Delirium after a traumatic brain injury: predictors and symptom patterns

An Improvised External Ventricular Drain Fixation Technique to Avoid Pullout-Related Complications in a Low-Resource Setting: A Descriptive Cross-Sectional Study in a Single Center of Nepal

BACKGROUND AND OBJECTIVES

An external ventricular drain (EVD) placement is a commonly performed life-saving procedure. Its accidental pullout can occur in complex environments, patient care, and positioning, which leads to significant morbidity. The method of EVD fixation and pullout rates is sparsely described in the literature, and there exists a wide variation among the techniques practiced for fixation. However, some techniques require additional tools, which are expensive and unavailable in low-resource settings. We describe an improvised method of securely fixing the EVD to the scalp applicable in low-resources and describe the EVD pullout rate with the use of this technique.

METHODS

A retrospective review of pullout-related complications in 107 consecutive patients was performed. The EVD was fixed to the scalp using an improvised technique to loop the catheter around a soft flange and secure it with sutures.

RESULTS

Pullout occurred in 1 patient (0.93%), who was in an alcohol withdrawal state and deliberately pulled out the catheter. There were zero nondeliberate pullouts.

CONCLUSION

EVD fixation by coiling the catheter around a soft flange has a low pullout rate. Because it is secure and requires only a flange, it is suitable for low-resource settings.

Traumatic Brain Injury Patients Admitted on High-Census Days Receive Less Critical Care and Have an Increased Risk for Delirium

INTRODUCTION

The utilization of healthcare services in a growing population has raised concerns about its impact on clinical outcomes. Studies have shown that increased hospital census is associated with higher admission rates and unnecessary consults, tests, and procedures in various areas of healthcare. Traumatic brain injuries (TBIs), a significant concern due to their potential for long-term disabilities, are commonly encountered in intensive care units (ICUs) and are a leading cause of patient mortality. Despite extensive research on various aspects of TBI, the effect of the patient census on TBI outcomes remains unexplored. This study aims to investigate the relationship between healthcare provider patient census and clinical outcomes in TBI patients at a level I trauma center.

METHODS

A retrospective review was conducted from 2017 to 2022. The mean number of patients per day in the trauma service was determined, with patients below this average considered to be present on low-census days and those above it on high-census days. Patient demographics, mechanisms of injury, vital signs, TBI severity, and associated injuries were analyzed. Adjusted regression analyses were conducted.

RESULTS

Over the study period, 1,527 TBI patients were identified. Demographics were similar between patients admitted on high- and low-census days. Patients with moderate TBI were 30% less likely to be admitted to the ICU on high-census days, whereas there was no difference in ICU admission for patients with mild or severe TBI. Delirium was significantly higher in patients admitted on high-census days compared to those on low-census days. This was further identified to be predominantly driven by patients with mild TBI admitted on high-census days.

CONCLUSION

While most outcomes remained consistent, significant rates of delirium were found in our mild TBI patients admitted on high-census days suggesting the need for additional factors in the evaluation of these patients on admission. This study also reveals potential under-triage in moderate TBI patients on high-census days as they had significantly lower rates of ICU admission. These findings emphasize the need for further investigations to optimize patient care strategies within the context of fluctuating healthcare system demands.

Post-Intensive Care Syndrome in Neurocritical Care Patients

Post-intensive care syndrome (PICS) refers to unintended consequences of critical care that manifest as new or worsening impairments in physical functioning, cognitive ability, or mental health. As intensive care unit (ICU) survival continues to improve, PICS is becoming increasingly recognized as a public health problem. Studies that focus on PICS have typically excluded patients with acute brain injuries and chronic neurodegenerative problems. However, patients who require neurocritical care undoubtedly suffer from impairments that overlap substantially with those encompassed by PICS. A major challenge is to distinguish between impairments related to brain injury and those that occur as a consequence of critical care. The general principles for the prevention and management of PICS and multidomain impairments in patients with moderate and severe neurological injuries are similar including the ICU liberation bundle, multidisciplinary team-based care throughout the continuum of care, and increasing awareness regarding the challenges of critical care survivorship among patients, families, and multidisciplinary team members. An extension of this concept, PICS-Family (PICS-F) refers to the mental health consequences of the intensive care experience for families and loved ones of ICU survivors. A dyadic approach to ICU survivorship with an emphasis on recognizing families and caregivers that may be at risk of developing PICS-F after neurocritical care illness can help improve outcomes for ICU survivors. In this review, we will summarize our current understanding of PICS and PICS-F, emerging literature on PICS in severe acute brain injury, strategies for preventing and treating PICS, and share our recommendations for future directions.

The effect of dexmedetomidine on the postoperative recovery of patients with severe traumatic brain injury undergoing craniotomy treatment: a retrospective study

BACKGROUND

Traumatic brain injury (TBI) has been a worldwide problem for neurosurgeons. Patients with severe TBI may undergo craniotomy. These patients often require sedation after craniotomy. Dexmedetomidine (DEX) has been used in patients receiving anesthesia and in intensive care units. Not much is known about the postoperative effect of DEX in patients with severe TBIs undergoing craniotomy. The purpose of this study was to explore the effects of postoperative DEX administration on severe TBI patients who underwent craniotomy.

METHODS

Patients who underwent craniectomy for severe TBI at our hospital between January 2019 and February 2022 were included in this study. The patients were admitted to the intensive care unit (ICU) after surgery to receive sedative medication. The patients were then divided into DEX and control groups. We analyzed the sedation, hemodynamics, and other conditions of the patients (hypoxemia, duration of ventilation during endotracheal intubation, whether tracheotomy was performed, and the duration in the ICU) during their ICU stay. Other conditions, such as delirium after the patients were transferred to the general ward, were also analyzed.

RESULTS

A total of 122 patients were included in this study. Among them, 53 patients received DEX, and the remaining 69 did not. The incidence of delirium in the general ward in the DEX group was significantly lower than that in the control group (P < 0.05). The incidence of bradycardia in the control group was significantly lower than that in the DEX group (P < 0.05). Other data from the DEX group and the control group (hypotension, hypoxemia, etc.) were not significantly different (P > 0.05).

CONCLUSION

The use of DEX in the ICU can effectively reduce the incidence of delirium in patients who return to the general ward after craniotomy. DEX had no adverse effect on the prognosis of patients other than causing bradycardia.

Level of implementation of pain management and early mobilization strategies to prevent delirium in geriatric trauma patients: A mixed-methods study

BACKGROUND

Pain management and early mobilization strategies are recommended in clinical practice guidelines for the prevention of delirium in older adults. However, available data on the implementation of these strategies in trauma are limited.

AIMS

To describe the use of pain management and early mobilization strategies in older adults at a level I trauma center, as well as the facilitators and barriers to their implementation.

METHODS

A convergent mixed methods study was used. Quantitative data were collected from sixty medical records. Qualitative data was collected through a focus group with healthcare providers to explore their perspectives regarding the use of the target practices and on barriers and facilitators to their implementation. Descriptive statistics were calculated, and a thematic analysis using an inductive and deductive interpretative descriptive approach was undertaken.

RESULTS

A question on the presence/absence of pain was the most frequently documented pain assessment method. Pain assessment was poorly documented. Frequencies of non-opioid and opioid administrations were similar, but non-pharmacological strategies were not widely used. The first mobilization was performed quickly and was most commonly to a chair. The focus group discussion confirmed many of the data collected in the medical records. Barriers to implementing the targeted strategies were primarily related to organizational context and facilitation processes.

CONCLUSIONS

Areas for improvement were identified including pain assessment, the use of non-pharmacological pain management strategies and ambulation as a mobilization strategy. Our findings will serve as a starting point for optimizing and adapting practices for geriatric trauma patients and evaluating their impact.

Prevention and treatment of traumatic brain injury-related delirium: a systematic review

BACKGROUND

Our systematic review examines the effectiveness and safety of non-pharmacologic and pharmacologic interventions in preventing or treating traumatic brain injury (TBI)-related delirium in acute care.

METHODS

We searched four electronic databases (MEDLINE, EMBASE, CENTRAL/CDSR, and PsycINFO) to identify randomized controlled trials (RCTs), quasi-experimental, and observational studies. Eligible studies included adults with TBI, at least one comparator group, delirium as an outcome and took place in acute care. Two reviewers independently completed all study screening, data abstraction, and risk of bias assessment using the Cochrane risk of bias 2 tool for RCTs or risk of bias in non-randomized studies-of interventions tool for observational studies. We implemented the PROGRESS-Plus framework to describe social determinants of health (SDoH) reporting.

RESULTS

We identified 20,022 citations, reviewed 301 in full text, and included eight studies in the descriptive synthesis. The mean age of study participants ranged from 32 to 62 years. 12.5% of included studies reported SDoH. Included studies had moderate-to-high risk of bias. Studies compared reorientation programs and an intervention bundle to usual care, but these interventions were not better than usual care in treating TBI-related delirium. Individual studies found that rosuvastatin and aripiprazole were more efficacious than placebo, and dexmedetomidine was more efficacious than propofol and haloperidol for preventing TBI-related delirium. No studies reported safety as the primary outcome.

CONCLUSIONS

We identified efficacious pharmacologic interventions for preventing TBI-related delirium, but these studies were at moderate-to-high risk of bias, which limits our confidence in these findings. Future studies should incorporate safety outcomes, and a diverse study population, including older adults.

Neurological Examination Frequency and Time-to-Delirium After Traumatic Brain Injury

BACKGROUND

Frequent neurological examinations in patients with traumatic brain injury (TBI) disrupt sleep-wake cycles and potentially contribute to the development of delirium.

OBJECTIVE

To evaluate the risk of delirium among patients with TBI with respect to their neuro-check frequencies.

METHODS

A retrospective study of patients presenting with TBI at a single level I trauma center between January 2018 and December 2019. The primary exposure was the frequency of neurological examinations (neuro-checks) assigned at the time of admission. Patients admitted with hourly (Q1) neuro-check frequencies were compared with those who received examinations every 2 (Q2) or 4 (Q4) hours. The primary outcomes were delirium and time-to-delirium. The onset of delirium was defined as the first documented positive Confusion Assessment Method for the Intensive Care Unit score.

RESULTS

Of 1552 patients with TBI, 458 (29.5%) patients experienced delirium during their hospital stay. The median time-to-delirium was 1.8 days (IQR: 1.1, 2.9). Kaplan-Meier analysis demonstrated that patients assigned Q1 neuro-checks had the greatest rate of delirium compared with the patients with Q2 and Q4 neuro-checks ( P < .001). Multivariable Cox regression modeling demonstrated that Q2 neuro-checks (hazard ratio: 0.439, 95% CI: 0.33-0.58) and Q4 neuro-checks (hazard ratio: 0.48, 95% CI: 0.34-0.68) were protective against the development of delirium compared with Q1. Other risk factors for developing delirium included pre-existing dementia, tobacco use, lower Glasgow Coma Scale score, higher injury severity score, and certain hemorrhage patterns.

CONCLUSION

Patients with more frequent neuro-checks had a higher risk of developing delirium compared with those with less frequent neuro-checks.

Calibration of the PREdiction of DELIRium in ICu Patients (PRE-DELIRIC) Score in a Cohort of Critically Ill Patients: A Retrospective Cohort Study

BACKGROUND

To predict delirium in intensive care unit (ICU) patients, the Prediction of Delirium in ICU Patients (PRE-DELIRIC) score may be used. This model may help nurses to predict delirium in high-risk ICU patients.

OBJECTIVES

The aims of this study were to externally validate the PRE-DELIRIC model and to identify predictive factors and outcomes for ICU delirium.

METHOD

All patients underwent delirium risk assessment by the PRE-DELIRIC model at admission. We used the Intensive Care Delirium Screening Check List to identify patients with delirium. The receiver operating characteristic curve measured discrimination capacity among patients with or without ICU delirium. Calibration ability was determined by slope and intercept.

RESULTS

The prevalence of ICU delirium was 55.8%. Discrimination capacity (Intensive Care Delirium Screening Check List score ≥4) expressed by the area under the receiver operating characteristic curve was 0.81 (95% confidence interval, 0.75-0.88), whereas sensitivity was 91.3% and specificity was 64.4%. The best cut-off was 27%, obtained by the max Youden index. Calibration of the model was adequate, with a slope of 1.03 and intercept of 8.14. The onset of ICU delirium was associated with an increase in ICU length of stay (P < .0001), higher ICU mortality (P = .008), increased duration of mechanical ventilation (P < .0001), and more prolonged respiratory weaning (P < .0001) compared with patients without delirium.

DISCUSSION

The PRE-DELIRIC score is a sensitive measure that may be useful in early detection of patients at high risk for developing delirium. The baseline PRE-DELIRIC score could be useful to trigger use of standardized protocols, including nonpharmacologic interventions.

Factors Affecting Delirium in ICU Patients

This study examined delirium severity using a delirium screening tool and analyzed the predictors, including pain, acuity, level of consciousness, fall risk, and pain score, to increase understanding of delirium and present foundational data for developing nursing interventions for delirium prevention. This was a retrospective study of 165 patients admitted to three intensive care units (ICUs). the Nursing Delirium Screening Scale (Nu-DESC) was used as a research tool to screen for delirium and measure the degree of delirium. The incidence of delirium in patients was 53.3%, and the average delirium score in the delirium group was 2.40 ± 0.56. Nu-DESC scores were significantly correlated with ICU days, ventilator days, restraint applications, the number of catheters inserted, sedative medication use, the Simplified Acute Physiology Score (SAPS III), the Morse Fall Scale (MFS), the Glasgow Coma Scale (GCS) scores, pain scores, and blood urea nitrogen (BUN). Stepwise multiple linear regression showed that the number of restraint applications, GCS score, ICU days, and BUN levels were factors influencing delirium. Based on the findings, ICU nurses should use delirium screening tools to ensure accurate delirium screening and work to reduce the incidence and degree of delirium by observing factors affecting delirium in patients.

Delusions and Hallucinations Are Associated With Greater Severity of Delirium

BACKGROUND

The 3 core domains of delirium (cognitive, higher level thinking, circadian) do not include the less common noncore psychotic symptoms. However, psychosis might inform about perturbations of neural circuitry, outcomes, or suggest tailored clinical management.

OBJECTIVE

We assessed for the first time the relationships between psychosis and other characteristics of delirium in patients without confounders for delirium phenotype, such as dementia or antipsychotics treatment.

METHODS

Cross-sectional analysis of 366 adults with delirium per the Delirium Rating Scale Revised-98, whose items distinguish hallucinations and delusions from other types of misperceptions and abnormal thought content, assessed during the preceding 24 hours to capture symptom severity fluctuation. The relationship of psychosis with other delirium characteristics was assessed using bivariate comparisons and analysis of variance as appropriate for groups with no psychosis and any psychosis (hallucinations and/or delusions), and subgroups with only hallucinations, only delusions, or both. A discriminant logistic model assessed variables associated with presence of any psychotic features versus none.

RESULTS

Delirium with any psychotic features occurred in 44.5% (163 of 366). Of the 366, 119 (32.5%) had only hallucinations (Hall), 14 (3.8%) had only delusions (Del), and 30 (8.2%) had both (Both). In the psychotic group (n = 163), 73.0% were Hall, 8.6% Del, and 18.4% Both. All psychotic patient groupings had significantly greater delirium severity on the Delirium Rating Scale Revised-98. Delusions and hallucinations were discordant for occurring together. The discriminant model found increased odds of having psychosis as 3 symptom severities increased (visuospatial ability, thought process, and sleep-wake cycle) where these each represented a delirium core domain. The noncore symptom of lability of affect had high odds ratio for psychosis, while motor retardation reduced odds of psychosis in this model.

CONCLUSIONS

Consistent with prior reports, psychosis occurred in less than half of delirious patients with delusions being infrequent, and an association with affective lability was found. We are the first to report that psychotic features are a marker for more severe delirium affecting all core domains. Given that previous functional magnetic resonance imaging research found a correlation between neural network dysconnectivity with greater severity of delirium, psychotic symptoms might be a clinical marker for greater underlying cerebral cortical neural circuitry dysfunction.

Psychiatric mimics of neurosurgical disorders

Every year there are about 22.6 million people in need of neurosurgical care around the world, and one or several interventions are required to save lives and restore functional losses in more than half of these cases (13.8 million). Most neurosurgical interventions are performed in patients with traumatic brain and spinal cord injuries, strokes, central nervous system (CNS) tumors, hydrocephalus, and epilepsy. In addition to neurological symptoms, many CNS disorders are often accompanied by cognitive and/or behavioral changes. Physical and psychological symptoms can be intertwined as follows: 1) neurological symptoms may be manifested as a result of complex psychological processes; 2) psychological disorders may be manifested as neurological symptoms; 3) neurological disorders commonly cause secondary psychological responses; 4) psychological disorder may be induced more or less directly by an organic brain disease. In the present paper, we focus on the psychiatric conditions occurring in the patients with neurosurgical disorders who either get prepared for surgery or have already received it.

Chronic cerebral aspects of long COVID, post-stroke syndromes and similar states share their pathogenesis and perispinal etanercept treatment logic

The chronic neurological aspects of traumatic brain injury, post-stroke syndromes, long COVID-19, persistent Lyme disease, and influenza encephalopathy having close pathophysiological parallels that warrant being investigated in an integrated manner. A mechanism, common to all, for this persistence of the range of symptoms common to these conditions is described. While TNF maintains cerebral homeostasis, its excessive production through either pathogen-associated molecular patterns or damage-associated molecular patterns activity associates with the persistence of the symptoms common across both infectious and non-infectious conditions. The case is made that this shared chronicity arises from a positive feedback loop causing the persistence of the activation of microglia by the TNF that these cells generate. Lowering this excess TNF is the logical way to reducing this persistent, TNF-maintained, microglial activation. While too large to negotiate the blood-brain barrier effectively, the specific anti-TNF biological, etanercept, shows promise when administered by the perispinal route, which allows it to bypass this obstruction.

Melatonin Receptor Agonists for the Prevention of Delirium: An Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Although a previous review illustrated the efficacy of melatonin receptor agonists (MRAs) in preventing delirium, some recent randomized controlled trials (RCTs) did not confirm these effects.

OBJECTIVES

This study systematically reviewed the efficacy, acceptability, and tolerability of MRAs for delirium prevention.

MATERIALS AND METHODS

We searched electronic databases, including Scopus, PubMed, CINAHL, and Controlled Trials Register, from their inception to February 20, 2022. The primary efficacy outcome was delirium incidence rate after MRA administration; relative risks (RRs), overall discontinuation, and discontinuation due to adverse events are also presented.

RESULTS

The overall pooled incidence rates of delirium in MRA-treated and placebo-treated groups were significantly different with RR (95% CI)=0.66(0.52, 0.84, ), I2=59%. Similarly, the incidence rate was significantly lower in the melatonin-treated group than in the placebo-treated group [RR (95% CI) =0.65 (0.49, 0.88), I2=65%]. Unfortunately, incidence rates were not significantly different between ramelteon-treated and placebo-treated groups [RR (95% CI) =0.67 (0.42, 1.08), I2=50%]. The pooled incidence rate of delirium in either melatonin or ramelteon-treated groups was not significantly different from the placebo-treated group in elderly patients. The pooled incidence rate of delirium was significantly lower in the melatonin-treated group than in the benzodiazepinetreated group.

CONCLUSION

Based on this review, melatonin could prevent delirium with a small effect size. However, ramelteon did not show efficacy in preventing delirium. Additionally, neither melatonin nor ramelteon individually showed effectiveness in preventing delirium in elderly patients. Therefore, using MRAs to prevent delirium in clinical practice should be cautious. However, future welldefined and large sample size studies could verify these findings.

Delirium in neurosurgery: a systematic review and meta-analysis

Delirium is a frequent occurring complication in surgical patients. Nevertheless, a scientific work-up of the clinical relevance of delirium after intracranial surgery is lacking. We conducted a systematic review (CRD42020166656) to evaluate the current diagnostic work-up, incidence, risk factors and health outcomes of delirium in this population. Five databases (Embase, Medline, Web of Science, PsycINFO, Cochrane Central) were searched from inception through March 31st, 2021. Twenty-four studies (5589 patients) were included for qualitative analysis and twenty-one studies for quantitative analysis (5083 patients). Validated delirium screening tools were used in 70% of the studies, consisting of the Confusion Assessment Method (intensive care unit) (45%), Delirium Observation Screening Scale (5%), Intensive Care Delirium Screening Checklist (10%), Neelon and Champagne Confusion Scale (5%) and Nursing Delirium Screening Scale (5%). Incidence of post-operative delirium after intracranial surgery was 19%, ranging from 12 to 26% caused by variation in clinical features and delirium assessment methods. Meta-regression for age and gender did not show a correlation with delirium. We present an overview of risk factors and health outcomes associated with the onset of delirium. Our review highlights the need of future research on delirium in neurosurgery, which should focus on optimizing diagnosis and assessing prognostic significance and management.

Prevalence and Factors Affecting Postoperative Delirium in a Neurosurgical Intensive Care Unit

ABSTRACT

PURPOSE: The aim of this study was to identify the prevalence of, and factors affecting, postoperative delirium (POD) in patients in the neurosurgical intensive care unit. METHODS: A cross-sectional study of 127 Turkish neurosurgical intensive care unit patients admitted between May 2018 and May 2019 was conducted. Patients were assessed for the development of POD using the Intensive Care Delirium Screening Checklist. We collected other independent data variables daily. Data were analyzed using independent sample t test, χ2 test, and logistic regression. RESULTS: The prevalence rates of POD on the first and second postoperative days were 18.9% and 8.7%, respectively. Logistic regression analysis showed that the Glasgow Coma Scale score, albumin level, Spo2 level, hemoglobin values, undergoing cranial surgery, and having intra-arterial catheter were the independent risk factors for POD. CONCLUSION: These findings may contribute to identifying patients at risk for developing POD and developing strategies to improve patient outcomes.

Prediction of Postictal Delirium Following Status Epilepticus in the ICU: First Insights of an Observational Cohort Study

OBJECTIVES

To identify early predictors of postictal delirium in adult patients after termination of status epilepticus.

DESIGN

Retrospective study.

SETTING

ICUs at a Swiss tertiary academic medical center.

PATIENTS

Status epilepticus patients treated on the ICUs for longer than 24 hours from 2012 to 2018.

INTERVENTIONS

None.

METHODS

Primary outcome was postictal delirium during post-status epilepticus treatment defined as an Intensive Care Delirium Screening Checklist greater than or equal to 4. Associations with postictal delirium were secondary outcomes. A time-dependent multivariable Cox proportional hazards model was used to identify risks of postictal delirium. It included variables that differed between patients with and without delirium and established risk factors for delirium (age, sex, number of inserted catheters, illness severity [quantified by the Sequential Organ Failure Assessment and Status Epilepticus Severity Score], neurodegenerative disease, dementia, alcohol/drug consumption, infections, coma during status epilepticus, dose of benzodiazepines, anesthetics, and mechanical ventilation).

MEASUREMENTS AND MAIN RESULTS

Among 224 patients, post-status epilepticus Intensive Care Delirium Screening Checklist was increased in 83% with delirium emerging in 55% with a median duration of 2 days (interquartile range 1-3 d). Among all variables, only the history of alcohol and/or drug consumption was associated with increased hazards for delirium in multivariable analyses (hazard ratio = 3.35; 95% CI, 1.53-7.33).

CONCLUSIONS

Our study provides first exploratory insights into the risks of postictal delirium in adult status epilepticus patients treated in the ICU. Delirium following status epilepticus is frequent, lasting mostly 2-3 days. Our findings that with the exception of a history of alcohol and/or drug consumption, other risk factors of delirium were not found to be associated with a risk of postictal delirium may be related to the limited sample size and the exploratory nature of our study. Further investigations are needed to investigate the role of established risk factors in other status epilepticus cohorts. In the meantime, our results indicate that the risk of delirium should be especially considered in patients with a history of alcohol and/or drug consumption.

Sleep after Traumatic Brain Injury

Sleep disturbances are common after traumatic brain injury of all levels of severity, interfere with acute and long-term recovery, and can persist for years after injury. There is increasing evidence of the importance of sleep in improving brain function and recovery. Noticing and addressing sleep disturbances are important aspects of nursing care, especially for the prevention or early recognition of delirium. Nonpharmacologic interventions can improve sleep. Teaching about the importance of sleep after traumatic brain injury, promoting sleep hygiene, and multidisciplinary approaches to addressing sleep problems and improving sleep are important for recovery from traumatic brain injury.

Challenges of Delirium Management in Patients with Traumatic Brain Injury: From Pathophysiology to Clinical Practice

Traumatic brain injury (TBI) can initiate a very complex disease of the central nervous system (CNS), starting with the primary pathology of the inciting trauma and subsequent inflammatory and CNS tissue response. Delirium has long been regarded as an almost inevitable consequence of moderate to severe TBI, but more recently has been recognized as an organ dysfunction syndrome with potentially mitigating interventions. The diagnosis of delirium is independently associated with prolonged hospitalization, increased mortality and worse cognitive outcome across critically ill populations. Investigation of the unique problems and management challenges of TBI patients is needed to reduce the burden of delirium in this population. In this narrative review, possible etiologic mechanisms behind post-traumatic delirium are discussed, including primary injury to structures mediating arousal and attention and secondary injury due to progressive inflammatory destruction of the brain parenchyma. Other potential etiologic contributors include dysregulation of neurotransmission due to intravenous sedatives, seizures, organ failure, sleep cycle disruption or other delirium risk factors. Delirium screening can be accomplished in TBI patients and the presence of delirium portends worse outcomes. There is evidence that multi-component care bundles including an analgesia-prioritized sedation algorithm, regular spontaneous awakening and breathing trials, protocolized delirium assessment, early mobility and family engagement can reduce the burden of ICU delirium. The aim of this review is to summarize the approach to delirium in TBI patients with an emphasis on pathogenesis and management. Emerging CNS-active drug therapies that show promise in preclinical studies are highlighted.

Association of COMT Val158Met Polymorphism With Delirium Risk and Outcomes After Traumatic Brain Injury

OBJECTIVE

The authors investigated the association of the catechol-o-methyltransferase (COMT) gene Val¹⁵⁸Met polymorphism with delirium risk and functional and cognitive outcomes among patients with complicated mild to moderate traumatic brain injury (TBI).

METHODS

In a prospective observational cohort study, patients were monitored for occurrence of delirium during the first 4 days of admission by using the Confusion Assessment Method. Functional and cognitive outcomes were evaluated with the Glasgow Outcome on Discharge Scale and the Montreal Cognitive Assessment test, respectively. Eighty-nine patients were included in the study; of these, 17 (19%) were diagnosed with delirium.

RESULTS

The COMT Val¹⁵⁸/Val¹⁵⁸ polymorphism was associated with increased risk of delirium in multivariable regression analyses adjusted for alcohol misuse, history of neurological disorder, age, and admission Glasgow Coma Scale score (odds ratio=4.57, 95% CI=1.11, 18.9, p=0.036). The COMT Met¹⁵⁸ allele was associated with better functional outcomes in univariate analysis (odds ratio=2.82, 95% CI=1.10, 7.27, p=0.031) but not in multivariable analysis (odds ratio=2.33, 95% CI=0.89, 6.12, p=0.085). Cognitive outcomes were not associated with the COMT Val¹⁵⁸Met polymorphism in univariate regression analysis (p=0.390). Delirium was a significant predictor of worse functional and cognitive outcomes in multivariable regression analyses adjusted for other risk factors (odds ratio=0.04, 95% CI=0.01, 0.16, p<0.001, and β=-3.889, 95% CI=-7.55, -0.23, p=0.038, respectively).

CONCLUSIONS

The COMT genotype is important in delirium risk and functional outcomes of patients with mild to moderate TBI. Whether the COMT genotype is associated with outcomes through incident delirium remains to be determined in larger studies.

Risk Factors for Continuation of Atypical Antipsychotics at Hospital Discharge in Two Intensive Care Unit Cohorts

Introduction:

Atypical antipsychotics are frequently initiated in the intensive care unit (ICU) to treat delirium. Many patients continue on these agents at hospital discharge despite a lack of data to support long-term use.

Objectives:

The primary aim of this study was to determine underlying risk factors for continuation of antipsychotics at hospital discharge in medical intensive care unit (MICU) and surgical intensive care unit (SICU) patients when evaluated as separate cohorts.

Methods:

A single-center, retrospective study in patients newly initiated on quetiapine, risperidone, or olanzapine in a 22-bed mixed medical-surgical ICU admitted from January 2017 to July 2018.

Results:

A total of 78 (62.9%) MICU patients and 46 (37.1%) SICU patients met the inclusion criteria during this time frame. A total of 29 MICU patients (37.2%) were prescribed antipsychotics at hospital discharge compared to 25 SICU patients (54.3%), P = .063. The percentage of MICU patients prescribed antipsychotics at hospital discharge was significantly higher in patients ⩾60 years of age (22 [75.9%] vs 26 [53.1%], P = .045), with a history of dementia (5 [17.2%] vs 1 [2%], P = .015), admitted with hemorrhagic stroke (5 [17.2%] vs 2 [4.1%], P = .049), and initiated on risperidone (3 [10.3%] vs 0%, P = .022). The risk of pre-existing dementia remained significant in a multivariate logistic regression that controlled for confounding variables, odds ratio (OR) = 10 (95% confidence interval [CI]: 1.11-90.5, P = .040). The percentage of SICU patients prescribed antipsychotics at discharge was significantly higher in those with severe traumatic brain injury (TBI; 8 [72.7%] vs 0%, P = .004) and initiated on quetiapine (19 [76%] vs 9 [42.9%], P = .022).

Conclusion:

Antipsychotics were commonly continued at hospital discharge in both MICU and SICU patients. Several risk factors for continuation of antipsychotics were identified in these two cohorts. Future efforts assessing the appropriateness of antipsychotics at transitions of care are warranted.

Stimulant Therapy in Acute Traumatic Brain Injury: Prescribing Patterns and Adverse Event Rates at 2 Level 1 Trauma Centers

BACKGROUND/OBJECTIVE

Pharmacological stimulant therapies are routinely administered to promote recovery in patients with subacute and chronic disorders of consciousness (DoC). However, utilization rates and adverse drug event (ADE) rates of stimulant therapies in patients with acute DoC are unknown. We aimed to determine the frequency of stimulant use and associated ADEs in intensive care unit (ICU) patients with acute DoC caused by traumatic brain injury (TBI).

METHODS

We retrospectively identified patients with TBI admitted to the ICU at 2 level 1 trauma centers between 2015 and 2018. Patients were included if they were stimulant naive at baseline and received amantadine, methylphenidate, or modafinil during ICU admission. Stimulant dose reduction or discontinuation during ICU admission was considered a surrogate marker of an ADE. Targeted chart review was performed to identify reasons for dose reduction or discontinuation.

RESULTS

Forty-eight of 608 patients with TBI received pharmacological stimulant therapy (7.9%) during the study period. Most patients were diagnosed with severe TBI at presentation (60.4%), although stimulants were also administered to patients with moderate (14.6%) and mild (25.0%) TBI. The median time of stimulant initiation was 11 days post-injury (range: 2-28 days). Median Glasgow Coma Scale score at the time of stimulant initiation was 9 (range: 4-15). Amantadine was the most commonly prescribed stimulant (85.4%) followed by modafinil (14.6%). Seven (14.6%) patients required stimulant dose reduction or discontinuation during ICU admission. The most common ADE resulting in therapy modification was delirium/agitation (n = 2), followed by insomnia (n = 1), anxiety (n = 1), and rash (n = 1); the reason for therapy modification was undocumented in 2 patients.

CONCLUSIONS

Pharmacological stimulant therapy is infrequently prescribed but well tolerated in ICU patients with acute TBI at level 1 trauma centers. These retrospective observations provide the basis for prospective studies to evaluate the safety, optimal dose range, and efficacy of stimulant therapies in this population.

Delirium Incidence and Risk Factors in Adult Critically Ill Patients in Saudi Arabia

BACKGROUND

Delirium in intensive care units (ICUs) is associated with long ICU stay, long hospital stay and increased costs of treatment. Unfortunately, delirium in ICU is significantly underestimated and overlooked by healthcare providers.

AIMS

The aim of this tudy is to determine the incidence and associated risk factors of delirium among critically ill patients in Saudi Arabia.

METHODS

This is a prospective study. Patients were assessed for delirium using the confusion assessment method for the ICU. Delirium was the independent variable in this study.

RESULTS

Fifty-nine patients (17.3%) showed positive delirium at least once compared to 283 patients (82.7%) who did not show positive delirium. Certain factors for delirium found to be significantly correlated with delirium (P < 0.005); including receiving sedation, mode of sedation, receiving mechanical ventilation, resistance to mechanical ventilator, and baseline Glasgow Coma Scale.

CONCLUSION

Delirium occurred in >17% of our ICU patients. More efforts should be directed to consider ICU delirium and to minimize its triggering factors.