assessment and management for the multidisciplinary team were also produced. Audit data were collected at 6 weeks and 5 months post-implementation to evaluate compliance with the use of the tool across three critical care units within a single hospital in London. At 6 weeks, in 134 assessment points out of a possible 202, the tool was deemed to be used appropriately, meaning that 60% of patients received timely assessment; 18% of patients were identified as delirious in audit one. Five months later, only 95 assessment points out of a possible 199 were being appropriately assessed (47%); however, a greater number (32%) were identified as delirious. This project emphasizes the complexity of changing practice in a large busy critical care centre. Despite an initial increase in delirium assessment, this was not sustained over time. The use of a QI model highlights the continuous process of embedding changes into clinical practice and the need to use a QI method that can address the challenging nature of modern health care. QI models guide changes in practice. Consideration should be given to the type of QI model used.
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Affiliation(s)
- C Stewart
- Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, UK
| | - S Bench
- School of Health and Social Care, London South Bank University, London, UK
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19
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Barbateskovic M, Kraus SR, Collet MO, Mathiesen O, Jakobsen JC, Perner A, Wetterslev J. Haloperidol for delirium in critically ill patients - protocol for a systematic review. Acta Anaesthesiol Scand 2018; 62:712-723. [PMID: 29441518 DOI: 10.1111/aas.13088] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 01/09/2018] [Accepted: 01/18/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND In the intensive care unit, the prevalence of delirium is high. Delirium has been associated with morbidity and mortality including more ventilator days, longer intensive care unit stay, increased long-term mortality, and cognitive impairment. Thus, the burden of delirium for patients, relatives, and societies is considerable. The objective of this systematic review was to critically access the evidence of randomised clinical trials on the effects of haloperidol vs. placebo or any other agents for delirium in critically ill patients. METHODS We will search for randomised clinical trials in the following databases: Cochrane Library, MEDLINE, EMBASE, Science Citation Index, BIOSIS, Cumulative Index to Nursing and Allied Health Literature, Latin American and Caribbean Health Sciences Literature, and Allied and Complementary Medicine Database. Two authors will independently screen and select references for inclusion using Covidence, extract data and assess the methodological quality of the included randomised clinical trials using the Cochrane risk of bias tool. Any disagreement will be resolved by consensus. We will analyse the extracted data using Review Manager, STATA 15, and Trial Sequential. ANALYSIS The aim of this study was to assess the quality of the evidence, we will create a 'Summary of Findings' table containing our primary and secondary outcomes using the GRADE assessment. DISCUSSION Our ambition with this systematic review is to provide reliable and powered evidence to better inform decision makers on the use of or future trials with haloperidol for the management of delirium in critically ill patients.
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Affiliation(s)
- M. Barbateskovic
- Copenhagen Trial Unit; Centre for Clinical Intervention Research; Copenhagen Denmark
- Centre for Research in Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - S. R. Kraus
- Copenhagen Trial Unit; Centre for Clinical Intervention Research; Copenhagen Denmark
| | - M. O. Collet
- Centre for Research in Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
- Department of Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - O. Mathiesen
- Centre for Research in Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
- Department of Anaesthesiology and Intensive Care; Zealand University Hospital; Køge Denmark
| | - J. C. Jakobsen
- Copenhagen Trial Unit; Centre for Clinical Intervention Research; Copenhagen Denmark
- Centre for Research in Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
- Department of Cardiology; Holbaek Hospital; Holbaek Denmark
| | - A. Perner
- Centre for Research in Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
- Department of Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - J. Wetterslev
- Copenhagen Trial Unit; Centre for Clinical Intervention Research; Copenhagen Denmark
- Centre for Research in Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
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20
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Wang J, Peng ZY, Zhou WH, Hu B, Rao X, Li JG. A National Multicenter Survey on Management of Pain, Agitation, and Delirium in Intensive Care Units in China. Chin Med J (Engl) 2018; 130:1182-1188. [PMID: 28485318 PMCID: PMC5443024 DOI: 10.4103/0366-6999.205852] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background: The management of pain, agitation, and delirium (PAD) in Intensive Care Unit (ICU) is beneficial for patients and makes it widely applied in clinical practice. Previous studies showed that the clinical practice of PAD in ICU was improving; yet relatively little information is available in China. This study aimed to investigate the practice of PAD in ICUs in China. Methods: A multicenter, nationwide survey was conducted using a clinician-directed questionnaire from September 19 to December 18, 2016. The questionnaire focused on the assessment and management of PAD by the clinicians in ICUs. The practice of PAD was compared among the four regions of China (North, Southeast, Northwest, and Southwest). The data were expressed as percentage and frequency. The Chi-square test, Fisher's exact test, and line-row Chi-square test were used. Results: Of the 1011 valid questionnaire forms, the response rate was 80.37%. The clinicians came from 704 hospitals across 158 cities of China. The rate of PAD assessment was 75.77%, 90.21%, and 66.77%, respectively. The rates of PAD scores were 45.8%, 68.94%, and 34.03%, respectively. The visual analog scale, Richmond agitation-sedation scale, and confusion assessment method for the ICU were the first choices of scales for PAD assessment. Fentanyl, midazolam, and dexmedetomidine were the first choices of agents for analgesic, sedation, and delirium treatment. While choosing analgesics and sedatives, the clinicians put the pharmacological characteristics of drugs in the first place (66.07% and 76.36%). Daily interruption for sedation was carried out by 67.26% clinicians. Most of the clinicians (87.24%) used analgesics while using sedatives. Of the 738 (73%) clinicians titrating the sedatives on the basis of the proposed target sedation level, 268 (26.61%) clinicians just depended on their clinical experience. Totally, 519 (51.34%) clinicians never used other nondrug strategies for PAD. The working time of clinicians was an important factor in the management of analgesia and sedation rather than their titles and educational background. The ratios of pain score and sedation score in the Southwest China were the highest and the North China were the lowest. The ratios of delirium assessment and score were the same in the four regions of China. Moreover, the first choices of scales for PAD in the four regions were the same. However, the top three choices of agents in PAD treatment in the four regions were not the same. Conclusions: The practice of PAD in China follows the international guidelines; however, the pain assessment should be improved. The PAD practice is a little different across the four regions of China; however, the trend is consistent. Trial Registration: The study is registered at http://www.clinicaltrials.gov (No. ChiCTR-OOC-16009014, www.chictr.org.cn/index.aspx.).
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Affiliation(s)
- Jing Wang
- Department of Intensive Care Unit, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, China
| | - Zhi-Yong Peng
- Department of Intensive Care Unit, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, China
| | - Wen-Hai Zhou
- Department of Clinical Medicine, City College, Wuhan university of Science and Technology, Wuhan, Hubei 430083, China
| | - Bo Hu
- Department of Intensive Care Unit, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, China
| | - Xin Rao
- Department of Intensive Care Unit, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, China
| | - Jian-Guo Li
- Department of Intensive Care Unit, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, China
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21
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Schrijver EJM, de Vries OJ, van de Ven PM, Bet PM, Kamper AM, Diepeveen SHA, van Marum RJ, van Strien AM, Anten S, Lagaay AM, Boelaarts L, Bloemers FW, Kramer MHH, Nanayakkara PWB. Haloperidol versus placebo for delirium prevention in acutely hospitalised older at risk patients: a multi-centre double-blind randomised controlled clinical trial. Age Ageing 2018; 47:48-55. [PMID: 28985255 DOI: 10.1093/ageing/afx124] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 06/22/2017] [Indexed: 11/14/2022] Open
Abstract
Background because the few randomised placebo-controlled trials investigating the potential role for prophylactic haloperidol in delirium prevention have focused on specific surgical populations, we investigated its efficacy and safety in acutely hospitalised older patients. Methods this multi-centre, double-blind, stratified, block randomised, placebo-controlled trial was conducted at six Dutch hospitals. Patients age ≥70 years, acutely admitted through the emergency department for general medicine or surgical specialties and at risk for delirium were randomised (n = 245) to haloperidol or placebo 1 mg orally twice-daily (maximum of 14 doses) on top of standard nonpharmacological prevention strategies. The primary outcome was delirium incidence. Other endpoints included delirium severity and duration, drug safety and clinical outcomes. Results intention-to-treat analysis included 242 participants (calculated sample size n = 390, statistical power of current sample 59%) allocated to haloperidol (n = 118) or placebo (n = 124). In the haloperidol and placebo group, delirium incidence was 19.5 versus 14.5% (OR 1.43, 95% CI 0.72 to 2.78); median (IQR) delirium duration 4 (2, 5) versus 3 (1, 6) days (P = 0.366); maximum DRS-R-98 score 16 (9.8, 19.5) versus 10 (5.5, 22.5) (P = 0.549; 53.7% missing data); hospital LOS 7 (4, 10.3) versus 7 (5, 11.8) days (P = 0.343); 3-month mortality 9.9 versus 12.5% (OR 0.77, 95% CI 0.34 to 1.75), respectively. No treatment-limiting side effects were noted. Conclusions prophylactic low-dose oral haloperidol did not reduce delirium incidence in acutely hospitalised older patients. Therefore, prophylactic use of haloperidol in this population is not recommended.
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Affiliation(s)
- Edmée J M Schrijver
- Department of Internal Medicine, VU University Medical Centre, Amsterdam, The Netherlands
| | - Oscar J de Vries
- Department of Internal Medicine, VU University Medical Centre, Amsterdam, The Netherlands
- Department of Internal Medicine, Onze Lieve Vrouwe Gasthuis (OLVG Hospital), Amsterdam, The Netherlands
| | - Peter M van de Ven
- Department of Epidemiology and Biostatistics, VU University Medical Centre, Amsterdam, The Netherlands
| | - Pierre M Bet
- Department of Clinical Pharmacology and Pharmacy, VU University Medical Centre, Amsterdam, The Netherlands
| | - Ad M Kamper
- Department of Internal Medicine, Isala Hospital, Zwolle, The Netherlands
| | | | - Rob J van Marum
- Department of Geriatric Medicine, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
- Department of General Practice and Elderly Care Medicine, VU University Medical Centre, EMGO Institute for Health and Care Research, Amsterdam, The Netherlands
| | - Astrid M van Strien
- Department of Geriatric Medicine, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - Sander Anten
- Department of Internal Medicine, Alrijne Hospital, Leiderdorp, The Netherlands
| | - Anne M Lagaay
- Department of Internal Medicine, Spaarne Hospital, Hoofddorp, The Netherlands
- Department of Internal Medicine, VU University Medical Centre, Amsterdam, The Netherlands
| | - Leo Boelaarts
- Department of Geriatric Medicine, Northwest Clinics, Alkmaar, The Netherlands
| | - Frank W Bloemers
- Department of Trauma Surgery, VU University Medical Centre, Amsterdam, The Netherlands
| | - Mark H H Kramer
- Department of Internal Medicine, VU University Medical Centre, Amsterdam, The Netherlands
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22
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Kassie GM, Kalisch Ellett LM, Nguyen TA, Roughead EE. Knowledge of Australian hospital pharmacists regarding delirium in elderly patients. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2017. [DOI: 10.1002/jppr.1352] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Gizat M. Kassie
- Quality Use of Medicines and Pharmacy Research Centre; School of Pharmacy and Medical Sciences; Sansom Institute for Health Research; University of South Australia; Adelaide Australia
| | - Lisa M. Kalisch Ellett
- Quality Use of Medicines and Pharmacy Research Centre; School of Pharmacy and Medical Sciences; Sansom Institute for Health Research; University of South Australia; Adelaide Australia
| | - Tuan A. Nguyen
- Quality Use of Medicines and Pharmacy Research Centre; School of Pharmacy and Medical Sciences; Sansom Institute for Health Research; University of South Australia; Adelaide Australia
| | - Elizabeth E. Roughead
- Quality Use of Medicines and Pharmacy Research Centre; School of Pharmacy and Medical Sciences; Sansom Institute for Health Research; University of South Australia; Adelaide Australia
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23
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Kassie GM, Kalisch Ellett LM, Nguyen TA, Roughead EE. Current practice and opinions of hospital pharmacists regarding their role in the screening, prevention and treatment of delirium. Int J Clin Pharm 2017; 39:1194-1200. [PMID: 29038936 DOI: 10.1007/s11096-017-0547-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 10/06/2017] [Indexed: 11/28/2022]
Abstract
Background An interdisciplinary approach is fundamental for effective prevention and treatment of delirium. Pharmacists could play a role in identifying and resolving medication-related delirium. However, little is known about their role in delirium care. Objective The main purpose of this survey was to assess the current practice and opinions of pharmacists concerning their involvement in screening, prevention and treatment of delirium. Setting Pharmacists in public and private hospitals in Australia. Method A cross-sectional survey was conducted using a pilot tested web-based questionnaire which was distributed primarily via a link in the electronic newsletter of the Society of Hospital Pharmacists of Australia. Main outcome measure Number and proportion of respondents answering questions related to the practice and perceptions of pharmacists in delirium management. Results Responses from 106 pharmacists were included in the analysis. Most respondents believed that pharmacists could play a role in prevention (92%) and screening (62%) of patients for delirium. However, in practice only 8% of pharmacists reported that they had ever screened a patient for delirium using a validated tool and 79% indicated that pharmacists were never or rarely involved in delirium treatment. When pharmacists did make recommendations half of the respondents said that pharmacists' recommendations were frequently or always accepted by the delirium treating teams. Conclusion Hospital pharmacists are underutilised in the prevention and management of delirium. Strategies to increase their involvement in the prevention and management of delirium should be implemented.
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Affiliation(s)
- Gizat M Kassie
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, GPO Box 2471, Adelaide, SA, 5001, Australia.
| | - Lisa M Kalisch Ellett
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, GPO Box 2471, Adelaide, SA, 5001, Australia
| | - Tuan A Nguyen
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, GPO Box 2471, Adelaide, SA, 5001, Australia
| | - Elizabeth E Roughead
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, GPO Box 2471, Adelaide, SA, 5001, Australia
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24
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Hyde-Wyatt J. Prevention, recognition and management of delirium in patients who are critically ill. Nurs Stand 2017; 32:41-52. [PMID: 29094525 DOI: 10.7748/ns.2017.e10667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2016] [Indexed: 11/09/2022]
Abstract
Delirium is common in patients who are critically ill, often resulting in extended hospital stays and increased mortality and morbidity. There are several subtypes of delirium, which are often undiagnosed and untreated, resulting in suboptimal patient outcomes. This article examines delirium in patients in the intensive care unit, including its signs and symptoms, incidence, causes and subtypes. It outlines the assessment of delirium and the pharmacological and non-pharmacological interventions that can be used to manage the condition, as well as describing the optimal prevention measures.
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Affiliation(s)
- Jaime Hyde-Wyatt
- Northern Lincolnshire and Goole NHS Foundation Trust, Scunthorpe, England
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25
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Xing J, Sun Y, Jie Y, Yuan Z, Liu W. Perceptions, attitudes, and current practices regards delirium in China: A survey of 917 critical care nurses and physicians in China. Medicine (Baltimore) 2017; 96:e8028. [PMID: 28953621 PMCID: PMC5626264 DOI: 10.1097/md.0000000000008028] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The purpose of this study is to assess the knowledge, attitudes, and managements regarding delirium of intensive care nurses and physicans, and to assess the perceived barriers related to intensive care unit (ICU) delirium monitoring in China. A descriptive survey was distributed to 1156 critical care nurses and physicians from 74 tertiary and secondary hospitals across Shandong province, China. The overall response rate was 86.18% (n = 917). The majority of respondents (88%) believed that deirium was associated with prolonged mechanical ventilation, and 79.72% thought delirium was associated with prolonged length of hospitalization. Only 14.17% of respondents believed that delirium was common in the ICU setting. Only 25.62% of the respondents reported routine screening of ICU delirium, and only 15.81% utilized Confusion Assessment Method for Intensive Care Unit screening tools. "Lack of appropriate screening tools" and "time restraints" were the most common perceived barriers. 45.4% of the participants had never received any education on ICU delirium. In conclusion, most nurses and physicians consider ICU delirium to be a serious problem, but lack knowledge on delirium and monitor this condition poorly. The survey infers a disconnection between the perceived significance and current monitoring of ICU delirium. There is a critical unmet need for in-service education on ICU delirium for physicians and nurses in China.
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Affiliation(s)
- Jinyan Xing
- Department of Critical Care Medicine, The Affiliated Hospital of Qingdao University
| | - Yunbo Sun
- Department of Critical Care Medicine, The Affiliated Hospital of Qingdao University
| | - Yaqi Jie
- Qingdao Development Zone No.1 Middle School
| | - Zhiyong Yuan
- Department of Critical Care Medicine, The Affiliated Hospital of Qingdao University
| | - Wenjuan Liu
- School of Nursing, Qingdao University, Qingdao, China
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Abstract
AIMS The aim of this study was to examine perceived barriers to assessment of delirium for critical care nurses, and the impact of education on their knowledge and practice. BACKGROUND Delirium is a significant problem in critical care, leading to increased morbidity and mortality. Many authors have found variations in assessment by critical care nurses, but there has been limited analysis of the reasons for this. Education on the topic improves knowledge and practice, but the best approach has not been examined. DESIGN A questionnaire survey design. METHODS A self-reported questionnaire was distributed to critical care nurses (n=31) at a district general hospital. Data were analysed with descriptive statistics. RESULTS Knowledge and practice were variable, but correlation was seen between nursing band and years of experience with better scores. Any type of education led to significantly improved scores. Several barriers to assessment were found, with the most common being lack of knowledge and difficulty in assessing intubated patients. CONCLUSION It is essential to improve practice in delirium assessment and management. Education is vital to improve the knowledge and practice of critical care nurses regarding delirium.
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Affiliation(s)
- Gabby Rowley-Conwy
- Clinical Skills Tutor, Department of Nursing, Swansea University College of Human and Health Sciences, Swansea
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Boehm LM, Vasilevskis EE, Dietrich MS, Wells N, Ely EW, Pandharipande P, Mion LC. Organizational Domains and Variation in Attitudes of Intensive Care Providers Toward the ABCDE Bundle. Am J Crit Care 2017; 26:e18-e28. [PMID: 28461551 DOI: 10.4037/ajcc2017297] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The ABCDE interprofessional bundle (Awakening and Breathing Coordination, Delirium monitoring and management, and Early mobility) reduces delirium and weakness in critically ill patients. OBJECTIVE To understand the relationship between organizational domains and provider attitudes. METHODS A 1-time electronic survey of 315 care providers in 10 intensive care units across the country to examine associations between organizational domains (policy/protocol factors, unit milieu, tasks, labor quality, labor quantity, and physical environment) and provider attitudes about perceived ease of completion, perceived safety, confidence, and perceived strength of evidence regarding the ABCDE bundle. Spearman correlations (rs) were used to examine the associations between organizational domains and provider attitude subscales (rs ≥ 0.32 was considered clinically important). RESULTS Protocol attributes (rs = 0.37-0.58), role clarity (rs = 0.38-0.59), training/understanding (rs = 0.33-0.46), coordination (rs = 0.32-0.46), and peer advocates (rs = 0.37-0.48) were associated with less difficulty performing the bundle and better confidence, perceived safety, and strength of evidence. Participants also reported less difficulty carrying out the bundle when the team worked well together. Task autonomy was associated with better perceived safety (rs = 0.35) and confidence (rs = 0.47) related to the bundle. CONCLUSIONS Focusing interventions on policy and protocol factors, unit milieu, and task autonomy, which have the strongest associations with providers' attitudes, may facilitate ABCDE bundle uptake.
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Affiliation(s)
- Leanne M Boehm
- Leanne M. Boehm is a postdoctoral fellow, Vanderbilt University School of Nursing, a quality scholar, VA Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), and a research nurse, Department of Medicine, Center for Health Services Research, Vanderbilt University, Nashville, Tennessee. Eduard E. Vasilevskis is a staff physician, VA Tennessee Valley Healthcare System, GRECC and an assistant professor of medicine, Center for Health Services Research, Vanderbilt University. Mary S. Dietrich is a professor of biostatistics, School of Nursing and School of Medicine, Vanderbilt University. Nancy Wells is a research professor, Vanderbilt University School of Nursing and Vanderbilt University Medical Center, Nashville, Tennessee. E. Wesley Ely is associate director, VA Tennessee Valley Healthcare System, GRECC, and a professor, Department of Medicine and Center for Health Services Research, Vanderbilt University. Pratik Pandharipande is a professor of anesthesiology and surgery, Vanderbilt University School of Medicine and a staff physician, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System. Lorraine C. Mion is a research professor and interim director of the Center of Excellence in Critical and Complex Care, The Ohio State University School of Nursing, Columbus, Ohio.
| | - Eduard E Vasilevskis
- Leanne M. Boehm is a postdoctoral fellow, Vanderbilt University School of Nursing, a quality scholar, VA Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), and a research nurse, Department of Medicine, Center for Health Services Research, Vanderbilt University, Nashville, Tennessee. Eduard E. Vasilevskis is a staff physician, VA Tennessee Valley Healthcare System, GRECC and an assistant professor of medicine, Center for Health Services Research, Vanderbilt University. Mary S. Dietrich is a professor of biostatistics, School of Nursing and School of Medicine, Vanderbilt University. Nancy Wells is a research professor, Vanderbilt University School of Nursing and Vanderbilt University Medical Center, Nashville, Tennessee. E. Wesley Ely is associate director, VA Tennessee Valley Healthcare System, GRECC, and a professor, Department of Medicine and Center for Health Services Research, Vanderbilt University. Pratik Pandharipande is a professor of anesthesiology and surgery, Vanderbilt University School of Medicine and a staff physician, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System. Lorraine C. Mion is a research professor and interim director of the Center of Excellence in Critical and Complex Care, The Ohio State University School of Nursing, Columbus, Ohio
| | - Mary S Dietrich
- Leanne M. Boehm is a postdoctoral fellow, Vanderbilt University School of Nursing, a quality scholar, VA Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), and a research nurse, Department of Medicine, Center for Health Services Research, Vanderbilt University, Nashville, Tennessee. Eduard E. Vasilevskis is a staff physician, VA Tennessee Valley Healthcare System, GRECC and an assistant professor of medicine, Center for Health Services Research, Vanderbilt University. Mary S. Dietrich is a professor of biostatistics, School of Nursing and School of Medicine, Vanderbilt University. Nancy Wells is a research professor, Vanderbilt University School of Nursing and Vanderbilt University Medical Center, Nashville, Tennessee. E. Wesley Ely is associate director, VA Tennessee Valley Healthcare System, GRECC, and a professor, Department of Medicine and Center for Health Services Research, Vanderbilt University. Pratik Pandharipande is a professor of anesthesiology and surgery, Vanderbilt University School of Medicine and a staff physician, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System. Lorraine C. Mion is a research professor and interim director of the Center of Excellence in Critical and Complex Care, The Ohio State University School of Nursing, Columbus, Ohio
| | - Nancy Wells
- Leanne M. Boehm is a postdoctoral fellow, Vanderbilt University School of Nursing, a quality scholar, VA Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), and a research nurse, Department of Medicine, Center for Health Services Research, Vanderbilt University, Nashville, Tennessee. Eduard E. Vasilevskis is a staff physician, VA Tennessee Valley Healthcare System, GRECC and an assistant professor of medicine, Center for Health Services Research, Vanderbilt University. Mary S. Dietrich is a professor of biostatistics, School of Nursing and School of Medicine, Vanderbilt University. Nancy Wells is a research professor, Vanderbilt University School of Nursing and Vanderbilt University Medical Center, Nashville, Tennessee. E. Wesley Ely is associate director, VA Tennessee Valley Healthcare System, GRECC, and a professor, Department of Medicine and Center for Health Services Research, Vanderbilt University. Pratik Pandharipande is a professor of anesthesiology and surgery, Vanderbilt University School of Medicine and a staff physician, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System. Lorraine C. Mion is a research professor and interim director of the Center of Excellence in Critical and Complex Care, The Ohio State University School of Nursing, Columbus, Ohio
| | - E Wesley Ely
- Leanne M. Boehm is a postdoctoral fellow, Vanderbilt University School of Nursing, a quality scholar, VA Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), and a research nurse, Department of Medicine, Center for Health Services Research, Vanderbilt University, Nashville, Tennessee. Eduard E. Vasilevskis is a staff physician, VA Tennessee Valley Healthcare System, GRECC and an assistant professor of medicine, Center for Health Services Research, Vanderbilt University. Mary S. Dietrich is a professor of biostatistics, School of Nursing and School of Medicine, Vanderbilt University. Nancy Wells is a research professor, Vanderbilt University School of Nursing and Vanderbilt University Medical Center, Nashville, Tennessee. E. Wesley Ely is associate director, VA Tennessee Valley Healthcare System, GRECC, and a professor, Department of Medicine and Center for Health Services Research, Vanderbilt University. Pratik Pandharipande is a professor of anesthesiology and surgery, Vanderbilt University School of Medicine and a staff physician, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System. Lorraine C. Mion is a research professor and interim director of the Center of Excellence in Critical and Complex Care, The Ohio State University School of Nursing, Columbus, Ohio
| | - Pratik Pandharipande
- Leanne M. Boehm is a postdoctoral fellow, Vanderbilt University School of Nursing, a quality scholar, VA Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), and a research nurse, Department of Medicine, Center for Health Services Research, Vanderbilt University, Nashville, Tennessee. Eduard E. Vasilevskis is a staff physician, VA Tennessee Valley Healthcare System, GRECC and an assistant professor of medicine, Center for Health Services Research, Vanderbilt University. Mary S. Dietrich is a professor of biostatistics, School of Nursing and School of Medicine, Vanderbilt University. Nancy Wells is a research professor, Vanderbilt University School of Nursing and Vanderbilt University Medical Center, Nashville, Tennessee. E. Wesley Ely is associate director, VA Tennessee Valley Healthcare System, GRECC, and a professor, Department of Medicine and Center for Health Services Research, Vanderbilt University. Pratik Pandharipande is a professor of anesthesiology and surgery, Vanderbilt University School of Medicine and a staff physician, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System. Lorraine C. Mion is a research professor and interim director of the Center of Excellence in Critical and Complex Care, The Ohio State University School of Nursing, Columbus, Ohio
| | - Lorraine C Mion
- Leanne M. Boehm is a postdoctoral fellow, Vanderbilt University School of Nursing, a quality scholar, VA Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), and a research nurse, Department of Medicine, Center for Health Services Research, Vanderbilt University, Nashville, Tennessee. Eduard E. Vasilevskis is a staff physician, VA Tennessee Valley Healthcare System, GRECC and an assistant professor of medicine, Center for Health Services Research, Vanderbilt University. Mary S. Dietrich is a professor of biostatistics, School of Nursing and School of Medicine, Vanderbilt University. Nancy Wells is a research professor, Vanderbilt University School of Nursing and Vanderbilt University Medical Center, Nashville, Tennessee. E. Wesley Ely is associate director, VA Tennessee Valley Healthcare System, GRECC, and a professor, Department of Medicine and Center for Health Services Research, Vanderbilt University. Pratik Pandharipande is a professor of anesthesiology and surgery, Vanderbilt University School of Medicine and a staff physician, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System. Lorraine C. Mion is a research professor and interim director of the Center of Excellence in Critical and Complex Care, The Ohio State University School of Nursing, Columbus, Ohio
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28
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Roberts RJ, Alhammad AM, Crossley L, Anketell E, Wood L, Schumaker G, Garpestad E, Devlin JW. A survey of critical care nurses' practices and perceptions surrounding early intravenous antibiotic initiation during septic shock. Intensive Crit Care Nurs 2017; 41:90-97. [PMID: 28363592 DOI: 10.1016/j.iccn.2017.02.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 01/07/2017] [Accepted: 02/10/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Delays in antibiotic administration after severe sepsis recognition increases mortality. While physician and pharmacy-related barriers to early antibiotic initiation have been well evaluated, those factors that affect the speed by which critical care nurses working in either the emergency department or the intensive care unit setting initiate antibiotic therapy remains poorly characterized. AIM To evaluate the knowledge, practices and perceptions of critical care nurses regarding antibiotic initiation in patients with newly recognised septic shock. METHODS A validated survey was distributed to 122 critical care nurses at one 320-bed academic institution with a sepsis protocol advocating intravenous(IV) antibiotic initiation within 1hour of shock recognition. RESULTS Among 100 (82%) critical care nurses responding, nearly all (98%) knew of the existence of the sepsis protocol. However, many critical care nurses stated they would optimise blood pressure [with either fluid (38%) or both fluid and a vasopressor (23%)] before antibiotic initiation. Communicated barriers to rapid antibiotic initiation included: excessive patient workload (74%), lack of awareness IV antibiotic(s) ordered (57%) or delivered (69%), need for administration of multiple non-antibiotic IV medications (54%) and no IV access (51%). CONCLUSIONS Multiple nurse-related factors influence IV antibiotic(s) initiation speed and should be incorporated into sepsis quality improvement efforts.
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Affiliation(s)
- Russel J Roberts
- Department of Pharmacy, Tufts Medical Center, 800 Washington Street, Box 420, Boston, MA 02111, USA; School of Pharmacy, Northeastern University, 360 Huntington Ave, R218 TF, Boston, MA 02115, USA.
| | - Abdullah M Alhammad
- Department of Pharmacy, King Khalid University Hospital, P.O. Box 2457, Riyadh 11451, Saudi Arabia.
| | | | - Eric Anketell
- Department of Nursing, Tufts Medical Center, Boston, MA, USA.
| | - LeeAnn Wood
- Department of Nursing, Tufts Medical Center, Boston, MA, USA.
| | - Greg Schumaker
- Division of Pulmonary, Critical Care and Sleep Medicine, USA.
| | - Erik Garpestad
- Division of Pulmonary, Critical Care and Sleep Medicine, USA.
| | - John W Devlin
- School of Pharmacy, Northeastern University, 360 Huntington Ave, R218 TF, Boston, MA 02115, USA; Division of Pulmonary, Critical Care and Sleep Medicine, USA.
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Garpestad E, Devlin JW. Polypharmacy and Delirium in Critically Ill Older Adults: Recognition and Prevention. Clin Geriatr Med 2017; 33:189-203. [PMID: 28364991 DOI: 10.1016/j.cger.2017.01.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Among older adults, polypharmacy is a sequelae of admission to the intensive care unit and is associated with increased medication-associated adverse events, drug interactions, and health care costs. Delirium is prevalent in critically ill geriatric patients and medications remain an underappreciated modifiable risk for delirium in this setting. This article reviews the literature on polypharmacy and delirium, with a focus on highlighting the relationships between polypharmacy and delirium in critically ill, older adults. Discussed are clinician strategies on how to recognize and reduce medication-associated delirium and recommendations that help prevent polypharmacy when interventions to reduce the burden of delirium in this vulnerable population are being formulated.
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Affiliation(s)
- Erik Garpestad
- Division of Pulmonary, Critical Care, and Sleep Medicine, Tufts Medical Center, 200 Washington Street, Boston, MA 02111, USA
| | - John W Devlin
- Division of Pulmonary, Critical Care, and Sleep Medicine, Tufts Medical Center, 200 Washington Street, Boston, MA 02111, USA; School of Pharmacy, Northeastern University, 360 Huntington Avenue 140TF RD218F, Boston, MA 02115, USA.
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30
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Abstract
Delirium is common in critically ill patients and associated with increased length of stay in the intensive care unit (ICU) and long-term cognitive impairment. The pathophysiology of delirium has been explained by neuroinflammation, an aberrant stress response, neurotransmitter imbalances, and neuronal network alterations. Delirium develops mostly in vulnerable patients (e.g., elderly and cognitively impaired) in the throes of a critical illness. Delirium is by definition due to an underlying condition and can be identified at ICU admission using prediction models. Treatment of delirium can be improved with frequent monitoring, as early detection and subsequent treatment of the underlying condition can improve outcome. Cautious use or avoidance of benzodiazepines may reduce the likelihood of developing delirium. Nonpharmacologic strategies with early mobilization, reducing causes for sleep deprivation, and reorientation measures may be effective in the prevention of delirium. Antipsychotics are effective in treating hallucinations and agitation, but do not reduce the duration of delirium. Combined pain, agitation, and delirium protocols seem to improve the outcome of critically ill patients and may reduce delirium incidence.
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Affiliation(s)
- A J C Slooter
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - R R Van De Leur
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - I J Zaal
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
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31
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Sinvani L, Kozikowski A, Pekmezaris R, Akerman M, Wolf-Klein G. Delirium: A Survey of Healthcare Professionals’ Knowledge, Beliefs, and Practices. J Am Geriatr Soc 2016; 64:e297-e303. [DOI: 10.1111/jgs.14544] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Liron Sinvani
- Division of Hospital Medicine; Department of Medicine; Northwell Health; Manhasset New York
| | | | | | - Meredith Akerman
- The Feinstein Institute for Medical Research; Manhasset New York
| | - Gisele Wolf-Klein
- Division of Geriatric and Palliative Medicine; Department of Medicine; Northwell Health; Manhasset New York
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32
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Mo Y, Yam FK. Rational Use of Second-Generation Antipsychotics for the Treatment of ICU Delirium. J Pharm Pract 2016; 30:121-129. [PMID: 26033792 DOI: 10.1177/0897190015585763] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Delirium, described as an acute neuropsychiatric syndrome, occurs commonly in critically ill patients and leads to many negative outcomes including increased mortality and long-term cognitive deficits. Despite the lack of clinical data supporting the use of antipsychotics for the management of intensive care unit (ICU) delirium, pharmacological interventions are often needed to control acutely agitated patients. Given that the most current guidelines do not advocate the use of haloperidol for either the prevention or treatment of ICU delirium due to a lack of evidence, second-generation antipsychotics (SGAs) have been commonly used as alternatives to haloperidol for ICU patients with delirium. Nonetheless, the evidence supporting the use of SGAs to treat ICU delirium remains limited. This review is designed to assess the available clinical evidence and highlights the different neuropharmacological and safety properties of SGAs in order to guide the rational use of SGAs for the treatment of ICU delirium.
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Affiliation(s)
- Yoonsun Mo
- 1 Critical Care, Western New England University College of Pharmacy, Springfield, MA, USA
| | - Felix K Yam
- 2 Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, La Jolla, San Diego, CA, USA
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33
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Mo Y, Zimmermann AE, Thomas MC. Practice Patterns and Opinions on Current Clinical Practice Guidelines Regarding the Management of Delirium in the Intensive Care Unit. J Pharm Pract 2016; 30:162-171. [PMID: 26763340 DOI: 10.1177/0897190015625396] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The aim of this study was to determine current delirium practices in the intensive care unit (ICU) setting and evaluate awareness and adoption of the 2013 Pain, Agitation, and Delirium (PAD) guidelines with emphasis on delirium management. DESIGN, SETTING, AND PARTICIPANTS A large-scale, multidisciplinary, online survey was administered to physician, pharmacist, nurse, and mid-level practitioner members of the Society of Critical Care Medicine (SCCM) between September 2014 and October 2014. A total of 635 respondents completed the survey. MEASUREMENTS AND MAIN RESULTS Nonpharmacologic interventions such as early mobilization were used in most ICUs (83%) for prevention of delirium. A majority of respondents (97%) reported using pharmacologic agents to treat hyperactive delirium. Ninety percent of the respondents answered that they were aware of the 2013 PAD guidelines, and 75% of respondents felt that their delirium practices have been changed as a result of the new guidelines. In addition, logistic regression analysis of this study showed that respondents who use delirium screening tools were twice more likely to be fully aware of key components of the updated guidelines (odds ratio [OR] = 2.07, 95% confidence interval [CI] = 1.20-3.60). CONCLUSIONS Most critical care practitioners are fully aware and knowledgeable of key recommendations in the new guidelines and have changed their delirium practices accordingly.
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Affiliation(s)
- Yoonsun Mo
- 1 Department of Pharmacy Practice, Western New England University College of Pharmacy, Springfield, MA, USA
| | - Anthony E Zimmermann
- 1 Department of Pharmacy Practice, Western New England University College of Pharmacy, Springfield, MA, USA
| | - Michael C Thomas
- 1 Department of Pharmacy Practice, Western New England University College of Pharmacy, Springfield, MA, USA
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Farrokh S, Castle AC, Heavner M, Pisani MA. Continuation Rate of Atypical Antipsychotics After Discharge When Initiated in the Intensive Care Unit. J Pharm Pract 2016; 30:342-346. [DOI: 10.1177/0897190016645026] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: The frequency with which atypical antipsychotics initiated in the intensive care unit (ICU) is unknown. While there is lack of evidence to support the exact duration of treatment, antipsychotics should not be continued chronically for agitation and psychosis related to critical illness. The objective of this study was to determine whether atypical antipsychotics initiated in the ICU at a large tertiary academic medical center were continued after hospital discharge. Safety outcomes were also assessed. Materials: A total of 1023 patients who received atypical antipsychotics during ICU stay were identified. Patients were assessed in a pseudo-randomized fashion until a sample of 191 patients was reached. After review of the exclusion criteria, the final study population was 100 patients. When antipsychotics were discontinued, progress notes were reviewed to identify the reason for discontinuation. Safety outcomes were assessed based on physician documentation in the medical charts. Results: Atypical antipsychotics were continued in 23% of patients. Atypical antipsychotics were discontinued in 1 patient due to QTc prolongation. Conclusions: Atypical antipsychotics initiated in the ICU are frequently continued after hospital discharge. Given the known risks associated with extended therapy, initiatives are needed to prevent inappropriate continuation.
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Affiliation(s)
- Salia Farrokh
- Yale New Haven Hospital, New Haven, CT, USA
- Department of Pharmacy Practice and Administration, Critical Care Clinical Faculty, University of Saint Joseph School of Pharmacy, Hartford, CT, USA
| | | | | | - Margaret A. Pisani
- Yale New Haven Hospital, New Haven, CT, USA
- Yale University School of Medicine, New Haven, CT, USA
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Trogrlić Z, Ista E, Ponssen HH, Schoonderbeek JF, Schreiner F, Verbrugge SJ, Dijkstra A, Bakker J, van der Jagt M. Attitudes, knowledge and practices concerning delirium: a survey among intensive care unit professionals. Nurs Crit Care 2016; 22:133-140. [PMID: 26996876 DOI: 10.1111/nicc.12239] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 02/16/2016] [Accepted: 02/17/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND Delirium is a common form of vital organ dysfunction in intensive care unit (ICU) patients and is associated with poor outcomes. Adherence to guideline recommendations pertaining to delirium is still suboptimal. AIMS We performed a survey aimed at identifying barriers for implementation that should be addressed in a tailored implementation intervention targeted at improved ICU delirium guideline adherence. DESIGN The survey was conducted among ICU professionals. METHODS An online survey was conducted among 360 ICU health care professionals (nurses, physicians and delirium consultants) from six ICUs in the southwest of the Netherlands as part of a multicentre prospective implementation project [response rate: 64% of 565 invited; 283 (79%) were nurses]. RESULTS Although the majority (83%) of respondents considered delirium a common and major problem in the ICU, we identified several barriers for implementation of a delirium guideline. The most important barriers were knowledge deficit, low delirium screening rate, lack of trust in the reliability of delirium screening tools, belief that delirium is not preventable, low familiarity with delirium guidelines, low satisfaction with physician-described delirium management, poor collaboration between nurses and physicians, reluctance to change delirium care practices, lack of time, disbelief that patients would receive optimal care when adhering to the guideline and the perception that the delirium guideline is cumbersome or inconvenient in daily practice. CONCLUSION Although ICU professionals consider delirium a serious problem, several important barriers to adhere to guidelines on delirium management are still present today. RELEVANCE TO CLINICAL PRACTICE Identification of implementation barriers for adherence to guidelines pertaining to delirium is feasible with a survey. Results of this study may help to design-targeted implementation strategies for ICU delirium management.
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Affiliation(s)
- Zoran Trogrlić
- Department of Intensive Care, Erasmus MC, University Medical Centre, Rotterdam, the Netherlands
| | - Erwin Ista
- Department of Pediatric Surgery, Intensive Care Unit, Erasmus MC-Sophia Children's Hospital, University Medical Center, Rotterdam, the Netherlands
| | - Huibert H Ponssen
- Department of Intensive Care, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | | | - Frodo Schreiner
- Department of Intensive Care, IJsselland Hospital, Rotterdam, the Netherlands
| | - Serge J Verbrugge
- Department of Intensive Care, Sint Franciscus Gasthuis, Rotterdam, the Netherlands
| | - Annemieke Dijkstra
- Department of Intensive Care, Maasstad Ziekenhuis, Rotterdam, the Netherlands
| | - Jan Bakker
- Department of Intensive Care, Erasmus MC, University Medical Centre, Rotterdam, the Netherlands
| | - Mathieu van der Jagt
- Department of Intensive Care, Erasmus MC, University Medical Centre, Rotterdam, the Netherlands
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Devlin JW, Michaud CJ, Bullard HM, Harris SA, Thomas WL. Quetiapine for Intensive Care Unit Delirium: The Evidence Remains Weak. Pharmacotherapy 2016; 36:e12-3; discussion e13-4. [DOI: 10.1002/phar.1690] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- John W. Devlin
- School of Pharmacy; Northeastern University; Boston Massachusetts
- Division of Pulmonary, Critical Care and Sleep Medicine; Tufts Medical Center; Boston Massachusetts
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Schrijver EJM, de Graaf K, de Vries OJ, Maier AB, Nanayakkara PWB. Efficacy and safety of haloperidol for in-hospital delirium prevention and treatment: A systematic review of current evidence. Eur J Intern Med 2016; 27:14-23. [PMID: 26553001 DOI: 10.1016/j.ejim.2015.10.012] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 10/14/2015] [Accepted: 10/16/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Haloperidol is generally considered the drug of choice for in-hospital delirium management. We conducted a systematic review to evaluate the evidence for the efficacy and safety of haloperidol for the prevention and treatment of delirium in hospitalized patients. METHODS PubMed, Embase, Cumulative Index to Nursing and Allied Health (CINAHL), PsycINFO, and the Cochrane Library were systematically searched up to April 21, 2015. We included English full-text randomized controlled trials using haloperidol for the prevention or treatment of delirium in adult hospitalized patients reporting on delirium incidence, duration, or severity as primary outcome. Quality of evidence was graded. Meta-analysis was not conducted because of between-study heterogeneity. RESULTS Twelve studies met our inclusion criteria, four prevention and eight treatment trials. Methodological limitations decreased the graded quality of included studies. Results from placebo-controlled prevention studies suggest a haloperidol-induced protective effect for delirium in older patients scheduled for surgery: two studies reported a significant reduction in ICU delirium incidence and one study found a significant reduction in delirium severity and duration. Although placebo-controlled trials are missing, pharmacological treatment of established delirium reduced symptom severity. Haloperidol administration was not associated with treatment-limiting side-effects, but few studies used a systematic approach to identify adverse events. CONCLUSION Although results on haloperidol for delirium management seem promising, current prevention trials lack external validity and treatment trials did not include a placebo arm on top of standard nonpharmacological care. We therefore conclude that the current use of haloperidol for in-hospital delirium is not based on robust and generalizable evidence.
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Affiliation(s)
- E J M Schrijver
- VU University Medical Center, Section Acute Medicine, Section Gerontology, Department of Internal Medicine, De Boelelaan 1117, 1007 MB Amsterdam, The Netherlands.
| | - K de Graaf
- VU University Medical Center, Section Acute Medicine, Section Gerontology, Department of Internal Medicine, De Boelelaan 1117, 1007 MB Amsterdam, The Netherlands.
| | - O J de Vries
- VU University Medical Center, Section Acute Medicine, Section Gerontology, Department of Internal Medicine, De Boelelaan 1117, 1007 MB Amsterdam, The Netherlands.
| | - A B Maier
- VU University Medical Center, Section Acute Medicine, Section Gerontology, Department of Internal Medicine, De Boelelaan 1117, 1007 MB Amsterdam, The Netherlands.
| | - P W B Nanayakkara
- VU University Medical Center, Section Acute Medicine, Section Gerontology, Department of Internal Medicine, De Boelelaan 1117, 1007 MB Amsterdam, The Netherlands.
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Rowe AS, Hamilton LA, Curtis RA, Davis CR, Smith LN, Peek GK, Reynolds VW. Risk factors for discharge on a new antipsychotic medication after admission to an intensive care unit. J Crit Care 2015; 30:1283-6. [DOI: 10.1016/j.jcrc.2015.08.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 08/10/2015] [Accepted: 08/13/2015] [Indexed: 11/27/2022]
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Sri-On J, Tirrell GP, Wuthisuthimethawee P, Liu SW. Knowledge and practices of Thai emergency physicians regarding the care of delirious elderly patients. Int J Emerg Med 2015; 7:38. [PMID: 25635198 PMCID: PMC4306074 DOI: 10.1186/s12245-014-0038-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Accepted: 09/09/2014] [Indexed: 11/17/2022] Open
Abstract
Background The Society for Academic Emergency Medicine (SAEM) Geriatric Emergency Medicine Task Force recommends assessment of delirium for all elderly emergency department (ED) patients. Little is known about emergency physicians' (EPs) opinions regarding care of delirious elderly patients. We sought to determine the knowledge and practice experience of members of the Thai Association for Emergency Medicine regarding the care of delirious elderly ED patients. Methods We surveyed all Thai emergency physicians from July to September 2013 using a brief online survey as this does not include any non-trained physician working in the private/provincial/community EDs, still a significant part of the ED workforce in Thailand. Results We had a response rate of 50% (239/474) of which 95% (228/239) completed the survey. Respondents largely reported that <10% of their patients experience delirium. Eighty-five percent of the respondents recognized delirium as a problem that required active intervention, and 76% of the respondents thought it was underdiagnosed in the ED. Only 24% of the respondents reported routinely screening delirium in the ED and 16% reported using a specific screening tool for delirium assessment. Forty-two percent of the respondents reported treating delirium with a long acting benzodiazepine and 29% reported using haloperidol. Forty percent of respondents thought that oversedation was the most common complication associated with drug treatment of delirium. Conclusions Basic knowledge and perceptions surrounding the recognition, diagnosis, and treatment of delirium in elderly ED patients by Thai EPs vary. Most of the Thai EPs consider delirium in the ED an emergency condition, while far fewer screen for this condition. Future research and quality improvement should determine which single screening tool is appropriate for EPs in regular practice as well as how to standardize delirium management in the ED.
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Affiliation(s)
- Jiraporn Sri-On
- Emergency Department, Vajira Hospital, Faculty of Medicine, Navamindradhiraj University, Khao street, Wachira Phayaban, Dusit 10300, Bangkok, Thailand ; Emergency Department, Massachusetts General Hospital (MGH), 55 Fruit St, Boston 02114, MA, USA
| | - Gregory Philip Tirrell
- Emergency Department, Massachusetts General Hospital (MGH), 55 Fruit St, Boston 02114, MA, USA
| | - Prasit Wuthisuthimethawee
- Emergency Department, Prince of Songklanagarind University, 15 Karnchanavanich Street, Hatyai 90110, Songkla, Thailand
| | - Shan Woo Liu
- Emergency Department, Massachusetts General Hospital (MGH), 55 Fruit St, Boston 02114, MA, USA
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Recognition and management of delirium among doctors, nurses, physiotherapists, and psychologists: an Italian survey. Int Psychogeriatr 2014; 26:2093-102. [PMID: 25137033 DOI: 10.1017/s1041610214001653] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND There are no studies that have identified the ability to recognize and manage delirium among Italian health providers caring for patients at risk. Therefore, the Italian Association of Psychogeriatrics (AIP) conducted a multicenter survey among doctors, nurses, psychologists and physiotherapists to assess their competence regarding the theme of delirium and its management in the everyday clinical practice. METHODS The survey period was 1st June 2013 to 30th November 2013. The invitation to participate was sent via email, with publication on the AIP website. The survey included 14 questions and two case vignettes. RESULTS A total of 648/1,500 responses were collected. Most responders were doctors (n = 322/800), followed by nurses (n = 225/500), psychologists (n = 51/100), and physiotherapists (n = 30/100). Generally, doctors and psychologists correctly defined delirium, while nurses and physiotherapists did not. The most frequently used diagnostic tools were the Confusion Assessment Method (CAM) and the Diagnostic and Statistical Manual of Mental Disorders-IV. Delirium intensity was rarely assessed. Hypoactive delirium was generally managed with non-pharmacological approaches, while hyperactive delirium with a combination of non-pharmacological and pharmacological approaches. However, possible causes of delirium were under-assessed by half of doctors and by the majority of other professionals. Nurses, psychologists and physiotherapists did not answer the case vignettes, while doctors identified the correct answer in most cases. CONCLUSIONS This is the first Italian survey among health providers caring for patients at risk of delirium. This is also the first survey including doctors, nurses, psychologists and physiotherapists. The results emphasize the importance of training to improve knowledge of this relevant unmet medical need.
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Delirium, sedation and analgesia in the intensive care unit: a multinational, two-part survey among intensivists. PLoS One 2014; 9:e110935. [PMID: 25398099 PMCID: PMC4232258 DOI: 10.1371/journal.pone.0110935] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 09/25/2014] [Indexed: 11/19/2022] Open
Abstract
Analgesia, sedation and delirium management are important parts of intensive care treatment as they are relevant for patients' clinical and functional long-term outcome. Previous surveys showed that despite this fact implementation rates are still low. The primary aim of the prospective, observational multicenter study was to investigate the implementation rate of delirium monitoring among intensivists. Secondly, current practice concerning analgesia and sedation monitoring as well as treatment strategies for patients with delirium were assesed. In addition, this study compares perceived and actual practice regarding delirium, sedation and analgesia management. Data were obtained with a two-part, anonymous survey, containing general data from intensive care units in a first part and data referring to individual patients in a second part. Questionnaires from 101 hospitals (part 1) and 868 patients (part 2) were included in data analysis. Fifty-six percent of the intensive care units reported to monitor for delirium in clinical routine. Fourty-four percent reported the use of a validated delirium score. In this respect, the survey suggests an increasing use of delirium assessment tools compared to previous surveys. Nevertheless, part two of the survey revealed that in actual practice 73% of included patients were not monitored with a validated score. Furthermore, we observed a trend towards moderate or deep sedation which is contradicting to guideline-recommendations. Every fifth patient was suffering from pain. The implementation rate of adequate pain-assessment tools for mechanically ventilated and sedated patients was low (30%). In conclusion, further efforts are necessary to implement guideline recommendations into clinical practice. The study was registered (ClinicalTrials.gov identifier: NCT01278524) and approved by the ethical committee.
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Xin C, Ge X, Yang X, Lin M, Jiang C, Xia Z. The impact of pharmaceutical care on improving outcomes in patients with type 2 diabetes mellitus from China: a pre- and postintervention study. Int J Clin Pharm 2014; 36:963-8. [DOI: 10.1007/s11096-014-9978-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Accepted: 06/20/2014] [Indexed: 10/25/2022]
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Acute Hyperglycemia Associated with Short-Term Use of Atypical Antipsychotic Medications. Drugs 2014; 74:183-94. [DOI: 10.1007/s40265-013-0171-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Kalabalik J, Brunetti L, El-Srougy R. Intensive care unit delirium: a review of the literature. J Pharm Pract 2013; 27:195-207. [PMID: 24326408 DOI: 10.1177/0897190013513804] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE The recent literature regarding intensive care unit (ICU) delirium and updated clinical practice guidelines are reviewed. SUMMARY Recent studies show that ICU delirium in critically ill patients is an independent predictor of higher mortality, longer ICU and hospital stay, and is associated with multiple clinical complications. Delirium has been reported to occur in greater than 80% of hospitalized critically ill patients, yet it remains an underdiagnosed condition. Several subtypes of delirium have been identified including hypoactive, hyperactive, and mixed presentation. Although the exact mechanism is unknown, several factors are thought to interact to cause delirium. Multiple risk factors related to medications, acute illness, the environment, and patient characteristics may contribute to the development of delirium. Practical bedside screening tools have been validated and are recommended to identify ICU patients with delirium. Nonpharmacologic interventions such as early mobilization have resulted in better functional outcomes, decreased incidence and duration of delirium, and more ventilator-free days. Data supporting pharmacologic treatments are limited. CONCLUSION Clinicians should become familiar with tools to identify delirium in order to initiate treatment and remove mitigating factors early in hospitalization to prevent delirium. Pharmacists are in a unique position to reduce delirium through minimization of medication-related risk factors and development of protocols.
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Affiliation(s)
- Julie Kalabalik
- School of Pharmacy, Fairleigh Dickinson University, Florham Park, NJ, USA
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Abstract
BACKGROUND There are still substantial uncertainties over best practice in delirium care. The European Delirium Association (EDA) conducted a survey of its members and other interested parties on various aspects of delirium care. METHODS The invitation to participate in the online survey was distributed among the EDA membership. The survey covered assessment, treatment of hyperactive and hypoactive delirium, and organizational management. RESULTS A total of 200 responses were collected (United Kingdom 28.6%, Netherlands 25.3%, Italy 15%, Switzerland 9.7%, Germany 7.1%, Spain 3.8%, Portugal 2.5%, Ireland 2.5%, Sweden 0.6%, Denmark 0.6%, Austria 0.6%, and others 3.2%). Most of the responders were doctors (80%), working in geriatrics (45%) or internal medicine (14%). Ninety-two per cent of the responders assessed patients for delirium daily. The most commonly used assessment tools were the Confusion Assessment Method (52%) and the Delirium Observation Screening Scale (30%). The first-line choice in the management of hyperactive delirium was a combination of non-pharmacological and pharmacological approaches (61%). Conversely, non-pharmacological management was the first-line choice in hypoactive delirium (67%). Delirium awareness (34%), knowledge (33%), and lack of education (13%) were the most commonly reported barriers to improving the detection of delirium. Interestingly, 63% of the responders referred patients after an episode of delirium to a follow-up clinic. CONCLUSIONS This is the first systematic survey involving an international group of specialists in delirium. Several areas of lack of consensus were found. These results emphasise the importance of further research to improve care of this major unmet medical need.
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Meagher DJ, McLoughlin L, Leonard M, Hannon N, Dunne C, O'Regan N. What do we really know about the treatment of delirium with antipsychotics? Ten key issues for delirium pharmacotherapy. Am J Geriatr Psychiatry 2013; 21:1223-38. [PMID: 23567421 DOI: 10.1016/j.jagp.2012.09.008] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Revised: 09/06/2012] [Accepted: 09/26/2012] [Indexed: 12/31/2022]
Abstract
Despite the significant burden of delirium among hospitalized adults, no pharmacologic intervention is approved for delirium treatment. Antipsychotic agents are the best studied but there are uncertainties as to how these agents can be optimally applied in everyday practice. We searched Medline and PubMed databases for publications from 1980 to April 2012 to identify studies of delirium treatment with antipsychotic agents. Studies of primary prevention using pharmacotherapy were not included. We identified 28 prospective studies that met our inclusion criteria, of which 15 were comparison studies (11 randomized), 2 of which were placebo-controlled. The quality of comparison studies was assessed using the Jadad scale. The DRS (N = 12) and DRS-R98 (N = 9) were the most commonly used instruments for measuring responsiveness. These studies suggest that around 75% of delirious patients who receive short-term treatment with low-dose antipsychotics experience clinical response. Response rates appear quite consistent across different patient groups and treatment settings. Studies do not suggest significant differences in efficacy for haloperidol versus atypical agents, but report higher rates of extrapyramidal side effects with haloperidol. Comorbid dementia may be associated with reduced response rates but this requires further study. The available evidence does not indicate major differences in response rates between clinical subtypes of delirium. The extent to which therapeutic effects can be explained by alleviation of specific symptoms (e.g. sleep or behavioral disturbances) versus a syndromal effect that encompasses both cognitive and noncognitive symptoms of delirium is not known. Future research needs to explore the relationship between therapeutic effects and changes in pathophysiological markers of delirium. Less than half of reports were rated as reasonable quality evidence on the Jadad scale, highlighting the need for future studies of better quality design, and in particular incorporating placebo-controlled work.
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Affiliation(s)
- David J Meagher
- Department of Adult Psychiatry, University Hospital Limerick, Ireland; University of Limerick Medical School, Limerick, Ireland; Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Ireland.
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Michaud CJ, Thomas WL, McAllen KJ. Early Pharmacological Treatment of Delirium May Reduce Physical Restraint Use. Ann Pharmacother 2013; 48:328-34. [DOI: 10.1177/1060028013513559] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Introduction: Evidence surrounding pharmacological treatment of delirium is limited. The negative impact of physical restraints on patient outcomes in the intensive care unit (ICU), however, is well published. The objective of this study was to evaluate whether initiating pharmacologic delirium treatment within 24 hours of a positive screen reduces the number of days in physical restraints and improves patient outcomes compared with delayed or no treatment. Methods: Patients from a mixed ICU with a documented positive delirium score using the Intensive Care Delirium Screening Checklist were retrospectively grouped based on having received pharmacologic treatment within 24 hours of the first positive screen or not. Primary end points were number of days spent in physical restraints and time to extubation after delirium onset. Secondary end points included hospital and ICU length of stay (LOS) and survival to discharge. Results: Two hundred intubated patients were either pharmacologically treated (n = 98) or not treated (n = 102) within 24 hours of the first positive delirium score. Patients receiving treatment spent a shorter median time in restraints compared with patients who were not treated (3 vs 6 days; P < .001), and had a shorter median time to extubation (3 vs 6.5 days; P < .001). The treatment group also experienced a shorter ICU LOS (9.5 vs 16 days; P < .001) and hospital LOS (14.5 vs 22 days; P < .001) compared with the no-treatment group. Conclusions: Delirious patients who received pharmacological treatment within 24 hours of the first positive screen spent fewer days in physical restraints and less time receiving mechanical ventilation compared with those who did not. Although delirium management is multifactorial, early pharmacological therapy may benefit patients diagnosed with delirium.
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Benzodiazepine versus nonbenzodiazepine-based sedation for mechanically ventilated, critically ill adults: a systematic review and meta-analysis of randomized trials. Crit Care Med 2013; 41:S30-8. [PMID: 23989093 DOI: 10.1097/ccm.0b013e3182a16898] [Citation(s) in RCA: 185] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Use of dexmedetomidine or propofol rather than a benzodiazepine sedation strategy may improve ICU outcomes. We reviewed randomized trials comparing a benzodiazepine and nonbenzodiazepine regimen in mechanically ventilated adult ICU patients to determine if differences exist between these sedation strategies with respect to ICU length of stay, time on the ventilator, delirium prevalence, and short-term mortality. METHODS We searched CINAHL, MEDLINE, the Cochrane databases, and the American College of Critical Care Medicine's Pain, Agitation, Delirium Management Guidelines' literature database from 1996 to 2013. Citations were screened for randomized trials that enrolled critically ill, mechanically ventilated adults comparing an IV benzodiazepine-based to a nonbenzodiazepine-based sedative regimen and reported duration of ICU length of stay, duration of mechanical ventilation, delirium prevalence, and/or short-term mortality. Trial characteristics and results were abstracted in duplicate and independently, and the Cochrane risk of bias tool was used for quality assessment. We performed random effects model meta-analyses where possible. RESULTS We included six trials enrolling 1,235 patients: midazolam versus dexmedetomidine (n = 3), lorazepam versus dexmedetomidine (n = 1), midazolam versus propofol (n = 1), and lorazepam versus propofol (n = 1). Compared to a benzodiazepine sedative strategy, a nonbenzodiazepine sedative strategy was associated with a shorter ICU length of stay (n = 6 studies; difference = 1.62 d; 95% CI, 0.68-2.55; I = 0%; p = 0.0007) and duration of mechanical ventilation (n = 4 studies; difference = 1.9 d; 95% CI, 1.70-2.09; I2 = 0%; p < 0.00001) but a similar prevalence of delirium (n = 2; risk ratio = 0.83; 95% CI, 0.61-1.11; I2 = 84%; p = 0.19) and short-term mortality rate (n = 4; risk ratio = 0.98; 95% CI, 0.76-1.27; I2 = 30%; p = 0.88). CONCLUSIONS Current controlled data suggest that use of a dexmedetomidine- or propofol-based sedation regimen rather than a benzodiazepine-based sedation regimen in critically ill adults may reduce ICU length of stay and duration of mechanical ventilation. Larger controlled studies are needed to further define the impact of nonbenzodiazepine sedative regimens on delirium and short-term mortality.
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Passmore MJ, Virani A, Hendel K. Antipsychotic options for delirium-related agitation--a multidisciplinary practitioner survey. Issues Ment Health Nurs 2013; 34:836-8. [PMID: 24131416 DOI: 10.3109/01612840.2013.821565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
The management of pain, agitation, and delirium in critically ill patients can be complicated by multiple factors. Decisions to administer opioids, sedatives, and antipsychotic medications are frequently driven by a desire to facilitate patients' comfort and their tolerance of invasive procedures or other interventions within the ICU. Despite accumulating evidence supporting new strategies to optimize pain, sedation, and delirium practices in the ICU, many critical care practitioners continue to embrace false perceptions regarding appropriate management in these critically ill patients. This article explores these perceptions in more detail and offers new evidence-based strategies to help critical care practitioners better manage sedation and delirium, particularly in ICU patients.
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