- A core outcome set for studies evaluating interventions to prevent and/or treat delirium for adults requiring an acute care hospital admission: an international key stakeholder informed consensus study.
Rose Louise BMC medicine 2021;19(1):143.
BACKGROUNDTrials of interventions to prevent or treat delirium in adults in an acute hospital setting report heterogeneous outcomes. Our objective was to develop international consensus among key stakeholders for a core outcome set (COS) for future trials of interventions to prevent and/or treat delirium in adults with an acute care hospital admission and not admitted to an intensive care unit.METHODSA rigorous COS development process was used including a systematic review, qualitative interviews, modified Delphi consensus process, and in-person consensus using nominal group technique (registration http://www.comet - initiative.org/studies/details/796 ). Participants in qualitative interviews were delirium survivors or family members. Participants in consensus methods comprised international representatives from three stakeholder groups: researchers, clinicians, and delirium survivors and family members.RESULTSItem generation identified 8 delirium-specific outcomes and 71 other outcomes from 183 studies, and 30 outcomes from 18 qualitative interviews, including 2 that were not extracted from the systematic review. De-duplication of outcomes and formal consensus processes involving 110 experts including researchers (N = 32), clinicians (N = 63), and delirium survivors and family members (N = 15) resulted in a COS comprising 6 outcomes: delirium occurrence and reoccurrence, delirium severity, delirium duration, cognition, emotional distress, and health-related quality of life. Study limitations included exclusion of non-English studies and stakeholders and small representation of delirium survivors/family at the in-person consensus meeting.CONCLUSIONSThis COS, endorsed by the American and Australian Delirium Societies and European Delirium Association, is recommended for future clinical trials evaluating delirium prevention or treatment interventions in adults presenting to an acute care hospital and not admitted to an intensive care unit.
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core outcome set for studies evaluating interventions to prevent and/or treat delirium for adults requiring an acute care hospital admission: an international key stakeholder informed consensus study this link
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- A Processed Electroencephalogram-Based Brain Anesthetic Resistance Index Is Associated With Postoperative Delirium in Older Adults: A Dual Center Study.
Cooter Wright Mary Anesthesia and analgesia 2021;:No page numbers.
BACKGROUNDSome older adults show exaggerated responses to drugs that act on the brain. The brain's response to anesthetic drugs is often measured clinically by processed electroencephalogram (EEG) indices. Thus, we developed a processed EEG-based measure of the brain's resistance to volatile anesthetics and hypothesized that low scores on it would be associated with postoperative delirium risk.METHODSWe defined the Duke Anesthesia Resistance Scale (DARS) as the average bispectral index (BIS) divided by the quantity (2.5 minus the average age-adjusted end-tidal minimum alveolar concentration [aaMAC] inhaled anesthetic fraction). The relationship between DARS and postoperative delirium was analyzed in 139 older surgical patients (age ≥65) from Duke University Medical Center (n = 69) and Mt Sinai Medical Center (n = 70). Delirium was assessed by geriatrician interview at Duke, and by research staff utilizing the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) instrument at Mt Sinai. We examined the relationship between DARS and delirium and used the Youden index to identify an optimal low DARS threshold (for delirium risk), and its associated 95% bootstrap confidence bounds. We used multivariable logistic regression to examine the relationship between low DARS and delirium risk.RESULTSThe relationship between DARS and delirium risk was nonlinear, with higher delirium risk at low DARS scores. A DARS threshold of 28.755 maximized the Youden index for the association between low DARS and delirium, with bootstrap 95% confidence bounds of 26.18 and 29.80. A low DARS (<28.755) was associated with increased delirium risk in multivariable models adjusting for site (odds ratio [OR] [95% confidence interval {CI}] = 4.30 [1.89-10.01]; P = .001), or site-plus-patient risk factors (OR [95% CI] = 3.79 [1.63-9.10]; P = .003). These associations with postoperative delirium risk remained significant when using the 95% bootstrap confidence bounds for the low DARS threshold (P < .05 for all). Further, a low DARS (<28.755) was associated with delirium risk after accounting for opioid, midazolam, propofol, phenylephrine, and ketamine dosage as well as site (OR [95% CI] = 4.21 [1.80-10.16]; P = .002). This association between low DARS and postoperative delirium risk after controlling for these other medications remained significant (P < .05) when using either the lower or the upper 95% bootstrap confidence bounds for the low DARS threshold.CONCLUSIONSThese results demonstrate that an intraoperative processed EEG-based measure of lower brain anesthetic resistance (ie, low DARS) is independently associated with increased postoperative delirium risk in older surgical patients.
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- Adult sedation and analgesia in a resource limited intensive care unit - A Systematic Review and evidence based guideline.
Temesgen Netsanet Annals of medicine and surgery (2012) 2021;66:102356.
BackgroundSedation and analgesia are essential in the intensive care unit in order to promote control of pain, anxiety, prevent loss of materials, accidental extubation and improve the synchrony of patients with ventilator. However, excess of these medications leads to an increased morbidity and mortality, and thus demands protocol.MethodsPreferred Reporting Items for Systematic Reviews and the Meta-Analysis Protocol have been used to undertake this review. Pub Med, Cochrane Library, and Google Scholar search engines were used to find up-to-date evidence that helps to draw recommendations and conclusions.ResultsIn this Guideline and Systematic Review, we have used 16 Systemic Review and Meta-Analysis, 3 Evidence-Based Guidelines and 10 RCT Meta-Analysis, 6 Systemic Reviews of Non-randomized Studies, 8 Randomized Clinical Trials, 11 Cohort Studies, 5 Cross-Sectional Studies and 1 Case Report with their respective study descriptions.DiscussionAnalgesia, which as a sedation basement can reduce sedative use, is key aspect of treatment in ICU patients, and we can also conclude that an analgesic sedation regimen can reduce the occurrence of delirium by reducing sedatives. The aim of this guideline and the systematic review is to write up and formulate analgesia-based sedation for limited resource settings.ConclusionsAnalgesia and sedation are effective in critically ill patients; however, too much sedation is associated with longer periods of mechanical ventilation and longer duration of ICU stay. Poorly managed ICU patients have a delirium rate of up to 80%, increased mortality, longer hospital stays, higher hospital costs and bad long-term outcomes.
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- Association between ankle brachial index and development of postoperative intensive care unit delirium in patients with peripheral arterial disease.
Kang Jihee Scientific reports 2021;11(1):12744.
Patients with vascular diseases are prone to developing postoperative delirium (POD). Ankle brachial index (ABI) is a non-invasive clinical indicator of lower-extremities peripheral arterial disease (PAD) and has been identified as an indicator of cognitive impairment. We investigated the association between ABI and POD. 683 PAD patients who underwent elective leg arterial bypass surgery between October 1998 and August 2019 were collected for retrospective analysis. Demographic information, comorbidities, preoperative ABI and the Rutherford classification within one month prior to surgery were obtained. POD was assessed using the Confusion assessment method -intensive care unit. Logistic regression and receiver operating characteristics (ROC) curve analysis were used to assess the association between ABI and POD. The mean value of ABI was significantly lower in patients with POD than it was those without POD. Older age, more medical comorbidities, longer length of surgery, decreased ABI, and higher Rutherford class were all significantly associated with POD. The area under ROC (0.74) revealed that ABI below 0.35 was associated with development of POD. Lower preoperative ABI was associated with POD in PAD patients who underwent arterial bypass surgery.
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between ankle brachial index and development of postoperative intensive care unit delirium in patients with peripheral arterial disease this link
between ankle brachial index and development of postoperative intensive care unit delirium in patients with peripheral arterial disease this link
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- Association Between Dexamethasone and Delirium in Critically Ill Patients: A Retrospective Cohort Study of a Large Clinical Database.
Wu Zehao The Journal of surgical research 2021;263:89-101.
BACKGROUNDDelirium is a common complication in intensive care unit (ICU) patients, and it can significantly increase the length of hospital stay and cost. Dexamethasone is widely used in various inflammatory diseases and must be used with caution in critically ill patients. Previous studies have shown that the effect of corticosteroid use on the development of delirium in critically ill patients is still controversial, and there is inconclusive conclusion about the effect of dexamethasone on delirium in such patients. Therefore, this study aimed to confirm the effect of dexamethasone use and the dose on the incidence of delirium and patient prognosis in critically ill patients through a large cohort study.METHODSA retrospective cohort study was conducted using data extracted from the Medical Information Mart for Intensive Care III database, which is a large and freely available database of all 46,476 patients who visited Beth Israel Deaconess Medical Center in Boston, Massachusetts, USA and were admitted to the ICU between 2001 and 2012. The primary outcome was the development of delirium, using multivariate logistic regression analysis to reveal the relationship between dexamethasone and delirium. Secondary endpoints were in-hospital mortality, ICU mortality, total length of stay, and length of ICU stay, and the relationship between dexamethasone and prognosis was assessed with Cox proportional hazards models. Propensity score matching with 1:1 grouping was used to eliminate the effect of confounders on both cohorts. The locally weighted scatter plot smoothing technique was used to investigate the dose correlation between dexamethasone and outcomes, subgroup analysis was used to account for heterogeneity, and different correction models and propensity matching analysis were used to eliminate potential confounders.RESULTSFinally, 38,509 patients were included, and 2204 (5.7%) used dexamethasone. No significant statistical difference was observed in basic demographic information after propensity score matching between the two study groups. A significantly higher incidence of delirium (5.0% versus 3.4%, P < 0.001), increased in-hospital mortality (14.9% versus 10.3%, P < 0.001), ICU mortality (9.0% versus 7.5%, P = 0.008), and longer length of stay and ICU stay were observed in patients taking dexamethasone compared with those not taking dexamethasone. Multivariate logistic and Cox regression analyses confirmed that dexamethasone was significantly associated with delirium (adjusted odds ratio = 1.48, 95% confidence interval [CI] = 1.09-2.00, P = 0.012), in-hospital mortality (adjusted hazard ratio = 1.19, 95% CI = 1.02-1.40, P = 0.032), and ICU mortality (adjusted hazard ratio = 1.62, 95% CI = 1.22-2.15, P = 0.001). Compared with critically ill patients using high-dose dexamethasone, the risk of delirium was lower in the dose less than the 10 mg group, and patients using 10-14 mg may be associated with a lower risk of in-hospital death and the least ICU mortality, length of hospital stay, and ICU stay.CONCLUSIONSThis study demonstrated that the use of dexamethasone in critically ill patients exacerbated the occurrence of delirium while increasing the risk of in-hospital death, ICU death, and length of hospital stay, with a lower risk of delirium and a shorter total length of hospital stay with low-dose dexamethasone than with larger doses.
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- Association Between Early Tracheostomy and Delirium in Older Adults in the United States.
Gazda Alexander J. Journal of cardiothoracic and vascular anesthesia 2021;35(7):1974-1980.
OBJECTIVESEarly tracheostomy (fewer than eight days after intubation) is associated with shorter length of stay in the intensive care unit and shorter duration of mechanical ventilation. Studies assessing the association between early tracheostomy and incidence of delirium, however, are lacking. This investigation sought to fill this gap.DESIGNRetrospective cross-sectional study.SETTINGMulti-institutional acute care facilities in the United States.PARTICIPANTSData were derived from the National Inpatient Sample data from 2010 to 2014. Included patients were 65 or older and underwent both intubation and tracheostomy during the hospitalization. The authors excluded patients who underwent multiple intubations or tracheostomy procedures.INTERVENTIONSEarly tracheostomy versus non-early tracheostomy.RESULTSIn total, 23,310 patients were included, of whom 24.8% underwent early tracheostomy. From multivariate logistic regression, early tracheostomy was associated with lower odds of having a delirium diagnosis (odds ratio [OR] 0.77, p < 0.00001) across all admission classifications. Upon subgroup analysis, early tracheostomy was associated significantly with lower odds of having delirium for patients admitted with medical (OR 0.74, p < 0.00001) and nonsurgical injury admissions (OR 0.74, p = 0.00116).CONCLUSIONSEarly tracheostomy was associated significantly with lower odds of delirium among all patients studied. This association held true across medical and nonsurgical subgroups.
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- Association of preoperative frailty with postoperative delirium after elective brain tumor resection: Retrospective analysis of a prospective cohort.
Wang Chun-Mei Surgery 2021;:No page numbers.
BACKGROUNDPreoperative frailty is associated with poor outcomes in major surgery. Postoperative delirium is common after neurosurgery. To date, the association of preoperative frailty with postoperative delirium after neurosurgery has not been established. We aimed to determine the association between preoperative frailty and postoperative delirium in patients undergoing elective brain tumor resection.METHODSWe retrospectively analyzed the data of a prospective cohort, consecutively enrolling adult patients admitted to the intensive care unit after elective craniotomy for brain tumor resection under general anesthesia in a tertiary hospital in China from March 1, 2017 to February 2, 2018. Preoperative frailty was evaluated using the modified frailty index. The primary outcome was postoperative delirium, assessed using the Confusion Assessment Method for the Intensive Care Unit. Univariate and multivariable regression analyses were performed to examine the association.RESULTS659 patients met inclusion criteria for our analysis. There were 398 (60.4%) non-frail (modified frailty index = 0), 237 (36.0%) pre-frail (modified frailty index = 1-2), and 24 (3.6%) frail (modified frailty index ≥ 3) patients. Of these, 124 (18.8%) developed postoperative delirium. In adjusted analyses, frailty was independently associated with postoperative delirium (odds ratio 1.7, 95% confidence interval 1.0-2.7, P = .032). Frail patients had longer length of hospital stay and higher total costs than non-frail patients.CONCLUSIONPreoperative frailty is associated with postoperative delirium, length of hospital stay, and total costs in patients undergoing elective brain tumor resection. Preoperative frailty assessment and appropriate management strategies should be involved in the perioperative management of postoperative delirium.
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- Biomarkers in delirium: A systematic review.
Dunne Suzanne S. Journal of psychosomatic research 2021;147:110530.
BACKGROUNDDelirium is a common neuropsychiatric disorder associated with prolonged hospital stays, and increased morbidity and mortality. Diagnosis is frequently missed due to varying disease presentation and lack of standardized testing. We examined biomarkers as diagnostic or prognostic indicators of delirium, and provide a rational basis for future studies.METHODSystematic review of literature published between Jan 2000 and June 2019. Searches included: PubMed; Web of Science; CINAHL; EMBASE; COCHRANE and Medline. Additional studies were identified by searching bibliographies of eligible articles.RESULTS2082 relevant papers were identified from all sources. Seventy-three met the inclusion criteria, all of which were observational. These assessed a range of fourteen biomarkers. All papers included were in the English language. Assessment methods varied between studies, including: DSM criteria; Confusion Assessment Method (CAM) or CAM-Intensive Care Unit (ICU). Delirium severity was measured using the Delirium Rating Scale (DRS). Delirium was secondary to post-operative dysfunction or acute medical conditions.CONCLUSIONEvidence does not currently support the use of any one biomarker. However, certain markers were associated with promising results and may warrant evaluation in future studies. Heterogeneity across study methods may have contributed to inconclusive results, and more clarity may arise from standardization of methods of clinical assessment. Adjusting for comorbidities may improve understanding of the pathophysiology of delirium, in particular the role of confounders such as inflammation, cognitive disorders and surgical trauma. Future research may also benefit from inclusion of other diagnostic modalities such as EEG as well as analysis of genetic or epigenetic factors.
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- Caffeine supplementation in the hospital: Potential role for the treatment of caffeine withdrawal.
Agritelley Matthew S. Food and chemical toxicology : an international journal published for the British Industrial Biological Research Association 2021;153:112228.
Caffeine use in the population is widespread. Caffeine withdrawal in the hospital setting is an underappreciated syndrome with symptoms including drowsiness, difficulty concentrating, mood disturbances, low motivation, flu-like symptoms, and headache. Withdrawal may occur upon abstinence from chronic daily exposure at doses as low as 100 mg/day and following only 3-7 days of consumption at higher doses. There are limited data investigating how caffeine withdrawal contributes to hospital morbidity. Some studies suggest caffeine withdrawal may contribute to intensive care delirium and that caffeine may promote wakefulness post-anesthesia. Caffeine supplementation has also shown promise in patients at risk of caffeine withdrawal, such as those placed on nil per os (NPO) status, in preventing caffeine withdrawal headache. These data on caffeine supplementation are not entirely consistent, and routine caffeine administration has not been implemented into clinical practice for patients at risk of withdrawal. Notably, caffeine serves a therapeutic role in the hospital for other conditions. Our review demonstrates that caffeine is largely safe in the general population and may be an appropriate therapeutic option for future studies, if administered properly. There is a need for a randomized controlled trial investigating in-hospital caffeine supplementation and the population that this would best serve.
- Clinical Effect of Systemic Steroids in Patients With Cirrhosis and Septic Shock.
Serafim Laura Piccolo Shock (Augusta, Ga.) 2021;:No page numbers.
PURPOSEEvidence regarding the utility of systemic steroids in treating patients with cirrhosis and septic shock remains equivocal. This study aimed to evaluate and elucidate the association of steroid use with outcomes and adverse effects in a cohort of patients with cirrhosis and septic shock.MATERIALS AND METHODSRetrospective cohort study of patients with cirrhosis and septic shock admitted to a tertiary hospital ICU from January 2007 to May 2017, using a validated ICU Datamart. Patients who received vasopressors within six hours of ICU admission were included in the multivariate analysis. The effect of steroids on outcomes was evaluated using multivariable regression, adjusting for confounding variables.RESULTSOut of 179 admissions of patients with cirrhosis and septic shock, 56 received steroids during the ICU admission. Patients who received steroids received a higher total dose of vasopressors (91.2 mg vs. 39.1 mg, p = 0.04) and had a lower initial lactate level (1.8 mmol/L vs. 2.6 mmol/L, p = 0.007). The multivariate analysis included 117 patients and showed no significant differences in mortality, length of ICU admission, or length of hospital stay. Bleeding events, delirium, and renal-replacement therapy requirements were also not associated with the use of steroids.CONCLUSIONThe use of systemic steroids was more prevalent in cirrhotic patients with higher vasopressor requirements. It was not associated with decreased mortality or increased ICU- and hospital-free days, or to adverse effects.
- Combination of delirium and coma predicts psychiatric symptoms at twelve months in critically ill patients: A longitudinal cohort study
Miyamoto Kyohei Journal of Critical Care 2021;63:76.
PurposeWe aimed to determine any associations between delirium and comas during intensive care unit (ICU) stay, and long-term psychiatric symptoms and disability affecting activity of daily living (ADL).Materials and methodsIn this prospective observational study, we enrolled critically ill adult patients that were emergently admitted to an ICU. We assessed psychiatric symptoms and disability affecting ADL at three and twelve months after ICU discharge.ResultsAmong the 81 and the 47 patients that responded to the questionnaires at three and twelve months, 22 (27%) and 13 (28%) patients experienced delirium, respectively. During their ICU stay, 28 (35%) and 21 (45%) had been in comas, respectively. At three and twelve months, 51 (63%) and 23 (49%) of patients experienced composite psychiatric symptoms or disability affecting ADL, respectively. After adjusting predefined confounders, the combination of delirium and comas was an independent risk factor for the presence of composite psychiatric symptoms or disability affecting ADL (adjusted odds ratio [aOR] 3.38; 1.10–10.38 at three months; aOR 8.28; 1.48–46.46 at twelve months).ConclusionsIn critically ill adults, combination of delirium and comas during ICU stay is a predictor of psychiatric symptoms or ADL disability.Trial registration: UMIN Clinical Trial Registry no. UMIN000023743, September 1, 2016.
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- Common biomarkers of physiologic stress and associations with delirium in patients with intracerebral hemorrhage
Reznik Michael E. Journal of Critical Care 2021;64:62.
PurposeTo examine associations between physiologic stress and delirium in the setting of a direct neurologic injury.Materials and methodsWe obtained initial neutrophil-to-lymphocyte ratio (NLR), glucose, and troponin in consecutive non-comatose patients with non-traumatic intracerebral hemorrhage (ICH) over 1 year, then used multivariable regression models to determine associations between each biomarker and incident delirium. Delirium diagnoses were established using DSM-5-based methods, with exploratory analyses further categorizing delirium as first occurring <24 h ("early-onset") or > 24 h after presentation ("later-onset").ResultsOf 284 patients, delirium occurred in 55% (early-onset: 39% [n = 111]; later-onset: 16% [n = 46]). Patients with delirium had higher NLR (mean 9.0 ± 10.4 vs. 6.4 ± 5.5; p = 0.01), glucose (mean 146.5 ± 59.6 vs. 129.9 ± 41.4 mg/dL; p = 0.008), and a higher frequency of elevated troponin (>0.05 ng/mL; 21% vs. 10%, p = 0.02). In adjusted models, elevated NLR (highest quartile: OR 3.4 [95% CI 1.5–7.8]), glucose (>180 mg/dL: OR 3.1 [95% CI 1.1–8.2]), and troponin (OR 3.0 [95% CI 1.2–7.2]) were each associated with delirium, but only initial NLR was specifically associated with later-onset delirium and with delirium in non-mechanically ventilated patients.ConclusionsStress-related biomarkers corresponding to multiple organ systems are associated with ICH-related delirium. Early NLR elevation may also predict delayed-onset delirium, potentially implicating systemic inflammation as a contributory delirium mechanism.
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- Comparative study of high flow nasal catheter device and noninvasive positive pressure ventilation for sequential treatment in sepsis patients after weaning from mechanical ventilation in intensive care unit.
Xuan Lizhen Annals of palliative medicine 2021;10(6):6270-6278.
BACKGROUNDThe hypoxemia condition after mechanical ventilation (MV) weaning is not rare among sepsis patients, so we compared the efficacy in two different intervention groups: high-flow nasal cannula device group and non-invasive positive pressure ventilation (NPPV) group.METHODSThis is a retrospective cohort study. Participants were patients with sepsis receiving high-flow nasal catheter (HFNC) device or NPPV within 24 hours after weaning from MV. The primary outcome was tracheal re-intubation within 72 hours after extubation. Secondary outcomes included: oxygenation index, complication rate, patient comfort evaluation, HFNC/NPPV treatment time, ICU length of stay (LOS), ICU mortality, and in-hospital 28-day mortality.RESULTSA total of 283 patients were included in the study with 167 in the HFNC group and 116 in the NPPV group. The re-intubation rates after extubation in both groups were respectively 4.2% and 5.2% without significant difference. Patients in the HFNC group experienced lower incidence of delirium, reflux aspiration, facial pressure ulcer and other complications, and higher score of patients comfort than that in the NPPV group. There was no significant difference in ICU LOS, ICU mortality and in-hospital 28-day mortality between the two groups.CONCLUSIONSHFNC and NPPV have similar efficacy in the sequential treatment of sepsis patients after weaning from MV. Compared with NPPV, those extubated to HFNC had lower rate of complications such as reflux aspiration and facial pressure ulcers. The patients extubation to HFNC is more comfortable (and associated with less delirium) than to NPPV.
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- Corrigendum to Pharmacogenomic response of low dose haloperidol in critically ill adults with delirium journal of critical care 57 (2020) 203–207
Zoran Trogrlic Zoran Trogrlić Journal of Critical Care 2021;63:282.
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- De-implementation of Restraint Use in the Medical Intensive Care Unit.
Anon. Nevada RNformation 2021;30(3):8-9.
of Restraint Use in the Medical Intensive Care Unit this link
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- Death in delirious palliative-care patients occurs irrespective of age: A prospective, observational cohort study of 229 delirious palliative-care patients
Seiler Annina Palliative & Supportive Care 2021;19(3):274.
ObjectivesPatients with terminal illness are at high risk of developing delirium, in particular, those with multiple predisposing and precipitating risk factors. Delirium in palliative care is largely under-researched, and few studies have systematically assessed key aspects of delirium in elderly, palliative-care patients.<sec sec-type="methods" id="sec_a2">MethodsIn this prospective, observational cohort study at a tertiary care center, 229 delirious palliative-care patients stratified by age: <65 (N = 105) and ≥65 years (N = 124), were analyzed with logistic regression models to identify associations with respect to predisposing and precipitating factors.<sec sec-type="results" id="sec_a3">ResultsIn 88% of the patients, the underlying diagnosis was cancer. Mortality rate and median time to death did not differ significantly between the two age groups. No inter-group differences were detected with respect to gender, care requirements, length of hospital stay, or medical costs. In patients ≥65 years, exclusively predisposing factors were relevant for delirium, including hearing impairment [odds ratio (OR) 3.64; confidence interval (CI) 1.90–6.99; P < 0.001], hypertension (OR 3.57; CI 1.84–6.92; P < 0.001), and chronic kidney disease (OR 4.84; CI 1.19–19.72; P = 0.028). In contrast, in patients <65 years, only precipitating factors were relevant for delirium, including cerebral edema (OR 0.02; CI 0.01–0.43; P = 0.012).Significance of resultsThe results of this study demonstrate that death in delirious palliative-care patients occurs irrespective of age. The multifactorial nature and adverse outcomes of delirium across all age in these patients require clinical recognition. Potentially reversible factors should be detected early to prevent or mitigate delirium and its poor survival outcomes.
- Delirium and Associated Factors in a Cohort of Hospitalized Patients With Coronavirus Disease 2019.
García-Grimshaw Miguel Journal of the Academy of Consultation-Liaison Psychiatry 2021;:No page numbers.
BACKGROUNDThe coronavirus disease 2019 (COVID-19) pandemic dramatically increased the number of patients requiring treatment in an intensive care unit (ICU) or invasive mechanical ventilation (IMV) worldwide. Delirium is a well-known neuropsychiatric complication of patients with acute respiratory diseases, representing the most frequent clinical expression of acute brain dysfunction in critically ill patients, especially in those undergoing IMV. Among hospitalized COVID-19 patients, delirium incidence ranges from 11-80%, depending on the studied population and hospital setting.OBJECTIVETo determine risk factors for the development of delirium in hospitalized patients with COVID-19 pneumonia.METHODSWe retrospectively studied consecutive hospitalized adult (≥18 years) patients with confirmed COVID-19 pneumonia from March 15 to July 15, 2020, in a tertiary-care hospital in Mexico City. Delirium was assessed by the attending physician or trained nurse, with either the Confusion Assessment Method (CAM) for the intensive care unit or the CAM brief version, according to the appropriate diagnostic tool for each hospital setting. Consultation-liaison psychiatrists and neurologists confirmed all diagnoses. We calculated adjusted hazard ratios (aHR) with 95% confidence interval (CI) using a Cox proportional-hazards regression model.RESULTSWe studied 1,017 (64.2% men; median age 54 years, interquartile range 44-64), of whom 166 (16.3%) developed delirium (hyperactive in 75.3%); 78.9% of our delirium cases were detected in patients under IMV. The median of days from admission to diagnosis was 14 (IQR 8-21) days. Unadjusted mortality rates between delirium and no delirium groups were similar (23.3% vs. 24.1; risk ratio 0.962, 95% CI 0.70-1.33). Age (aHR 1.02, 95% CI 1.01-1.04; P=0.006), an initial neutrophil-to-lymphocyte ratio ≥9 (aHR 1.81, 95% CI 1.23-2.65; P=0.003), and requirement of IMV (aHR 3.39, 95% CI 1.47-7.84; P=0.004) were independent risk factors for in-hospital delirium development.CONCLUSIONSDelirium is a common in-hospital complication of patients with COVID-19 pneumonia, associated with disease severity; given the extensive number of active COVID-19 cases worldwide, it is essential to detect patients who are most likely to develop delirium during hospitalization. Improving its preventive measures may reduce the risk of the long-term cognitive and functional sequelae associated with this neuropsychiatric complication.
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- Delirium and long term cognition in critically ill patients
Wilcox M. Elizabeth BMJ : British Medical Journal (Online) 2021;373:No page numbers.
Delirium, a form of acute brain dysfunction, is very common in the critically ill adult patient population. Although its pathophysiology is poorly understood, multiple factors associated with delirium have been identified, many of which are coincident with critical illness. To date, no drug or non-drug treatments have been shown to improve outcomes in patients with delirium. Clinical trials have provided a limited understanding of the contributions of multiple triggers and processes of intensive care unit (ICU) acquired delirium, making identification of therapies difficult. Delirium is independently associated with poor long term outcomes, including persistent cognitive impairment. A longer duration of delirium is associated with worse long term cognition after adjustment for age, education, pre-existing cognitive function, severity of illness, and exposure to sedatives. Interestingly, differences in prevalence are seen between ICU survivor populations, with survivors of acute respiratory distress syndrome experiencing higher rates of cognitive impairment at early follow-up compared with mixed ICU survivor populations. Although cognitive performance improves over time for some ICU survivors, impairment is persistent in others. Studies have so far been unable to identify patients at higher risk of long term cognitive impairment; this is an active area of scientific investigation.
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- Delirium at the end of life
Knoepfel Silvana Palliative & Supportive Care 2021;19(3):268.
BackgroundThe general in-hospital mortality and interrelationship with delirium are vastly understudied. Therefore, this study aimed to assess the rates of in-hospital mortality and terminal delirium.<sec sec-type="methods" id="sec_a2">MethodIn this prospective cohort study of 28,860 patients from 37 services including 718 in-hospital deaths, mortality rates and prevalence of terminal delirium were determined with simple logistic regressions and their respective odds ratios (ORs).<sec sec-type="results" id="sec_a3">ResultsAlthough overall in-hospital mortality was low (2.5%), substantial variance between services became apparent: Across intensive care services the rate was 10.8% with a 5.8-fold increased risk, across medical services rates were 4.4% and 2.4-fold, whereas at the opposite end, across surgical services rates were 0.7% and 87% reduction, respectively. The highest in-hospital mortality rate occurred on the palliative care services (27.3%, OR 19.45). The general prevalence of terminal delirium was 90.7% and ranged from 83.2% to 100%. Only across intensive care services (98.1%, OR 7.48), specifically medical intensive care (98.1%, OR 7.48) and regular medical services (95.8%, OR 4.12) rates of terminal delirium were increased. In contrast, across medical services (86.4%, OR 0.32) and in particular oncology (73.9%, OR 0.25), pulmonology (72%, OR 0.31) and cardiology (63.2%, OR 0.4) rates were decreased. For the remaining services, rates of terminal delirium were the same.Significance of resultsAlthough in-hospital mortality was low, the interrelationship with delirium was vast: most patients were delirious at the end of life. The implications of terminal delirium merit further studies.
- Delirium in ICU patients with COVID-19. Any difference?
van den Boogaard Mark Intensive & Critical Care Nursing 2021;64:No page numbers.
Since 2020 we have to deal with the COVID-19 pandemic with more and sicker patients that need ICU care, for a long time and with a prolonged need for mechanical ventilation (MV) support, most frequently with prone positioning acting as a rescue treatment.[...]it was unexpected, but nevertheless very important that recently two multicentre studies were published showing that the delirium prevalence is high in COVID-19 ICU patients, 55–65% (Khan et al., 2020; Pun et al., 2021) and benzodiazepines were administered in 64% (Pun et al., 2021) and 78% (Khan et al., 2020) of the patients.While MV, restraints, benzodiazepines, opioids, vasopressors and antipsychotics were associated with an increased delirium risk, family visitation was associated with less delirium.[...]not reported, ICU clinicians working in personal protective equipment and therefore more or less look like astronauts or aliens, will also contribute to delirium, at least to hallucinations (story telling during interviews with COVID-19 ICU patients).
- Delirium in older adults is associated with development of new dementia: a systematic review and meta-analysis.
Pereira Jarett Vanz-Brian International journal of geriatric psychiatry 2021;36(7):993-1003.
OBJECTIVESObservational studies have examined the association between delirium and development of new dementia. However, no recent review has collectively assessed the available evidence quantitatively and qualitatively. We systematically reviewed and critically evaluated the literature regarding the association between delirium and dementia, and calculated the odds of developing new dementia after having delirium.METHODSThis systematic review and meta-analysis was conducted according to Preferred reporting items for systematic reviews and meta-analyses guidelines. MEDLINE, EMBASE and PsycINFO, were searched for English-language articles that compared the incidence of new dementia in older adult (≥65) inpatients with delirium, to inpatients without delirium. A random effects model was used for meta-analysis, and overall effect size was calculated using reported raw data of event counts. The Newcastle-Ottawa Quality Assessment scale assessed risk of bias.RESULTSSix observational studies met eligibility criteria, with follow-up times ranging from six months to five years. Four looked at hip fracture surgical patients; one was on cardiac surgery patients and one examined geriatric medical patients. All studies excluded patients with pre-existing dementia. Pooled meta-analysis revealed that older adult inpatients who developed delirium had almost twelve times the odds of subsequently developing new dementia compared to non-delirious patients (OR = 11.9 [95% CI: 7.29-19.6]; p < 0.001).CONCLUSIONSOlder adult inpatients who develop delirium are at significant risk of subsequently developing dementia. This emphasises the importance of delirium prevention and cognitive monitoring post-delirium. The included studies mainly examined post-surgical patients-further research on medical and intensive care unit cohorts is warranted. Future studies should assess whether delirium duration, severity and subtype influence the risk of developing dementia.
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- Delirium in Older Patients after Combined Epidural-General Anesthesia or General Anesthesia for Major Surgery: A Randomized Trial.
Li Ya-Wei Anesthesiology 2021;135(2):218-232.
BACKGROUNDDelirium is a common and serious postoperative complication, especially in the elderly. Epidural anesthesia may reduce delirium by improving analgesia, reducing opioid consumption, and blunting stress response to surgery. This trial therefore tested the hypothesis that combined epidural-general anesthesia reduces the incidence of postoperative delirium in elderly patients recovering from major noncardiac surgery.METHODSPatients aged 60 to 90 yr scheduled for major noncardiac thoracic or abdominal surgeries expected to last 2 h or more were enrolled. Participants were randomized 1:1 to either combined epidural-general anesthesia with postoperative epidural analgesia or general anesthesia with postoperative intravenous analgesia. The primary outcome was the incidence of delirium, which was assessed with the Confusion Assessment Method for the Intensive Care Unit twice daily during the initial 7 postoperative days.RESULTSBetween November 2011 and May 2015, 1,802 patients were randomized to combined epidural-general anesthesia (n = 901) or general anesthesia alone (n = 901). Among these, 1,720 patients (mean age, 70 yr; 35% women) completed the study and were included in the intention-to-treat analysis. Delirium was significantly less common in the combined epidural-general anesthesia group (15 [1.8%] of 857 patients) than in the general anesthesia group (43 [5.0%] of 863 patients; relative risk, 0.351; 95% CI, 0.197 to 0.627; P < 0.001; number needed to treat 31). Intraoperative hypotension (systolic blood pressure less than 80 mmHg) was more common in patients assigned to epidural anesthesia (421 [49%] vs. 288 [33%]; relative risk, 1.47, 95% CI, 1.31 to 1.65; P < 0.001), and more epidural patients were given vasopressors (495 [58%] vs. 387 [45%]; relative risk, 1.29; 95% CI, 1.17 to 1.41; P < 0.001).CONCLUSIONSOlder patients randomized to combined epidural-general anesthesia for major thoracic and abdominal surgeries had one third as much delirium but 50% more hypotension. Clinicians should consider combining epidural and general anesthesia in patients at risk of postoperative delirium, and avoiding the combination in patients at risk of hypotension.EDITOR’S PERSPECTIVE
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- Delirium Variability is Influenced by the Sound Environment (DEVISE Study): How Changes in the Intensive Care Unit soundscape affect delirium incidence.
Sangari Ayush Journal of medical systems 2021;45(8):76.
Quantitative data on the sensory environment of intensive care unit (ICU) patients and its potential link to increased risk of delirium is limited. We examined whether higher average sound and light levels in ICU environments are associated with delirium incidence. Over 111 million sound and light measurements from 143 patient stays in the surgical and trauma ICUs were collected using Quietyme® (Neshkoro, Wisconsin) sensors from May to July 2018 and analyzed. Sensory data were grouped into time of day, then normalized against their ICU environments, with Confusion Assessment Method (CAM-ICU) scores measured each shift. We then performed logistic regression analysis, adjusting for possible confounding variables. Lower morning sound averages (8 am-12 pm) (OR = 0.835, 95% OR CI = [0.746, 0.934], p = 0.002) and higher daytime sound averages (12 pm-6 pm) (OR = 1.157, 95% OR CI = [1.036, 1.292], p = 0.011) were associated with an increased odds of delirium incidence, while nighttime sound averages (10 pm-8 am) (OR = 0.990, 95% OR CI = [0.804, 1.221], p = 0.928) and the ICU light environment did not show statistical significance. Our results suggest an association between the ICU soundscape and the odds of developing delirium. This creates a future paradigm for studies of the ICU soundscape and lightscape.
- Dexmedetomidine for Facilitating Mechanical Ventilation Extubation in Difficult-to-Wean ICU Patients: Systematic Review and Meta-Analysis of Clinical Trials.
Buckley Mitchell S. Journal of intensive care medicine 2021;36(8):925-936.
BACKGROUNDAgitation and delirium are common in mechanically ventilated adult intensive care unit (ICU) patients and may contribute to delayed extubation times. Difficult-to-wean ICU patients have been associated with an increased risk of longer ICU length of stays and mortality. The purpose of this systematic review and meta-analysis is to evaluate the evidence of dexmedetomidine facilitating successful mechanical ventilation extubation in difficult-to-wean ICU patients and clinical outcomes.METHODSA literature search was conducted using MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Global Health, Cochrane Central Register of Controlled Trials, Clinical Trial Registries, and the Health Technology Assessment Database from inception to December 5, 2019. Randomized controlled trials evaluating dexmedetomidine with the intended purpose to facilitate mechanical ventilation liberation in adult ICU patients (≥18 years) experiencing extubation failure were included. The primary outcome of time to extubation was evaluated using the weighted mean difference (WMD), with a random effects model. Secondary analyses included hospital and ICU length of stay, in-hospital mortality, hypotension, and bradycardia.RESULTSA total of 6 trials (n = 306 patients) were included. Dexmedetomidine significantly reduced the time to extubation (WMD: -11.61 hours, 95% CI: -16.5 to -6.7, P = .005) and ICU length of stay (WMD: -3.04 days; 95% CI: -4.66 to -1.43). Hypotension risk was increased with dexmedetomidine (risk ratio [RR]: 1.62, 95% CI: 1.05-2.51), but there was no difference in bradycardia risk (RR: 3.98, 95% CI: 0.70-22.78). No differences were observed in mortality rates (RR: 1.30, 95% CI: 0.45-3.75) or hospital length of stay (WMD: -2.67 days; 95% CI: -7.73 to 2.39).CONCLUSIONSDexmedetomidine was associated with a significant reduction in the time to extubation and shorter ICU stay in difficult-to-wean ICU patients. Although hypotension risk was increased with dexmedetomidine, no differences in other clinical outcomes were observed.
- Dexmedetomidine versus propofol for prolonged sedation in critically ill trauma and surgical patients.
Winings Natalie A. The surgeon : journal of the Royal Colleges of Surgeons of Edinburgh and Ireland 2021;19(3):129-134.
BACKGROUNDand Purpose: Currently, dexmedetomidine versus propofol has primarily been studied in medical and cardiac surgery patients with outcomes indicating safe and effective sedation. The purpose of this study was to assess the efficacy of dexmedetomidine versus propofol for prolonged sedation in trauma and surgical patients.METHODSThis was a single-center prospective study conducted in the Trauma/Surgical Intensive Care Unit (ICU) at a Level I academic trauma center. It included patients 18 years of age or older requiring mechanical ventilation who were randomly assigned based on unit bed location to receive either dexmedetomidine or propofol. The primary outcome was duration of mechanical ventilation. Secondary outcomes included mortality; proportion of time in target sedation; incidence of delirium, hypotension, and bradycardia; and ICU and hospital length of stay (LOS).RESULTSA total of 57 patients were included. Baseline characteristics were similar between groups. There was no significant difference in duration of mechanical ventilation (median [IQR]) between the dexmedetomidine (78.5[125] hours) and propofol (105[130] hours; p = 0.15) groups. There was no difference between groups in ICU mortality, ICU and hospital LOS, or incidence of delirium. Safety outcomes were also similar. Patients in the dexmedetomidine group spent a significantly greater percentage of time in target sedation (98[8] %) compared to propofol group (92[10] %; p = 0.02).CONCLUSIONSOur results suggest that, similar to medical and cardiac surgery patients, dexmedetomidine and propofol are safe and effective sedation agents in critically ill trauma and surgical patients; however, dexmedetomidine achieves target sedation better than propofol for this specific population.
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- Does an individualized goal-directed therapy based on cerebral oxygen balance benefit high-risk patients undergoing cardiac surgery?
Bartlett Journal of Clinical Anesthesia 2021;70:No page numbers.
• There were no differences in the intraoperative time course for MAP, BIS and rScO2 levels. • 72% of patients in GDT group achieved preoperative individual targets compared to 44% in the usual care group. • Study group showed a reduction in infection, low cardiac output syndrome, stroke, delirium and length of ICU stay. • No difference was shown between individualized GDT and standard treatment.
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- DREAMS, HALLUCINATIONS AND DELIRIUM.
Barnett Laura Therapy Today 2021;32(5):42-45.
In the article, the author discusses the potential trauma that can be experienced by patients in intensive care units (ICU) and how therapy can help them. Other topics include the dreams, delirium and hallucinations, collectively called intensive therapy unit (ITU) syndrome, experienced by patients, and his interviews with some post-ICU patients.
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HALLUCINATIONS AND DELIRIUM this link
- Economic Impact of Poststroke Delirium and Associated Risk Factors: Findings From a Prospective Cohort Study.
Zipser Carl Moritz Stroke 2021;:STROKEAHA120033005.
BACKGROUND AND PURPOSEDelirium is a common severe complication of stroke. We aimed to determine the cost-of-illness and risk factors of poststroke delirium (PSD).METHODSThis prospective single-center study included n=567 patients with acute stroke from a hospital-wide delirium cohort study and the Swiss Stroke Registry in 2014. Delirium was determined by Delirium Observation Screening Scale or Intensive Care Delirium Screening Checklist 3 times daily during the first 3 days of admission. Costs reflected the case-mix index and diagnosis-related groups from 2014 and were divided into nursing, physician, and total costs. Factors associated with PSD were assessed with multiple regression analysis. Partial correlations and quantile regression were performed to assess costs and other factors associated with PSD.RESULTSThe incidence of PSD was 39.0% (221/567). Patients with delirium were older than non-PSD (median 76 versus 70 years; P<0.001), 52% male (115/221) versus 62% non-PSD (214/346) and hospitalized longer (mean 11.5 versus 9.3 days; P<0.001). Dementia was the most relevant predisposing factor for PSD (odds ratio, 16.02 [2.83-90.69], P=0.002). Moderate to severe stroke (National Institutes of Health Stroke Scale score 16-20) was the most relevant precipitating factor (odds ratio, 36.10 [8.15-159.79], P<0.001). PSD was a strong predictor for 3-month mortality (odds ratio, 15.11 [3.33-68.53], P<0.001). Nursing and total costs were nearly twice as high in PSD (P<0.001). There was a positive correlation between total costs and admission National Institutes of Health Stroke Scale (correlation coefficient, 0.491; P<0.001) and length of stay (correlation coefficient, 0.787; P<0.001) in all patients. Quantile regression revealed rising nursing and total costs associated with PSD, higher National Institutes of Health Stroke Scale, and longer hospital stay (all P<0.05).CONCLUSIONSPSD was associated with greater stroke severity, prolonged hospitalization, and increased nursing and total costs. In patients with severe stroke, dementia, or seizures, PSD is anticipated, and additional costs are associated with hospitalization.
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- Effect of thiamine supplementation in critically ill patients: A systematic review and meta-analysis.
Sedhai Yub Raj Journal of critical care 2021;65:104-115.
INTRODUCTIONSeveral studies have previously shown the benefit of thiamine supplementation in critically ill patients. In order to fully appraise the available data, we performed a meta-analysis of 18 published studies.METHODSA thorough systematic search was conducted. The studies enrolling critically ill patients receiving thiamine supplementation was compared with the standard of care (SOC) group. Data was analyzed using RevMan 5.4. Clinical outcomes were pooled using Odds Ratio (OR) and mean differences.RESULTEighteen studies (8 RCTs and 10 cohort studies) met the criteria for quantitative synthesis. In the analysis of RCTs, thiamine supplementation showed 42% lower odds of developing ICU delirium (OR 0.58, 95% CI, 0.34-0.98). A reduction in mortaliy was observed on performing fixed effect model analysis however, a level of statistical significance could not be reached on performing randon effect model analysis (OR, 0.78; 95% CI, 0.59 to 1.04). Further sub-group analysis of 13 studies in patients with sepsis, there was no difference in mortality between the two groups (OR, 0.83; 95% CI, 0.63 to 1.09).CONCLUSIONThiamine supplementation in critically ill patients showed a reduction in the incidence of ICU delirium among RCTs. However, there was no significant benefit in terms of overall mortality, and mortality in patients with sepsis. Further, large scale randomized prospective studies are warranted to investigate the role of thiamine supplementation in critically ill patients.
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- Effects of a simulation-based education programme on delirium care for critical care nurses: A randomized controlled trial
Mu-Hsing Ho Journal of Advanced Nursing 2021;77(8):3483.
AimsTo evaluate the effects of a simulation-based education programme on critical care nurses’ knowledge, confidence, competence and clinical performance in providing delirium care.DesignSingle-blinded randomized controlled trial.MethodsRegistered nurses who work in intensive care units were recruited from a university-affiliated acute major metropolitan teaching hospital. The intervention group received: (i) five online-learning delirium care videos, (ii) one face-to-face delirium care education session and (iii) a simulation-based education programme with a role-play scenario-based initiative and an objective structured clinical examination. The control group received only online videos which were the same as those provided to the intervention group. Delirium care knowledge, confidence, competence, and clinical performance as outcomes were collected at: baseline, immediately after intervention, and within 6 weeks post-intervention to test whether there were any changes and if they were sustained over time. Data were collected between 2 October and 29 December 2020. The repeated-measures analysis of variance was used to examine for changes in delirium care knowledge, confidence, and competence within groups.ResultsSeventy-two critical care nurses participated with 36 each allocated to the intervention group and control group. No statistically significant difference was observed between the two groups in outcome variables at 6 weeks post-intervention. In the intervention group, significant within-group changes were observed in terms of delirium care knowledge, confidence, and competence over time. By contrast, no significant changes were observed in outcome measures over time in the control group.ConclusionThe simulation-based education programme is an effective and feasible strategy to improve delirium care by enhancing the knowledge, confidence, competence and clinical performance of critical care nurses.ImpactOur findings provide evidence regarding the development and implementation of a simulation-based education programme in hospitals for health professional education in Taiwan.
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- Effects of case-based confusion assessment methods for intensive care unit training on delirium knowledge and delirium assessment accuracy of intensive care units: A quasi-experimental study.
Kim Young-Nam Nurse education today 2021;103:104954.
BACKGROUNDDelirium evaluation is important because the development of delirium in critically ill patients negatively affects their progress and prognosis. Although delirium assessment tools have been developed, nurses have insufficient experience using these tools in clinical practice.OBJECTIVESThis study examined the effects of case-based confusion assessment methods for intensive care unit education on delirium knowledge and assessment accuracy for intensive care nurses.DESIGNThis study adopted a pre- and post-test non-equivalent control group design.SETTINGS AND PARTICIPANTSThe study participants were 122 general nurses (61 participants each in the experimental and control groups) working in the intensive care unit of one university hospital in South Korea.METHODSCase-based confusion assessment methods for intensive care unit education comprised lectures on delirium and confusion assessment methods for intensive care unit tools and delirium assessment education using standardized patients. The experimental group received 80-min case-based confusion assessment methods for intensive care unit training, whereas the control group received no intervention.RESULTSDifferences in the degree of pre- and post-knowledge in subcategories between the experimental and control groups were the cause, symptom, and management. The delirium assessment accuracy score of the experimental group changed from 2.89 ± 1.61 points before training to 8.11 ± 1.23 points after training, whereas that of the control group changed from 2.92 ± 1.94 points before training to 3.05 ± 2.99 points after training (Z = -9.668, p < .001).CONCLUSIONSThe case-based confusion assessment methods for intensive care unit educational program developed in this study is effective for improving delirium knowledge and delirium assessment accuracy in intensive care nurses. Based on the study results, various cases can be developed for the education of intensive care nurses.
- Effects of nonpharmacological delirium-prevention interventions on critically ill patients' clinical, psychological, and family outcomes: A systematic review and meta-analysis.
Liang Surui Australian critical care : official journal of the Confederation of Australian Critical Care Nurses 2021;34(4):378-387.
BACKGROUNDDelirium is common in critically ill patients and may lead to severe complications, such as falls and injuries. Nonpharmacological interventions have been widely suggested to prevent delirium, yet the effects remain uncertain.OBJECTIVESThe aim of the study was to determine the effects of nonpharmacological interventions on preventing delirium and improving critically ill patients' clinical, psychological, and family outcomes.METHODSTen databases were searched from their inception to September 2020. Two reviewers assessed the methodological quality and extracted details of the included studies. The data were narratively or statistically pooled where appropriate. Dichotomous variables are presented as odds ratio (OR), and continuous variables are presented as mean difference (MD). The Grading of Recommendations Assessment, Development, and Evaluation criteria were used to assess the quality of evidence for each review outcome.RESULTSThirty-four studies (10 randomised controlled trials, eight controlled clinical trials, and 16 before-and-after studies) were included in the analysis. Low-certainty evidence indicated that nonpharmacological interventions reduced delirium incidence (OR = 0.43, 95% confidence interval [CI] [0.33, 0.55]), delirium duration (MD = -1.43 days, 95% CI [-1.94, 0.92]), and length of stay in the intensive care unit (MD = -1.24 days, 95% CI [-2.05, -0.43]). Moderate-certainty evidence demonstrated no effect on mortality. Narrative synthesis further implied improvements in patients' psychological recovery (two studies, very low-certainty evidence) and families' satisfaction with care (two studies, very low-certainty evidence) through nonpharmacological interventions. As for effective intervention types, moderate-certainty evidence demonstrates that early mobilisation (OR = 0.33, 95% CI [0.24, 0.46], five studies, 859 participants, I2 = 24%), family participation (OR = 0.25, 95% CI [0.18, 0.34], four studies, 997 participants, I2 = 21%), and use of multicomponent interventions (OR = 0.48, 95% CI [0.34, 0.69], 13 studies, 3172 participants, I2 = 77%) are associated with reduced incidence of delirium.CONCLUSIONSHealthcare professionals are recommended to apply early mobilisation, family participation, or multicomponent interventions in clinical practice to prevent delirium. Further studies investigating the effects of nonpharmacological interventions on patients' psychological and family outcomes are warranted.
- Extrapyramidal Symptoms Induced by Treatment for Delirium: A Case Report.
Santos Christan D. Critical care nurse 2021;41(3):50-54.
INTRODUCTIONAntipsychotics are a treatment option for delirium in the intensive care unit. Atypical antipsychotics are preferred over first-generation antipsychotics because of their lower incidence of extrapyramidal adverse effects. The most common such effect is akathisia or restlessness. This report describes a case of atypical antipsychotic-induced akathisia and addresses the clinical distinction between extrapyramidal movements and movements due to intensive care unit delirium.CLINICAL FINDINGSA 56-year-old man who had a prolonged hospital stay after orthotopic liver transplant complicated by multisystem organ failure, primary graft failure requiring a second transplant, and enterocutaneous fistula developed agitated delirium on hospital day 28. Initial treatment included intravenous haloperidol and scheduled sublingual olanzapine (5 mg daily). His delirium and insomnia persisted, requiring dexmedetomidine infusion. Olanzapine dosing was increased to 10 mg daily on hospital day 34 and 15 mg daily on hospital day 45. The following day, his mentation improved; however, he exhibited asynchronous, nonrhythmic, involuntary rolling motions of his hands and choreiform gait.DIAGNOSIS AND OUTCOMESAntipsychotics were immediately discontinued owing to acute akathisia. All symptoms resolved within 2 days, and the patient was transferred out of the intensive care unit on hospital day 52.CONCLUSIONAlthough extrapyramidal adverse effects are less common with olanzapine than with typical antipsychotics, they sometimes occur and can mimic manifestations of delirium. Restlessness should alert the nurse to assess for possible extrapyramidal adverse effects. If they are suspected, antipsychotic medications should be reduced or discontinued to prevent progression to functional disability.
Symptoms Induced by Treatment for Delirium: A Case Report this link
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- Feasibility of a virtual reality intervention in the intensive care unit.
Jawed Yameena T. Heart & lung : the journal of critical care 2021;50(6):748-753.
BACKGROUNDDelirium prevention requires optimal management of pain and anxiety. Given the limitations of current pharmacologic interventions, evaluation of novel non-pharmacological interventions is required. Virtual reality (VR) stimulation may be a promising intervention because of its capability to reduce psychophysiological stress, pain, and anxiety and to restore cognitive and attentional capacities.OBJECTIVETo ascertain patients' and providers' perceptions of acceptability and safety of VR intervention in the intensive care unit (ICU).METHODSWe enrolled a cohort of 15 ICU patients and 21 health care providers to administer a 15-minute session showing a relaxing beach scene with VR headsets and nature sound effects. Participants were then asked to rate their experiences on a Likert scale survey.RESULTSThe majority of patients (86%, 12 of 14) rated the headsets as moderately to very comfortable. All had moderate or greater sense of presence in the virtual environment, and 79% (11 of 14) rated their overall experience at 3 or greater (5 indicating that they enjoyed it very much). Seventy-one percent (10 of 14) of the patients felt that their anxiety was better with VR, and 57% (8 of 14) did not notice a change in their pain or discomfort. All health care providers found the headset to be at least moderately comfortable and felt a moderate or greater sense of presence. All providers concluded that VR therapy should be available for their patients. Both groups experienced minimal side effects.CONCLUSIONIn this prospective study of perceptions of VR therapy for ICU patients and health care providers, there was a high level of acceptance, with minimal side effects, for both groups despite their low levels of prior experience with virtual reality and video gaming.
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- Front-loaded diazepam versus lorazepam for treatment of alcohol withdrawal agitated delirium.
Levine Alexander R. The American journal of emergency medicine 2021;44:415-418.
BACKGROUNDFront-loaded diazepam is used to rapidly control agitation in patients with severe alcohol withdrawal syndrome (AWS). Our institution began using front-loaded lorazepam in August 2017 secondary to a nation-wide shortage of intravenous (IV) diazepam. Currently, there are no studies comparing lorazepam to diazepam for frontloading in severe AWS.METHODRetrospective cohort study of all adults presenting to the emergency department with a diagnosis of AWS and prescribed the institution's alcohol withdrawal agitated delirium protocol 8 months pre and post shortage of IV diazepam were eligible inclusion for the study. Of these, 106 patients were front-loaded with diazepam and 70 patients were front-loaded with lorazepam.RESULTSThere was no difference in the mean change in Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised scores 24 h pre and post front-loading in the two groups (-13.9 ± -8.08 vs. -13.1 ± -8.91, p = 0.534). Patients who received front-loaded lorazepam had an increased incidence of ICU-delirium (positive for the Confusion Assessment Method in the ICU: 75% with lorazepam vs. 52.6% with diazepam, p = 0.009) and a higher risk of over-sedation, but this did not reach statistical significance (Richmond Agitation-Sedation Scale score < -1: 32.1% with lorazepam vs. 18.2% with diazepam, p = 0.063).CONCLUSIONFront-loaded lorazepam was similar to front-loaded diazepam in controlling AWS symptoms. Lorazepam's delayed onset of action should be considered when determining how quickly repeat doses are administered to avoid the potential for adverse drug events.
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- Gaps in Care Occur Between ICU and Acute Care Unit: ICU patients need careful follow-up.
AHC MEDIA Hospital Case Management 2021;29(7):1-3.
Patients who received ICU care experience problems that need to be resolved before they are discharged. These can include delirium, debility, and dysphagia, researchers say.
in Care Occur Between ICU and Acute Care Unit: ICU patients need careful follow-up this link
in Care Occur Between ICU and Acute Care Unit: ICU patients need careful follow-up this link
in Care Occur Between ICU and Acute Care Unit: ICU patients need careful follow-up this link
- Gravitational Ischemia in the Brain-May Contribute to Delirium and Mortality in the Intensive Care Unit.
Jaster J. Howard Cardiovascular pathology : the official journal of the Society for Cardiovascular Pathology 2021;:107349.
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- Guideline Update: Bundle Up for Pain, Agitation, and Delirium.
Anon. Critical Care Nurse 2021;41(3):80-80.
The article presents questions and answers related to pain, agitation and delirium, including the behavioral pain scales validated for pain assessment in critical care, how to lessen potential delirium in neurological intensive care units (ICU), and how to assess an intubated adult.
Update: Bundle Up for Pain, Agitation, and Delirium this link
- How We Do It: How We Prevent and Treat Delirium in the ICU.
Palakshappa Jessica A. Chest 2021;:No page numbers.
Delirium is a serious and complex problem facing critically ill patients, their families, and the healthcare system. When it develops, delirium is associated with prolonged hospital stays, increased costs, and long-term cognitive impairment in many patients. In this article, we use a clinical case to discuss our approach to delirium prevention and treatment in the intensive care unit (ICU). We believe that an effective strategy to combat delirium requires implementation and adherence to a pain and sedation protocol as part of bundled care, use of a validated tool to detect delirium when present, and a focus on non-pharmacologic care strategies including reorientation, early mobility, and incorporating family into care when possible. At present, the evidence does not support the routine administration of medications to prevent or treat delirium. A pharmacologic approach may be needed for agitated delirium and we discuss our evaluation of the evidence for and against particular medications. While delirium can be a distressing problem, there is evidence that it can be addressed through careful attention to prevention, detection, and minimizing the long-term impact on patients and their families.
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- Hyperactive delirium in patients after non-traumatic subarachnoid hemorrhage
Reimann Fabian Journal of Critical Care 2021;64:45.
PurposeHyperactive delirium is common after subarachnoid hemorrhage (SAH). We aimed to identify risk factors for delirium and to evaluate its impact on outcome.MethodsWe collected daily Richmond Agitation Sedation Scale (RASS) and Intensive Care Delirium Screening Checklist (ICDSC) scores in 276 SAH patients. Hyperactive delirium was defined as ICDSC ≥4 when RASS was >0. We investigated risk factors for delirium and its association with 3-month functional outcome using generalized linear models.ResultsPatients were 56 (IQR 47–67) years old and had a Hunt&Hess (H&H) grade of 3 (IQR 1–5). Sixty-five patients (24%) developed hyperactive delirium 6 (IQR 3–16) days after SAH. In multivariable analysis, mechanical ventilation>48 h (adjOR = 4.46; 95%-CI = 1.89–10.56; p = 0.001), the detection of an aneurysm (adjOR = 4.38; 95%-CI = 1.48–12.97; p = 0.008), a lower H&H grade (adjOR = 0.63; 95%-CI = 0.48–0.83; p = 0.001) and a pre-treated psychiatric disorder (adjOR = 3.17; 95%-CI = 1.14–8.83; p = 0.027) were associated with the development of delirium. Overall, delirium was not associated with worse outcome (p = 0.119). Interestingly, patients with delirium more often had a modified Rankin Scale Score (mRS) of 1–3 (77%) compared to an mRS of 0 (14%) or 4–6 (9%).ConclusionOur data indicate that hyperactive delirium is common after SAH patients and requires a certain degree of brain connectivity based ono the highest prevalence found in SAH patients with intermediate outcomes.
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- ICU Survivorship-The Relationship of Delirium, Sedation, Dementia, and Acquired Weakness.
Mart Matthew F. Critical care medicine 2021;:No page numbers.
The advent of modern critical care medicine has revolutionized care of the critically ill patient in the last 50 years. The Society of Critical Care Medicine (was formed in recognition of the challenges and need for specialized treatment for these fragile patients. As the specialty has grown, it has achieved impressive scientific advances that have reduced mortality and saved lives. With those advances, however, came growing recognition that the burden of critical illness did not end at the doorstep of the hospital. Delirium, once thought to be a mere by-product of critical illness, was found to be an independent predictor of mortality, prolonged mechanical ventilation, and long-lasting cognitive impairment. Similarly, deep sedation and immobility, so often used to keep patients "comfortable" and to facilitate mechanical ventilation and recovery, worsen mortality and lead to the development of ICU-acquired weakness. The realization that these outcomes are inextricably linked to one another and how we manage our patients has helped us recognize the need for culture change. We, as a specialty, now understand that although celebrating the successes of survival, we now also have a duty to focus on those who survive their diseases. Led by initiatives such as the ICU Liberation Campaign of the Society of Critical Care Medicine, the natural progression of the field is now focused on getting patients back to their homes and lives unencumbered by disability and impairment. Much work remains to be done, but the futures of our most critically ill patients will continue to benefit if we leverage and build on the history of our first 50 years.
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- ICU trauma...Barnett L. Dreams, hallucinations and delirium. Therapy Today, June 2021.
Trumfield Therapy Today 2021;32(6):17-18.
Available online at this link
trauma...Barnett L. Dreams, hallucinations and delirium. Therapy Today, June 2021 this link
- Impact of a Pharmacist-Led Intensive Care Unit Sleep Improvement Protocol on Sleep Duration and Quality.
Andrews Jessica L. The Annals of pharmacotherapy 2021;55(7):863-869.
BACKGROUNDSleep improvement protocols are recommended for use in the intensive care unit (ICU) despite questions regarding which interventions to include, whether sleep quality or duration will improve, and the role of pharmacists in their development and implementation.OBJECTIVETo characterize the impact of a pharmacist-led, ICU sleep improvement protocol on sleep duration and quality as evaluated by a commercially available activity tracker and patient perception.METHODSCritical care pharmacists from a 40-bed, mixed ICU at a large community hospital led the development and implementation of an interprofessional sleep improvement protocol. It included daily pharmacist medication review to reduce use of medications known to disrupt sleep or increase delirium and guideline-based recommendations on both environmental and nonpharmacological sleep-focused interventions. Sleep duration and quality were compared before (December 2018 to December 2019) and after (January to June 2019) protocol implementation in non-mechanically ventilated adults using both objective (total nocturnal sleep time [TST] measured by an activity tracker (Fitbit Charge 2) and subjective (patient-perceived sleep quality using the Richards-Campbell Sleep Questionnaire [RCSQ]) measures.RESULTSGroups before (n = 48) and after (n = 29) sleep protocol implementation were well matched. After protocol implementation, patients had a longer TST (389 ± 123 vs 310 ± 147 minutes; P = 0.02) and better RCSQ-perceived sleep quality (63 ± 18 vs 42 ± 24 mm; P = 0.0003) compared with before implementation.CONCLUSION AND RELEVANCEA sleep protocol that incorporated novel elements led to objective and subjective improvements in ICU sleep duration and quality. Application of this study may result in increased utilization of sleep protocols and pharmacist involvement.
- Impact of delirium on mortality in patients hospitalized for heart failure.
Ritchie Charlotte International journal of psychiatry in medicine 2021;:912174211028019.
OBJECTIVEHeart Failure (HF) is one of the leading causes of hospitalization in the United States accounting for ≈800,000 hospital discharges and $11 billion in annual costs. Delirium occurs in approximately 30% of elderly hospitalized patients and its incidence is significantly higher among those admitted to the critical care units. Despite this, there has been limited exploration of the clinical and economic impact of delirium in patients hospitalized with acute HF. We hypothesized that delirium in HF is associated with excess mortality and hospital costs.METHODSWe queried the 2001-2014 Nationwide Inpatient Sample to identify hospitalizations that included a primary discharge diagnosis of HF (ICD-9-CM: 428.xx) and stratified them by presence or absence of delirium (ICD-9-CM: 239.0, 290.41, 293.0, 293.1, 348.31). Differences in in-hospital mortality, length of stay (LOS), and hospital costs were assessed using propensity-score matched cohorts.RESULTSMajor predictors of delirium included advanced age, Caucasian race, underlying dementia or psychiatric diagnoses, higher Elixhauser Comorbidity Index, renal failure, cardiogenic shock, and coronary artery bypass surgery. In the propensity-score matched analysis of 76,411 hospitalization with delirium compared to 76,612 without delirium, in-hospital mortality (odds ratio: 1.67, 95% CI: 1.51-1.77), LOS (rate ratio [RR]: 1.47, 95% CI: 1.45-1.51), and hospital costs (RR: 1.44, 95% CI: 1.41-1.48) were all statistically higher in the presence of delirium (all p < 0.001).CONCLUSIONIn patients hospitalized with HF, delirium is an independent predictor of increased in-hospital mortality, longer LOS, and excess hospital costs despite adjustment for baseline characteristics.
- Incidence and influencing factors of post-intensive care cognitive impairment.
Yao Li Intensive & critical care nursing 2021;:103106.
OBJECTIVETo evaluate the incidence and risks factors of short-term post-intensive care (ICU) cognitive impairment.DESIGNProspective, observational study.SETTINGClosed university-affiliated intensive care unit.PATIENTSWe enrolled consecutive patients >18 yrs of age expected to be in intensive care unit for ≥24 hours.INTERVENTIONSNone.MEASUREMENTS AND MAIN RESULTSThe score of Montreal Cognitive Assessment (MoCA) less than 26 was defined as cognitive impairment at hospital discharge and short-term post-ICU cognitive impairment was diagnosed in 185 of 409 assessed patients (45.2%). According to univariate analysis, age, years of education, occupation, past medical history, main ICU diagnosis, Acute Physiology and Chronic Evaluation Scoring System (APACHE II) score, Sequential Organ Failure Assessment (SOFA) score, Charlson comorbidity index, ICU length-of-stay (LOS), total hospital LOS, sedation, vasoactive agents, muscle relaxants, mechanical ventilation and duration of mechanical ventilation, constraints, early active mobilisation, hypoxemia, frequency and severity of delirium, blood pressure, rescue experience, and infection were significant predictors of post-ICU cognitive impairment. Multivariate analysis results showed that the frequency and severity of delirium, and advanced age were risk factors of post-ICU cognitive impairment; high years of education and early active mobilisation were protective factors.CONCLUSIONSIncidence of post-ICU cognitive impairment is at a high level, which is similar to former researches' results; the frequency and severity of delirium, and advanced age were risk factors of post-ICU cognitive impairment; high years of education and early active mobilisation were protective factors of post-ICU cognitive impairment.
- Incidence of Delirium and Its Related Risk Factors Among Patients in Cardiac Intensive Care Unit.
Azimian Journal of Education & Research in Nursing / Hemsirelikte Egitim ve Arastirma Dergisi 2021;18(2):205-209.
Background: The incidence of delirium in patients who underwent open-heart surgery can cause them to face many short- and long-term complications. Having comprehensive information on the incidence and risk factors of delirium in patients who underwent open-heart surgery is essential for preventive care. Owing to the lack of studies in this regard, this study was conducted with the aim of investigating the incidence of delirium and its associated risk factors among patients undergoing cardiac surgery in a cardiac intensive care unit. Methods: This is a cross-sectional descriptive study conducted in the cardiac surgery intensive care unit of Booali Sina Hospital in Qazvin, Iran in 2018. The study sample comprised 230 patients who underwent open-heart surgery. For data collection, a demographic checklist and the Neelon and Champagne Confusion Scale were used. Data collection started in the evening before cardiac surgery and continued every day until patients left the intensive care unit. Collected data were then analyzed using descriptive tests and a nonlinear logistic regression model by Statistical Package for the Social Sciences, version 23. Results: Of all the patients who participated in this study, 53.5% showed some degree of delirium; 17 patients (7.4%) showed symptoms of moderate-to-severe delirium, 16 patients (7%) showed symptoms of mild delirium, and 90 patients (39.1%) developed confusion. Among the variables studied in this study, older age, history of renal diseases, history of stroke, the use of intraoperative cardiopulmonary bypass, clamp time, postoperative fibrillation, and postoperative stroke significantly predicted delirium (P < .05). Conclusion: More than half of the patients reported some degree of delirium. Therefore, it is necessary to take preventive measures into consideration in this regard.
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- Influence of Sex on Outcomes After Thoracic Endovascular Repair for Type B Aortic Dissection.
Luo Songyuan Angiology 2021;72(6):556-564.
We aimed to investigate whether sex differences influence the clinical outcomes of patients who undergo thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD). We retrospectively analyzed a prospectively maintained single-center cohort of patients with TBAD who underwent TEVAR between January 2010 and June 2017. We evaluated the in-hospital and long-term mortality and composite end point. Of the 913 patients, 793 (86.8%) were male and 120 (13.1%) were female. Compared to male patients, the female patients were older, more likely to have diabetes mellitus, but less likely to smoke or have hypertension. The proximal landing zone in 0 and 1 was higher in male patients (P = .023), who were more likely to require an aortic arch bypass. Endoleak, delirium, and ICU stay after stent-graft implantation were also more frequent in men. Sex factor was not associated with in-hospital or long-term mortality or the composite end point in the multivariable regression analyses and Cox regression model. The mean estimated survival time was similar between males and females (2462.9 ± 141.2 vs 2804.1 ± 117.4 days, P = .167) in the propensity score-matched cohort. Despite distinct characteristics between sex, there was no sex-related difference in long-term clinical outcomes after TEVAR for TBAD.
- Long-Term Outcomes after Delirium in the ICU: Addressing Gaps in our Knowledge.
Devlin John W. American journal of respiratory and critical care medicine 2021;:No page numbers.
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- Management of delirium in a medical and surgical intensive care unit.
Shivji Sheliza Journal of clinical pharmacy and therapeutics 2021;46(3):669-676.
WHAT IS KNOWN AND OBJECTIVEDelirium has been associated with increased mortality and prolonged hospital length of stay among critical care patients. Furthermore, treatment of delirium remains variable amongst clinicians due to limited evidence. The objective of this study was to determine the local incidence of delirium and to characterize the effectiveness and safety of pharmacological therapy used to treat delirium.METHODSA retrospective chart review evaluated patients diagnosed with delirium (Intensive Care Delirium Screening Checklist score ≥4) and requiring mechanical ventilation for ≥48 hours from January 2016 to June 2017. The primary outcomes included comparison of resolution, the time to first resolution and recurrence of delirium in patients prescribed pharmacological and/or pre-emptive therapy versus those who did not. Secondary outcomes included incidence of adverse effects of drug therapy and delirium attributable adverse events.RESULTS AND DISCUSSIONThe incidence of delirium during our defined study period was 49%. Of the 178 patients included in the study, 136 (76%) received drug therapy for delirium. Agents used for treatment of delirium included dexmedetomidine (n = 90 [66%]), haloperidol (n = 77 [57%]), and quetiapine (n = 74 [54%]). Resolution of delirium occurred in 94 (52%) of patients and the difference was statistically significant favoring patients who did not receive pharmacological therapy. There was no difference in the median time to resolution of delirium (3 days) for patients who received pharmacological and/or pre-emptive therapy versus those who did not. Bradycardia and hypotension were the most frequently documented medication-related adverse events. Self-removal of an invasive line/catheter, was reported in 36 (26%) patients despite receiving pharmacological treatment.WHAT IS NEW AND CONCLUSIONDespite unclear evidence that pharmacological interventions help with delirium management, the majority of our patients received such interventions. To improve patient outcomes, we should shift focus towards non-pharmacological interventions for delirium.
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- Management of Hypnotics in Patients with Insomnia and Heart Failure during Hospitalization: A Systematic Review.
Jorge-Samitier Nursing Reports 2021;11(2):373-381.
Background: Heart failure is a chronic, progressive syndrome of signs and symptoms, which has been associated to a range of comorbidities including insomnia. Acute decompensation of heart failure frequently leads to hospital admission. During hospital admission, long-term pharmacological treatments such as hypnotics can be modified or stopped. Aim: To synthesize the scientific evidence available about the effect of withdrawing hypnotic drugs during hospital admission in patients with decompensated heart failure and insomnia. Method: A systematic review of the literature following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines was carried out in the following scientific databases: PubMed, Scopus, Dialnet and Cochrane. Inclusion criteria: studies including a population of adults with heart failure and sleep disorders in treatment with hypnotics and admitted to hospital, studies written in English or Spanish and published until June 2020. Exclusion criteria: studies involving children, patients admitted to intensive care and patients diagnosed with sleep apnea. Results: We identified a total of 265 documents; only nine papers met the selection criteria. The most frequently used drugs for the treatment of insomnia in patients with heart failure were benzodiazepines and benzodiazepine agonists; their secondary effects can alter perceived quality of life and increase the risk of adverse effects. Withdrawal of these drugs during hospital admission could increase the risk of delirium. Future research in this area should evaluate the management of hypnotics during hospital admission in patients with decompensated heart failure. In addition, safe and efficient non-pharmacological alternatives for the treatment of insomnia in this population should be tested and implemented.
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- Meta-analysis of ICU Delirium Biomarkers and Their Alignment With the NIA-AA Research Framework.
Chan Carol K. American journal of critical care : an official publication, American Association of Critical-Care Nurses 2021;30(4):312-319.
BACKGROUNDBetween 30% and 80% of survivors of critical illness experience cognitive impairment, but the underlying mechanisms remain unknown.OBJECTIVETo determine whether intensive care unit (ICU) delirium biomarkers align with the National Institute on Aging-Alzheimer's Association (NIA-AA) research framework for diagnostic biomarkers for Alzheimer disease and other related dementias (ADRD).METHODSOvid MEDLINE, PsycInfo, Embase, and the Cochrane Library were systematically searched for articles published between January 1, 2000, and February 20, 2020, on the relationship between delirium and biomarkers listed in the NIA-AA framework. Only studies that addressed delirium in the ICU setting and fluid biomarkers were included in these analyses.RESULTSOf 61 256 records screened, 38 studies met inclusion criteria, 8 of which were suitable for meta-analysis. In pooled analysis, significant associations were found between ICU delirium and amyloid β-peptide 1-40 (standard mean difference [SMD], 0.42; 95% CI, 0.09-0.75), interleukin (IL)-1 receptor antagonist (SMD, 0.58; 95% CI, 0.21-0.94), and IL-6 (SMD, 0.31; 95% CI, 0.06-0.56). No significant association was observed in pooled analyses between ICU delirium and the other biomarkers. Few studies have examined ICU delirium and pathologic tau or neurodegeneration biomarkers.CONCLUSIONSInflammatory biomarkers and amyloid β are associated with ICU delirium and point to potential overlapping mechanisms between delirium and ADRD. Critical care providers should consider integrating diagnostic approaches used in ADRD in their assessment of post-ICU cognitive dysfunction.
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- Nurses' knowledge and attitudes regarding physical restraint in Turkish intensive care units
Büşra Ertuğrul Nursing in Critical Care 2021;26(4):253.
BackgroundPhysical restraint is still widely used despite studies supporting a reduction in its use. The development of guidelines to reduce the use of PR first requires the identification of factors related to the use of alternative methods.AimThis study aimed to determine factors associated with the use of alternatives to physical restraint (PR) in intensive care units.DesignThis was a cross-sectional descriptive study.MethodsData were collected from adult intensive care units of three hospitals in Turkey using the Physical Restraint Knowledge, Attitude and Practice Scale and a questionnaire including open-ended questions.ResultsOverall, 202 nurses (80% response rate) completed the questionnaire. Nurses' knowledge, attitude, and practice scores regarding PR were 6.89 ± 1.79, 29.85 ± 4.93, and 36.76 ± 3.36, respectively. PR was reported to be necessary for patients at risk of self-harm, with dangerous behaviours, and who were trying to remove their catheters. Most nurses (64.9%) stated that they needed a written doctor's order. Analysis of free-text responses showed that patient disorientation (because of delirium, sedation, or agitation), nurses' workload, and lack of training regarding restraint were the primary reasons why nurses could not use alternatives. The main alternatives suggested by nurses were categorized as sedation, communication, and environmental regulation. Logistic regression analysis identified training (P = .009), working unit (P = .001), and nurses' practice score to use PR (P = .004) as independent risk factors for not using alternative methods of PR.ConclusionsThe results of this study revealed a moderate level of knowledge, attitude, and practice among nurses regarding the use of PR. Thus, education of nurses about the prevention of delirium and alternatives to PR according to the characteristics of their units is required.Relevance to clinical practiceClinical guidelines and in-service training need to be developed to increase the use of alternatives to PR and delirium management.
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- Nutritional Risk at intensive care unit admission and outcomes in survivors of critical illness.
Mart Matthew F. Clinical nutrition (Edinburgh, Scotland) 2021;40(6):3868-3874.
BACKGROUND AND AIMSRisk factors for poor outcomes after critical illness are incompletely understood. While nutritional risk is associated with mortality in critically ill patients, its association with disability, cognitive, and health-related quality of life is unclear in survivors of critical illness. This study's objective was to determine whether greater nutritional risk at ICU admission is associated with greater disability, worse cognition, and worse HRQOL at 3 and 12-month follow-up.METHODSWe enrolled adults (≥18 years of age) with respiratory failure or shock treated in medical and surgical intensive care units from two U.S. centers. We measured nutritional risk using the modified Nutrition Risk in Critically Ill (mNUTRIC) score (range 0-9 [highest risk]) at intensive care unit admission. We measured associations between mNUTRIC scores and discharge destination, disability in basic activities of daily living (ADLs) using the Katz ADL, instrumental ADLs using the Functional Activities Questionnaire (FAQ), global cognition using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), executive function using the Trail Making Test Part B (Trails B), and health-related quality of life using the SF-36, adjusting for sex, education, BMI, baseline frailty, disability, and cognition, severity of illness, days of delirium, coma, and mechanical ventilation.RESULTSOf the 821 patients enrolled in the ICU, 636 patients survived to hospital discharge. We assessed outcomes in 448 of 535 survivors (84%) at 3 months and 382 of 476 survivors (80%) at 12 months. Higher mNUTRIC scores predicted greater odds of discharge to an institution (OR 2.0, 95% CI: 1.6 to 2.6; P < 0.01). Higher mNUTRIC scores were associated with a trend towards greater disability in basic activities of daily living (IRR 1.3, 95% CI 1.0 to 1.7) at 3 months that did not reach significance (p = 0.09) with no association demonstrated at 12 months. There were no associations between mNUTRIC scores and FAQ, RBANS, or Trails B scores. mNUTRIC scores were inconsistently associated with SF-36 physical and mental component scale scores.CONCLUSIONSGreater nutritional risk at ICU admission is associated with disability in survivors of critical illness. Future studies should evaluate interventions in those at high nutritional risk as a means to speed recovery.
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- Optimal interval and duration of CAM-ICU assessments for delirium detection after cardiac surgery.
Hamadnalla Hassan Journal of clinical anesthesia 2021;71:110233.
STUDY OBJECTIVEOur goal was to determine when postoperative delirium first occurs, and to assess evaluation strategies that reliably detect delirium with lowest frequency of testing'.DESIGNThis was a retrospective study that used a database from a five-center randomized trial.SETTINGPostoperative cardiothoracic ICU and surgical wards.PARTICIPANTAdults scheduled for elective coronary artery bypass and/or valve surgery.INTERVENTION AND MEASUREMENTSPostoperative delirium was assessed using CAM-ICU questionnaires twice daily for 5 days or until hospital discharge. Data were analyzed using frequency tables and Kaplan-Meier time-to-event estimators, the latter being used to summarize time to first positive CAM-ICU over POD1-5 for all patients for various evaluation strategies, including all assessments, only morning assessment, and only afternoon assessments. Sensitivity for various strategies were compared using McNemar's test for paired proportions.MAIN RESULTSA total of 95 of 788 patients (12% [95% CI, 10% to 15%]) had at least 1 episode of delirium within the first 5 postoperative days. Among all patients with delirium, 65% were identified by the end of the first postoperative day. Delirium was detected more often in the mornings (10% of patients) than evenings (7% of patients). Compared to delirium assessments twice daily for five days, we found that twice daily assessments for 4 days detected an estimated 97% (95% CI 91%, 99%) of delirium. Measurements twice daily for three days detected 90% (82%, 95%) of delirium.CONCLUSIONSPostoperative delirium is common, and CAM-ICU assessments twice daily for 4 days, versus 5 days, detects nearly all delirium with 20% fewer assessments. Four days of assessment may usually be sufficient for clinical and research purposes.
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- Optimising COVID-19 survivorship after ICU – Don’t forget eye care
Pirret Alison Intensive & Critical Care Nursing 2021;64:No page numbers.
In the COVID-19 era, increased nursing workload associated with donning and doffing personal safety equipment, decontamination procedures, caring for patients with no visitors to support them, and keeping families fully informed add to the nursing workload, further increasing the risk of eye care being overlooked (Lucchini et al., 2020b) and exposing patients to corneal injury.Corneal injury and its associated complications can cause irreversible vision loss, resulting in patients’ "loss of independence, reduced mobility and poor mental health" (Samsome and Lim, p.1) thus adding to the burden associated with post intensive care syndrome following ICU and hospital discharge.Whilst we have the ABCDEF bundle to improve the outcome of mechanically ventilated patients that focuses on "Assessing, preventing and managing pain; Both spontaneous awakening and breathing trials; Choice of sedation; Delirium-assess, prevent and manage; Early mobility; and Family Engagement (Boehm et al., 2020), there is no focus on eye care.
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- Outcome of Organ Dysfunction in the Perioperative Period.
Thiele Robert H. Anesthesia and analgesia 2021;133(2):393-405.
While intraoperative mortality has diminished greatly over the last several decades, the risk of death within 30 days of surgery remains stubbornly high and is ultimately related to perioperative organ failure. Perioperative strokes, while rare (<2% in noncardiac surgery), are associated with a more than 10-fold increase in mortality. Rapid identification and treatment are key to maximizing long-term outcomes. Postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) are separate but related perioperative neurological disorders, both of which are associated with poor long-term outcomes. To date, there are few known interventions that can ameliorate the risk of perioperative central nervous system dysfunction. Major adverse cardiac events (MACE) are a major contributor to adverse clinical outcomes following surgical procedures. Recently, advances in diagnostic strategies (eg, high-sensitivity cardiac troponin [hs-cTn] assays) have improved our understanding of MACE. Recently, the dabigatran in patients with myocardial injury after noncardiac surgery (MINS; Management of myocardial injury After NoncArdiac surGEry) trial demonstrated that a direct thrombin inhibitor could improve outcomes following MINS. While the risk of acute respiratory distress syndrome (ARDS) after surgery is approximately 0.2%, other less severe complications (eg, pneumonia, reintubation) are closer to 2%. While intensive care unit (ICU) concepts related to ARDS have migrated into the operating room, whether or not adverse pulmonary outcomes impact long-term outcomes in surgical patients remains a matter of debate. The standardization of acute kidney injury (AKI) definition has improved the ability of clinicians to measure and study the incidence of this important source of perioperative morbidity. AKI is associated with increased mortality as well as nonrenal morbidity (eg, myocardial infarction) after major surgery. Gastrointestinal complications after surgery range from ileus (common in abdominal procedures and associated with an increased length of stay) to less common complications such as mesenteric ischemia and gastrointestinal bleeding, both of which are associated with very high mortality. Outside of cardiothoracic surgery, the incidence of perioperative hepatic injury is not well described but, in this population, is associated with worsened long-term outcomes. Hyperglycemia is a common perioperative complication and occurs in patients undergoing both cardiac and noncardiac surgery. Both hyper- and hypoglycemia are associated with worsened long-term outcomes in cardiac and noncardiac surgery. Better diagnosis and increased understanding of perioperative organ injury has led to an increased appreciation for the specific role that particular organ systems play in poor long-term outcomes and has set the stage for targeted therapeutic interventions.
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- Pattern of Brain Injury in Patients With Thrombotic Thrombocytopenic Purpura in the Precaplacizumab Era.
Mirouse Adrien Critical care medicine 2021;:No page numbers.
OBJECTIVESTo describe short- and long-term neurologic prognosis of patients with thrombotic thrombocytopenic purpura and to identify clusters associated with evolution.DESIGNProspective French cohort.SETTINGICU in a reference center.PATIENTSAll consecutive patients with newly diagnosed thrombocytopenic purpura.INTERVENTIONComprehensive clinical, biological, and radiological evaluation at admission. Neurocognitive recovery was assessed using Glasgow Outcome Scale (range 1-5, with 1 representing death and 5 representing no or minimal neurologic deficit).MEASUREMENTS AND MAIN RESULTSAmong the 130 newly diagnosed patients with thrombocytopenic purpura, 108 (83%; age 43 [30-52]; 73% women) presented with neurologic signs, including headaches (51%), limb weakness, paresthesia, and/or aphasia (49%), pyramidal syndrome (30%), decreased consciousness (20%), seizure (19%), cognitive impairment (34%), cerebellar syndrome (18%), and visual symptoms (20%). A hierarchical cluster analysis identified three distinct groups of patients. Cluster 1 included younger patients (37 [27-48], 41 [32-52], and 48 [35-54], in clusters 1, 2 and 3, respectively; p = 0.045), with a predominance of headaches (75%, 27%, and 36%; p < 0.0001). Cluster 2 patients had ataxic gait and cerebellar syndrome (77%, 0%, and 0%; p < 0.0001) and dizziness (50%, 0%, and 0%; p < 0.0001). Cluster 3 included patients with delirium (36%, 0%, and 9%; p < 0.0001), obtundation (58%, 0%, and 24%; p < 0.0001), and seizure (36%, 0%, and 14%; p < 0.0001). Acute kidney injury was 32%, 68%, and 77%, in clusters 1, 2, and 3, respectively (p < 0.0001). The three clusters did not differ for other biological or brain imaging. After a median follow-up of 34 months (12-71 mo), 100 patients (93%) were alive with full neurocognitive recovery (i.e., Glasgow Outcome Scale score 5) in 89 patients (89%). Patients from cluster 1 more frequently exhibited full recovery (Glasgow Outcome Scale score of 5) compared with clusters 2 and 3, (44 [98%], 13 [65%], and 21 [60%] at 3 mo; p < 0.0001), (44 [100%], 15 [68%], and 23 [69%] at 6 mo; p < 0.0001), and (40 [100%], 15 [79%], and 20 [57%] at 1 yr; p < 0.0001).CONCLUSIONSInitial clinical neurologic evaluation in thrombocytopenic purpura patients distinguishes three groups of patients with different clinical and functional outcomes.
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- Prediction of Postictal Delirium Following Status Epilepticus in the ICU: First Insights of an Observational Cohort Study.
Baumann Sira M. Critical care medicine 2021;:No page numbers.
OBJECTIVESTo identify early predictors of postictal delirium in adult patients after termination of status epilepticus.DESIGNRetrospective study.SETTINGICUs at a Swiss tertiary academic medical center.PATIENTSStatus epilepticus patients treated on the ICUs for longer than 24 hours from 2012 to 2018.INTERVENTIONSNone.METHODSPrimary 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 RESULTSAmong 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).CONCLUSIONSOur 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.
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- Preoperative Vitamin D Deficiency Is Associated With Postoperative Delirium in Critically Ill Patients.
Qiu Yuwei Journal of intensive care medicine 2021;:8850666211021330.
INTRODUCTIONPostoperative delirium is common, with a reported incidence of 11% to 80% in critically ill patients. Delirium is an independent prognostic factor for poor hospital outcomes. Low vitamin D concentrations are associated with a decline in cognitive function. We therefore tested the hypothesis that low preoperative serum 25-hydroxyvitamin D [25(OH)D] concentrations are associated with postoperative delirium in critically ill patients.METHODWe conducted a retrospective analysis of adults in a surgical intensive care unit for at least 48 hours immediately after non-cardiac and non-neurosurgical operations at Cleveland Clinic between 2013 and 2018. Delirium was assessed by trained nurses using CAM-ICU twice daily for the initial 5 postoperative days. Any positive value was considered evidence of delirium. We assessed the association between 25(OH)D concentrations within a year before surgery and the incidence of postoperative delirium using logistic regression, adjusted for potential confounders. A linear spline term with a knot at 30 ng/ml, the threshold for normal 25(OH)D concentration, was added to accommodate a nonlinear relationship between 25(OH)D concentrations and delirium.RESULTSWe included 632 patients, who had a mean (SD) 25(OH)D concentration of 25 (15) ng/ml; 55% (346/632) experienced delirium. We observed an adjusted odds ratio of 1.4 (95% CI: [1.1, 1.8], P = 0.01) for delirium per 10 ng/ml decrease in 25(OH)D concentrations when patients' 25(OH)D concentrations were less than 30 ng/ml. In patients whose 25(OH)D concentrations were at least 30 ng/ml, the adjusted odds ratio was 0.9 (95% CI: [0.7, 1.1], P = 0.36).CONCLUSIONPreoperative 25(OH)D concentrations are associated with postoperative delirium in patients whose concentrations are below the normal threshold, but not at concentrations ≥30 ng/ml. A trial will be needed to determine whether the relationship is causal, and whether vitamin D supplementation before surgery might reduce the incidence of delirium.
- Prevalence and Factors Affecting Postoperative Delirium in a Neurosurgical Intensive Care Unit.
Kose Gulsah The Journal of neuroscience nursing : journal of the American Association of Neuroscience Nurses 2021;53(4):177-182.
ABSTRACTPURPOSE: 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.
- Routine Frailty Screening in Critical Illness: A Population-Based Cohort Study in Australia and New Zealand.
Darvall Jai N. Chest 2021;:No page numbers.
BACKGROUNDFrailty is associated with poor outcomes in critical illness. However, it is unclear whether frailty screening on admission to the ICU can be conducted routinely at the population level and whether it has prognostic importance.RESEARCH QUESTIONCan population-scale frailty screening with the Clinical Frailty Scale (CFS) be implemented for critically ill adults in Australia and New Zealand (ANZ) and can it identify patients at risk of negative outcomes?STUDY DESIGN AND METHODSWe conducted a binational prospective cohort study of critically ill adult patients admitted between July 1, 2018, and June 30, 2020, in 175 ICUs in ANZ. We classified frailty with the CFS on admission to the ICU. The primary outcome was in-hospital mortality; secondary outcomes were length of stay (LOS), discharge destination, complications (delirium, pressure injury), and duration of survival.RESULTSWe included 234,568 critically ill patients; 45,245 (19%) were diagnosed as living with frailty before ICU admission. Patients with vs without frailty had higher in-hospital mortality (16% vs 5%; P < .001), delirium (10% vs 4%; P < .001), longer LOS in the ICU and hospital, and increased new chronic care discharge (3% vs 1%; P < .001), with worse outcomes associated with increasing CFS category. Of patients with very severe frailty (CFS score, 8), 39% died in hospital vs 2% of very fit patients (CFS score, 1; multivariate categorical CFS score, 8 [reference, 1]; OR, 7.83 [95% CI, 6.39-9.59]; P < .001). After adjustment for illness severity, frailty remained highly significantly predictive of mortality, including among patients younger than 50 years, with improvement in the area under the receiver operating characteristic curve of the Acute Physiology and Chronic Health Evaluation III-j score to 0.882 (95% CI, 0.879-0.885) from 0.868 (95% CI, 0.866-0.871) with the addition of frailty (P < .001).INTERPRETATIONLarge-scale population screening for frailty degree in critical illness was possible and prognostically important, with greater frailty (especially CFS score of ≥ 6) associated with worse outcomes, including among younger patients.
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- Safety and Efficacy of Dexmedetomidine in Acutely Ill Adults Requiring Noninvasive Ventilation: A Systematic Review and Meta-analysis of Randomized Trials.
Lewis Kimberley Chest 2021;159(6):2274-2288.
BACKGROUNDAlthough clinical studies have evaluated dexmedetomidine as a strategy to improve noninvasive ventilation (NIV) comfort and tolerance in patients with acute respiratory failure (ARF), their results have not been summarized.RESEARCH QUESTIONDoes dexmedetomidine, when compared with another sedative or placebo, reduce the risk of delirium, mortality, need for intubation and mechanical ventilation, or ICU length of stay (LOS) in adults with ARF initiated on NIV in the ICU?STUDY DESIGN AND METHODSWe electronically searched MEDLINE, EMBASE, and the Cochrane Library from inception through July 31, 2020, for randomized clinical trials (RCTs). We calculated pooled relative risks (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes with the corresponding 95% CIs using a random-effect model.RESULTSTwelve RCTs were included in our final analysis (n = 738 patients). The use of dexmedetomidine, compared with other sedation strategies or placebo, reduced the risk of intubation (RR, 0.54; 95% CI, 0.41-0.71; moderate certainty), delirium (RR, 0.34; 95% CI, 0.22-0.54; moderate certainty), and ICU LOS (MD, -2.40 days; 95% CI, -3.51 to -1.29 days; low certainty). Use of dexmedetomidine was associated with an increased risk of bradycardia (RR, 2.80; 95% CI, 1.92-4.07; moderate certainty) and hypotension (RR, 1.98; 95% CI, 1.32-2.98; moderate certainty).INTERPRETATIONCompared with any sedation strategy or placebo, dexmedetomidine reduced the risk of delirium and the need for mechanical ventilation while increasing the risk of bradycardia and hypotension. The results are limited by imprecision, and further large RCTs are needed.TRIAL REGISTRYPROSPERO; No.: 175086; URL: www.crd.york.ac.uk/prospero/.
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- Simulation Training Exercise to Improve Outcomes of Emergence Delirium in Patients With Posttraumatic Stress Disorder.
Lovestrand AANA Journal 2021;89(3):187-193.
Information in the perianesthesia environment may not be communicated across healthcare disciplines, potentially causing division on best practice. An example is emergence delirium, which requires a timely cohesive response. Patients with posttraumatic stress disorder (PTSD) may be more susceptible to emergence delirium. Simulation is an effective method to rehearse and act on clinical situations without harming the patient. The authors developed an interprofessional, interinstitutional simulation exercise to unify the perianesthesia team's interventions based on recommended practices for patients who have PTSD and are exhibiting emergence delirium. The simulation was tested at an Army community hospital and a Veterans Affairs hospital. Staff rotated through 3 simulation stations located in the preoperative holding area and an operating room suite. A pretest and prerequisite reading with application and analysis of the content was performed before the simulation. After completing the simulation and before returning to patient care, participants completed the posttest. The pretest vs posttest average score was 49.2% vs 81.6%. Based on written and verbal evaluations, the exercise accomplished the goals of evaluating templates of a simulation exercise for perianesthesia personnel to work collaboratively in an interdisciplinary environment in an emergency situation that met the learning needs of anesthesia and nursing personnel.
Training Exercise to Improve Outcomes of Emergence Delirium in Patients With Posttraumatic Stress Disorder this link
Training Exercise to Improve Outcomes of Emergence Delirium in Patients With Posttraumatic Stress Disorder this link
Training Exercise to Improve Outcomes of Emergence Delirium in Patients With Posttraumatic Stress Disorder this link
- Targeting Delirium Risk Factors During a Pandemic: AGS CoCare®: HELP® in the Era of COVID-19 and Beyond
Hollmann Peter Journal of Gerontological Nursing 2021;47(7):51.
According to recent studies, delirium is not only common among older patients with COVID, but associated in this cohort with admission to intensive care, ventilator use, prolonged length of hospital stays, and death (Garcez et al., 2020; Kennedy et al., 2020).The AGS has been pleased to partner with Inouye and her team on launching the AGS CoCare®: HELP® program, a well-studied, effective, and innovative model of hospital care that takes a streamlined, stepwise approach to integrating the principles of geriatrics into standard nursing and medical care on any unit, and that brings geriatrics expertise to bear on decisions that impact not only enrolled patients, but those throughout an institution (Inouye et al., 1999).The program targets six known delirium risk factors—cognitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment, and dehydration—with specialized protocols performed by clinical staff with assistance from volunteers (Inouye et al., 2000; Inouye et al., 1999).During the COVID-19 pandemic, ELNSs at Maine Medical Center have been supporting other nursing staff on a daily basis by reviewing charts for patients aged ≥70 years on isolated COVID-19 floors for risk factors for and symptoms of delirium, and then offering their recommendations by phone or via chat on the hospital's electronic health records system.
Targeting Delirium Risk Factors During a Pandemic: AGS CoCare ® : HELP ® in the Era of COVID-19 and Beyond this link
Targeting Delirium Risk Factors During a Pandemic: AGS CoCare ® : HELP ® in the Era of COVID-19 and Beyond this link
- The ABCDE bundle implementation in an intensive care unit: Facilitators and barriers perceived by nurses and doctors.
Negro Alessandra International journal of nursing practice 2021;:e12984.
AIMTo describe the facilitators and barriers perceived by healthcare teams after the implementation of the Awakening, Breathing, Coordination, Delirium monitoring/management and Early mobility bundle in an intensive care unit in Italy. This multicomponent intervention strategy has been associated with lower probabilities of delirium, improved functional outcomes and shorter duration of mechanical ventilation.METHODSA survey study conducted between June 2015 and May 2016 explored variables related to intensive care unit team members: perceptions of delirium; knowledge of the Awakening, Breathing, Coordination, Delirium monitoring/management and Early mobility bundle; teamwork perception and resource availability.RESULTSMost of the participants affirmed having reasonable knowledge of delirium, outcomes of delirious episodes, Awakening, Breathing, Coordination, Delirium monitoring/management and Early mobility bundle components and their effectiveness. Low coordination between healthcare professionals was identified as a barrier. Overall, the time elapsing from the beginning of implementation of the bundle determined an increase in levels of awareness and confidence in the application of the bundle protocol and the Confusion Assessment Method Intensive Care Unit scale.CONCLUSIONIssues with the Awakening, Breathing, Coordination, Delirium monitoring/management and Early mobility bundle relating to coordination, management and interdisciplinary ward rounds are critical and should be remedied and monitored. This study could provide the basis for improving bundle implementation strategies and surveying levels of progression in other intensive care units.
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- The Association of Preoperative Frailty and Postoperative Delirium: A Meta-analysis.
Gracie Thomas J. Anesthesia and analgesia 2021;133(2):314-323.
BACKGROUNDBoth frailty and postoperative delirium (POD) are common in elective surgical patients 65 years of age and older. However, the association between preoperative frailty and POD remains difficult to characterize owing to the large number of frailty and POD assessment tools used in the literature, only a few of which are validated. Furthermore, some validated frailty tools fail to provide clear score cutoffs for distinguishing frail and nonfrail patients. We performed a meta-analysis to estimate the relationship between preoperative frailty and POD.METHODSWe searched several major databases for articles that investigated the relationship between preoperative frailty and POD in patients with mean age ≥65 years who were undergoing elective, nonemergent inpatient surgery. Inclusion criteria included articles published in English no earlier than 1999. Both preoperative frailty and POD must have been measured with validated tools using clear cutoff scores for frailty and delirium. Articles were selected and data extracted independently by 2 researchers. Risk of bias (ROBINS-I) and presence of confounders were summarized. Odds ratios (ORs) for POD associated with frailty relative to nonfrailty were computed with adjusted ORs when available. Original estimates were pooled by random effects analysis. Statistical significance was set at 2-sided P < .05.RESULTSNine studies qualified for meta-analysis. The Fried score or a modified version of it was used in 5 studies. Frailty prevalence ranged from 18.6% to 56%. Delirium was assessed with the Confusion Assessment Method (CAM) or Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) in 7 studies, Delirium Observation Scale in 1 study, and Intensive Care Delirium Screening Checklist in 1 study. The incidence of POD ranged from 7% to 56%. ROBINS-I risk of bias was low in 1 study, moderate in 4 studies, serious in 3 studies, and critical in 1 study. Random effects analysis (n = 794) of the OR for POD in frail versus nonfrail patients based on adjusted OR estimates was significant with an OR of 2.14 and a 95% confidence interval of 1.43-3.19. The I2 value was in the low range at 5.5, suggesting small variability from random effects. Funnel-plot analysis did not definitively support either the presence or absence of publication bias.CONCLUSIONSThis meta-analysis provides evidence for a significant association between preoperative frailty and POD in elective surgical patients age 65 years or older.
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- The effect of non-pharmacological interventions on physical restraint reduction in intensive care units: a protocol for an umbrella review of systematic reviews and meta-analysis.
Cui Nianqi Annals of palliative medicine 2021;10(6):6892-6899.
BACKGROUNDAs the last resort in intensive care units, physical restraint reduction is affected by various interventions. Several non-pharmacological interventions may directly reduce physical restraints, such as staff education, or indirectly reduce physical restraint, such as delirium prevention; however, their effectiveness has remained inconclusive. Therefore, we devised a protocol for umbrella reviews to summarize the evidence integrating data of different non-pharmacological interventions that may reduce physical restraint use.METHODSThe umbrella review will be conducted following the methodology formulated by the Joanna Briggs Institute (JBI). Electronic databases, including Web of Science, PubMed, EMBASE, PsycInfo, Psyc Articles, Psychology and Behavioral Science Collection, Cumulative Index to Nursing and Allied Health Literature (CINAHL), JBISRIS (JBI Database of Systematic Reviews and Implementation Reports), Cochrane Database of Systematic Reviews, China National Knowledge Infrastructure (CNKI, for Chinese literature), SinoMed (for Chinese literature), and WANFANG DATA (for Chinese literature), will be searched to identify articles published from January 2016 to December 2020. A systematic review and meta-analysis quality will be critically assessed by AMSTAR 2 (A Measurement Tool to Assess Systematic Reviews). According to the GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) guidelines, the evidence quality of each intervention will be assessed. Overlapping studies and the excess significance test will be performed to assess whether previous evidences are bias.DISCUSSIONThis protocol was devised according to the guidelines of the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P). Umbrella reviews will be an excellent supplement to the evidence of the guideline adaptation and provide a broader picture of non-pharmacological interventions that may reduce the use of physical restraint, which can provide critical care nurses in intensive care units with the evidence they need.TRIAL REGISTRATIONThis umbrella review protocol was documented in the PROSPERO registry (CRD42021242586).
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- The effects of a tailored postoperative delirium prevention intervention after coronary artery bypass graft: A randomized controlled trial.
Abbasinia Nursing Practice Today 2021;8(3):226-233.
Background & Aim: Delirium is a frequent complication in patients hospitalized in the intensive care unit following cardiac surgery. This study aimed to assess the effect of a tailored delirium preventive intervention on postoperative delirium and agitation reduction and length of intensive care unit stay in patients who underwent coronary artery bypass graft. Methods & Materials: In this single-blinded, single-center, randomized controlled design, 60 patients from a hospital in Qom, Iran, were randomly allocated to an intervention or a control group. In the control group, patients received routine care. In the intervention group, patients received routine care, a video tutorial, and the Hospital Elder Life Program. Outcomes were measured using the Confusion Assessment Method for the intensive care unit, Richmond Agitation-Sedation Scale, and length of intensive care unit stay in the second and third days after coronary artery bypass graft. Results: There were no significant differences in the rate of delirium episodes and mean scores of RASS between both groups in the second (P=0.301; P=0.125) and third days (P=0.389; P=0.057) after surgery, respectively. However, the mean duration of intensive care unit stays after surgery was significantly lower in the intervention group compared with the control group (P=0.042). Conclusion: This study indicated the tailored delirium prevention intervention could reduce the length of intensive care unit stay. However, the intervention did not reduce postoperative delirium episodes, nor did the intervention improve the RASS scores in the second and third days after coronary artery bypass graft. A future large multicenter trial with long-term follow-up is needed to assess further the effect of such an intervention.
effects of a tailored postoperative delirium prevention intervention after coronary artery bypass graft: A randomized controlled trial this link
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- The Impact of Nursing Delirium Preventive Interventions in the Intensive Care Unit: A Multicenter Cluster Randomized Controlled Trial.
Rood Paul Jt American journal of respiratory and critical care medicine 2021;:No page numbers.
Rationale Delirium is common in critically ill patients and associated with deleterious outcomes. Non-pharmacologic interventions are recommended in current delirium guidelines, but their effects have not been unequivocally established. Objective To determine the effects of a multicomponent nursing intervention program on delirium in the Intensive Care Unit. Methods Stepped wedge cluster randomized controlled trial, conducted in Intensive care units of 10 centers. Adult critically ill surgical, medical or trauma patients at high risk to develop delirium were included. A multicomponent nursing intervention program focusing on modifiable risk factors was implemented as standard of care. Primary outcome was the number of delirium-free and coma-free days alive in 28 days after Intensive Care Unit admission. Measurements and main results A total of 1749 patients were included. Time spent per 8 hours shift on interventions was median [IQR] 38 [14-116] in the intervention period and median 32 [13-73] minutes in the control period (p=0.44). Patients in the intervention period had median 23 [4-27] delirium-free and coma-free days alive, compared to median 23 [5-27] days for patients in the control group (mean difference -1.21 days, 95%CI -2.84 to 0.42 days; p=0.15). Also, the number of delirium days was similar: median 2 [1-4] days (ratio of medians 0.90, 95%CI 0.75 to 1.09; p=0.27). Conclusion In this large randomized controlled trial in adult ICU patients, a limited increase was achieved of the use of nursing interventions, and no change in the number of delirium-free and coma-free days alive in 28 days could be determined. Clinical trial registration available at www.clinicaltrials.gov, ID: NCT03002701.
- The Nexus Between Sleep Disturbance and Delirium Among Intensive Care Patients.
Delaney Lori J. Critical care nursing clinics of North America 2021;33(2):155-171.
Sleep in intensive care is hampered due to many factors; the clinical environment itself exacerbates sleep disturbance. Research suggests that interventions aimed at improving sleep quality have produced positive effects in reducing incidences and duration of delirium. Sleep disturbance is well documented among intensive care patients; however, its prognostic impact is not fully understood. Delirium, disproportionally prevalent among intensive care patients, has significant prognostic factors related to patient outcomes, in which sleep disturbance often is present. The relationship between sleep disturbance and delirium is complex, sharing commonalities in relation to neurobiological and neurohormonal alterations, which may contribute to a bidirectional relationship.
- The relationship between sensory stimuli and the physical environment in complex healthcare settings: A systematic literature review.
Bayramzadeh Sara Intensive & critical care nursing 2021;:103111.
OBJECTIVESThis systematic review presented the current status of literature on the outcomes resulted from sensory stimuli in critical care environments as well as the environmental interventions that can improve or impede the impact of such sensory stimuli.METHODSArticles found through a systematic search of PsycINFO, Web of Science, and PubMed databases, in combination with a hand search, were reviewed for eligibility by two independent coders. Reporting and quality appraisals were based on PRISMA and MMAT guidelines.RESULTSOut of 1118 articles found, and only 30 were eligible. Final articles were comprised of issues related to noise, lighting, and temperature. Identified sensory stimuli resulted in psychological and physiological outcomes among both patients and staff. Examples include impacts on stress, delirium, sleep disturbances, poor performance and communication. The environmental factors that influence sensory stimuli included layout, room size, artificial lighting, presence of windows and acoustical interventions.CONCLUSIONLiterature on the impact of sensory stimuli on staff is scarce compared to patients. Studies on environmental interventions are inadequate and lack structure. The physical environment can impact the patient and staff outcome resulting from noise, lighting, and temperature. When applied strategically, sensory stimuli can result in positive outcomes among patients and staff.
- The Significant Prognostic Factors in Prolonged Intensive/High Care Unit Stay After Living Donor Liver Transplantation.
Yoshiya Shohei Transplantation proceedings 2021;53(5):1630-1638.
BACKGROUNDProlonged stay in an intensive/high care unit (ICU/HCU) after living donor liver transplantation (LDLT) is a significant event with possible mortality.METHODSAdult-to-adult LDLTs (n = 283) were included in this study. Univariate and multivariate analyses were performed for the factors attributed to the prolonged ICU/HCU stay after LDLT.RESULTSRecipients who stayed in the ICU/HCU 9 days or longer were defined as the prolonged group. The prolonged group was older (P = .0010), had a higher model for end-stage liver disease scores (P < .0001), and had higher proportions of patients with preoperative hospitalization (P < .0001). Delirium (P < .0001), pulmonary complications (P < .0001), sepsis (P < .0001), reintubation or tracheostomy (P < .0001), relaparotomy due to bleeding (P = .0015) or other causes (P < .0001), and graft dysfunction (P < .0001) were associated with prolonged ICU/HCU stay. Only sepsis (P = .015) and graft dysfunction (P = .019) were associated with in-hospital mortality among patients with prolonged ICU/HCU stay or graft loss within 9 days of surgery. Among these patients, grafts from donors aged <42 years and with a graft-to-recipient weight ratio of >0.76% had significantly higher graft survival than grafts from others (P = .0013 and P < .0001, respectively).CONCLUSIONProlonged ICU/HCU stay after LDLT was associated with worse short-term outcomes. The use of grafts of sufficient volume from younger donors might improve graft survival.
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- Trauma and nontrauma damage-control laparotomy: The difference is delirium (data from the Eastern Association for the Surgery of Trauma SLEEP-TIME multicenter trial).
McArthur Kaitlin The journal of trauma and acute care surgery 2021;91(1):100-107.
BACKGROUNDDamage-control laparotomy (DCL) has been used for traumatic and nontraumatic indications. We studied factors associated with delirium and outcome in this population.METHODSWe reviewed DCL patients at 15 centers for 2 years, including demographics, Charlson Comorbidity Index (CCI), diagnosis, operations, and outcomes. We compared 30-day mortality; renal failure requiring dialysis; number of takebacks; hospital, ventilator, and intensive care unit (ICU) days; and delirium-free and coma-free proportion of the first 30 ICU days (DF/CF-ICU-30) between trauma (T) and nontrauma (NT) patients. We performed linear regression for DF/CF-ICU-30, including age, sex, CCI, achievement of primary fascial closure (PFC), small and large bowel resection, bowel discontinuity, abdominal vascular procedures, and trauma as covariates. We performed one-way analysis of variance for DF/CF-ICU-30 against traumatic brain injury severity as measured by Abbreviated Injury Scale for the head.RESULTSAmong 554 DCL patients (25.8% NT), NT patients were older (58.9 ± 15.8 vs. 39.7 ± 17.0 years, p < 0.001), more female (45.5% vs. 22.1%, p < 0.001), and had higher CCI (4.7 ± 3.3 vs. 1.1 ± 2.2, p < 0.001). The number of takebacks (1.7 ± 2.6 vs. 1.5 ± 1.2), time to first takeback (32.0 hours), duration of bowel discontinuity (47.0 hours), and time to PFC were similar (63.2 hours, achieved in 73.5%). Nontrauma and T patients had similar ventilator, ICU, and hospital days and mortality (31.0% NT, 29.8% T). Nontrauma patients had higher rates of renal failure requiring dialysis (36.6% vs. 14.1%, p < 0.001) and postoperative abdominal sepsis (40.1% vs. 17.1%, p < 0.001). Trauma and NT patients had similar number of hours of sedative (89.9 vs. 65.5 hours, p = 0.064) and opioid infusions (106.9 vs. 96.7 hours, p = 0.514), but T had lower DF/CF-ICU-30 (51.1% vs. 73.7%, p = 0.029), indicating more delirium. Linear regression analysis indicated that T was associated with a 32.1% decrease (95% CI, 14.6%-49.5%; p < 0.001) in DF/CF-ICU-30, while achieving PFC was associated with a 25.1% increase (95% CI, 10.2%-40.1%; p = 0.001) in DF/CFICU-30. Increasing Abbreviated Injury Scale for the head was associated with decreased DF/CF-ICU-30 by analysis of variance (p < 0.001).CONCLUSIONNontrauma patients had higher incidence of postoperative abdominal sepsis and need for dialysis, while T was independently associated with increased delirium, perhaps because of traumatic brain injury.LEVEL OF EVIDENCETherapeutic study, level IV.
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- Use of Intensive Care Unit Diary as an Integrated Tool in an Italian General Intensive Care Unit: A Mixed-Methods Pilot Study.
Iannuzzi Luigi Dimensions of critical care nursing : DCCN 2021;40(4):248-256.
PURPOSEThe aim of this study was to investigate the implementation of an intensive care unit (ICU) diary in an Italian general ICU.METHODSA mixed-methods pilot study was performed, enrolling all patients who received an ICU diary in an Italian ICU during the study period.RESULTSStudy results are presented in 2 sections: (1) diary evaluation and content themes and (2) follow-up program results. Sixty-six patients were assessed for eligibility. Diary administration was possible in 31 patients (47%). The overall diary entries, in 31 analyzed diaries, were 1331, with a median of 25 entries (interquartile range, 16-57 entries) for each diary. Participants' relatives and friends wrote a median of 1.2 (0.3-1.6), and nurses wrote 1.1 (0.8-1.2). Other ICU staff wrote a total of 24 entries (2%). Follow-up results revealed low incidence of delirium detected in only 1 patient at the 7-day visit (3%). The median value of PTSS-10 (Post Traumatic Stress Symptoms) score was 12 (3.5-12) at the 7-day visit, 6 (1.5-12) at 3 months' telephone interview, and 12 (1.5-17) at 6 months' visit.CONCLUSIONSTo our knowledge, this is the first Italian report about the introduction of an ICU diary. The diaries were easily implemented in our clinical practice as a "low-cost" initiative. In our study, nurses and participants' relatives and friends wrote a similar number of entries in each analyzed diary. This project could be effective in reducing survivors' delirium and post-traumatic stress disorder and in implementing mutual understanding between clinical staff and relatives during ICU stay.
- Validation of E-PRE-DELIRIC in cardiac surgical ICU delirium: A retrospective cohort study.
Gao Wen Nursing in critical care 2021;:No page numbers.
BACKGROUNDThe early prediction model for delirium in intensive care units (ICUs)-E-PRE-DELIRIC-has been created to predict delirium development during the length of stay in ICUs. However, there have been few early predictive models for delirium in the cardiac surgical ICU (CSICU), and the predictive ability of the E-PRE-DELIRIC among patients following cardiac surgeries is still unknown.AIMS AND OBJECTIVESTo validate the performance of E-PRE-DELIRIC in CSICU.DESIGNA retrospective cohort study.METHODSData were retrospectively extracted from the electronic records for patients admitted in CSICU from January 2018 to December 2018 in a tertiary teaching hospital in China. Adult patients were included following the criteria of the E-PRE-DELIRIC model. Predictors, including age, history of cognitive impairment, history of alcohol abuse, urgent admission, use of corticosteroids, respiratory failure, blood urea nitrogen, and mean arterial pressure, at the time of ICU admission were retrieved, and delirium was assessed twice a day using the Confusion Assessment Method for the ICU. The performance of the E-PRE-DELIRIC model was evaluated by area under receiver operator characteristic curve, precision-recall curve (AUPRC), Hosmer-Lemeshow (HL) test, and calibration belt.RESULTSOf the 725 patients included, 120 (16.6%) developed delirium. The AUROC was 0.54 (95% confidence interval [CI], 0.48-0.59), and the AUPRC was 0.18 (95% CI, 0.12-0.20). The HL test showed a significant difference between predicted probability and delirium occurrence (χ2 = 17.326, P = .027), and the overestimation chance of the E-PRE-DELIRIC score was 0.24 to 0.43.CONCLUSIONThe E-PRE-DELIRIC model has poor-to-fair predictive value in this study; thus, its application among the CSICU patients is limited. Development of reliable and validated tools for early prediction of delirium in CSICU is required.RELEVANCE TO CLINICAL PRACTICEEarly prediction of delirium risk at CSICU admission is of vital importance and could provide timely information to caregivers. However, the E-PRE-DELIRIC model should be applied cautiously in the CSICU because of the significant probability of over-estimating the risk of developing delirium.
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- Wellbeing of ICU patients with COVID-19
Schittek Gregor Alexander Intensive & Critical Care Nursing 2021;65:No page numbers.
The Centers for Disease Control and Prevention (CDC) identified in a web-based survey of 5412 adults in the United States (US), that approximately 41% experiencemental or behavioural health problems directly related to the coronavirus pandemic.In a study completed after the first wave of the pandemic in the United Kingdom (UK), nearly 50% of intensive care unit (ICU) staff reported symptoms including post-traumatic stress disorders, severe depression, anxiety or problem drinking (Mahase, 2021).[...]COVID-19 has created various burdens for the caregivers as well as for the patient and their relatives which make the work more difficult and exhausting.
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- Where should patients with or at risk of delirium be treated in an acute care system? Comparing the rates of delirium in patients receiving usual care vs alternative care: A systematic review and meta-analysis.
Ukwuoma Ekeozor Chinenye International journal of clinical practice 2021;75(7):e13859.
BACKGROUNDDelirium is an acute condition that occurs in hospitalised patients and leads to poor patient outcomes that can last long term. Therefore, the importance of prevention is undeniable and adopting new models of care for at-risk patients should be prioritised.OBJECTIVESThis systematic review and meta-analysis will assess the effectiveness of different interventions designed to prevent or manage delirium in acutely unwell hospitalised patients.METHODSMEDLINE, EMBASE, PsycINFO, OpenGrey, Web of Science and reference lists of journals were searched. Eligible studies reported on incidence or duration of delirium, used a validated delirium diagnostic tool and compared an intervention to either a control or another intervention group. Meta-analyses were conducted, and GRADEpro software was used to assess the certainty of evidence. This review is registered on PROSPERO.RESULTSA total of 59 studies were included and 33 were eligible for meta-analysis. Delirium incidence was most significantly reduced by non-pharmacological multicomponent interventions compared with usual care, with pooled risk ratios of 0.57 (95% CI: 0.44 to 0.73, 10 randomised controlled trials) and 0.47 (95% CI: 0.35 to 0.64, six observational studies). Single-component interventions did not significantly reduce delirium incidence compared with usual care in seven randomised trials (risk ratio = 0.92, 95% CI: 0.81 to 1.04). The most effective single-component intervention in reducing delirium incidence was a hospital-at-home intervention (risk ratio = 0.29, 95% CI: 0.09 to 0.87).CONCLUSIONSNon-pharmacological multicomponent interventions are effective in preventing delirium; however, the same cannot be said for other interventions because of uncertain results. There is some evidence that providing multicomponent interventions in patients' homes is more effective than in a hospital setting. Therefore, researching the benefits of hospital-at-home interventions in delirium prevention is recommended.
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