Delirium in Intensive Care Patients –  a Prospective Study


Authors: M. Káňová 1–3;  M. Burda 4;  J. Povová 1;  J. Neiser 2,3
Authors‘ workplace: Ústav epidemiologie a ochrany veřejného zdraví, LF OU v Ostravě 1;  Klinika anesteziologie, resuscitace a intenzivní medicíny LF OU a FN Ostrava 2;  Katedra intenzivní medicíny a forenzních oborů, LF OU v Ostravě 3;  Centrum excelence IT4Innovations, Ústav pro výzkum a aplikace fuzzy modelování, OU v Ostravě 4
Published in: Cesk Slov Neurol N 2015; 78/111(6): 662-667
Category: Original Paper

Overview

Introduction:
Delirium, as a manifestation of acute brain dysfunction, is a frequent complication in critical care patients. Any critical disorder is an independent risk factor for development of delirium. The prevalence of delirium in critically ill patients has been reported between 11 and 87%. Delirium is under-diagnosed even though it significantly worsens patient prognosis. The aim of our study was to support regular use of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), in order to facilitate early diagnostics, prevention and treatment of delirium.

Method:
A prospective study of the incidence of delirium as well as risk factors for its development in patients admitted to six-bed ICU from February to June 2014. All patients were assessed for predisposing and precipitating risk factors using the Czech version of CAM-ICU. Fisher’s Exact Test and Wilcoxon Rank-Sum were performed with the significance level of 0.05.

Results:
Delirium was diagnosed in 125 of the overall group of 142 patients. Seventeen patients were excluded from the study as they could not be assessed (16 due to prolonged coma, one due to language barrier). The incidence of delirium reached 31.2%. Within the study group consisting of surgical, medical and trauma patients with the median APACHE II score of 12, medical and trauma patients were more likely to develop delirium than surgical ones. Development of delirium was associated with the severity of the disease (APACHE II score), use of sedatives, analgesics and vasopressors. Delirious patients stayed longer at the ICU and they showed higher need for artificial ventilation.

Key words:
delirium – diagnostic tests – intensive care units – predisposing risk factors – precipitating risk factors – prevention

The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study.

The Editorial Board declares that the manuscript met the ICMJE “uniform requirements” for biomedical papers.


Sources

1. American Psychiatric As­sociation. Dia­gnostic and statistical manual of mental disorders. 4th ed., text revision. Washington, DC: American Psychiatric As­sociation 2000.

2. Girard TD, Pandharipande PP, Ely EW. Delirium in the intensive care unit. Crit Care 2008; 12 (Suppl 3): S3. doi: 10.1186/ cc6149.

3.Caval­lazzi R, Saad M, Marik PE. Delirium in the ICU:an overview. An­n Intensive Care 2012; 2(1): 49. doi: 10.1186/ 2110‑ 5820‑ 2‑ 49.

4. Pun BT, Ely EW. The importance of dia­gnos­ing and manag­ing ICU delirium. Chest 2007; 132(2): 624– 636.

5. Shehabi Y, Riker R­, Bokesch PM, Wisemandle W, Shintani A, Ely EW. Delirium duration and mortality in lightly sedated, mechanical­ly ventilated intensive care patients. Crit Care Med 2010; 38(12): 2311– 2318. doi: 10.1097/ CCM.0b013e3181f85759.

6. Ely EW, Gautam S, Margolin R, Francis J, May L, Sperof­f T et al. The impact of delirium in the intensive care unit on hospital length of stay. Intensive Care Med 2001; 27(12): 1892– 1900.

7. Ely EW, Shintani A, Truman B, Sperof­f T, Gordon SM, Har­rel­l FE et al. Delirium as a predictor of mortality in mechanical­ly ventilated patients in the intensive care unit. JAMA 2004; 291(14): 1753– 1762.

8. Girard TD, Jackson JC, Pandharipande PP, Pun BT, Thompson JL, Shintani AK et al. Delirium as a predictor of long‑term cognitive impairment in survivors of critical il­lnes­s. Crit Care Med 2010; 38(7): 1513– 1520. doi: 10.1097/ CCM.0b013e3181e47be1.

9. Meagher DJ, Trzepacz PT. Motoric subtypes of delirium. Semin Clin Neuropsychiatry 2000; 5(2): 75– 85.

10. Meagher DJ, Moran M, Raju B, Leonard M, Don­nel­ly S, Saunders J et al. A new data‑based motor subtypes schema for delirium. J Neuropsychiatry Clin Neurosci 2008; 20(2): 185– 193. doi: 10.1176/ appi.neuropsych.20.2.185.

11. Peterson JF, Pun BT, Dittus RS, Thomason JW, Jackson JC, Shintani AK et al. Delirium and its motoric subtypes: a study of 614 critical­ly il­l patients. J Am Geriatr Soc 2006; 54(3): 479– 484.

12. Van Rompaey B, Elseviers M­, Schuurmans MJ, Shortridge‑ Baggett LM, Truijen S, Bos­saert L. Risk factors for delirium in intensive care patients: a prospective cohort study. Crit Care 2009; 13(3): R77. doi: 10.1186/ cc7892.

13. Cerejeira J, Firmino H, Vaz‑ Ser­ra A, Mukaetova‑ Ladinska EB. The neuroinflam­matory hypothesis of delirium. Acta Neuropathol 2010; 119(6): 737– 754. doi: 10.1007/ s00401‑ 010‑ 0674‑ 1.

14. Cerejeira J, Nogueira V, Luis P, Vaz‑ Ser­ra A, Mukaetova‑ Ladinska EB. The cholinergic system and inflam­mation: com­mon pathways in delirium pathophysiology. J Am Geriatr Soc 2012; 60(4): 669– 675. doi: 10.1111/ j.1532‑ 5415.2011.03883.x.

15. Pustavoitau A, Stevens RD. Mechanisms of neurologic failure in critical il­lnes­s. Crit Care Clin 2008; 24(1): 1– 24. doi: 10.1016/ j.ccc.2007.11.004.

16. Inouye SK, Bogardus ST, Charpentier PA, Leo‑ Sum­mers L, Acampora D, Holford TR et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 1999; 340(9): 669– 676.

17. Ouimet S, Kavanagh BP, Gottfried SB, Skrobik Y. Incidence, risk factors and consequences of ICU delirium. Intensive Care Med 2007; 33(1): 66– 73.

18. Morandi A, Brum­mel NE, Ely EW. Sedation, delirium and mechanical ventilation: the „ABCDE“ ap­proach. Cur­r Opin Crit Care 2011; 17(1): 43– 49. doi: 10.1097/ MCC.0b013e3283427243.

19. Kres­s JP, Pohlman AS, O’Con­nor MF, Hal­l JB. Daily inter­ruption of sedative infusions in critical­ly il­l patients undergo­ing mechanical ventilation. N Engl J Med 2000; 342(20): 1471– 1477.

20. Girard TD, Kres­s JP, Fuchs BD, Thomason JW, Schweickert WD, Pun BT et al. Ef­ficacy and safety of a paired sedation and ventilator wean­ing protocol for mechanical­ly ventilated patients in intensive care (Awaken­ing and Breath­ing Control­led trial): a randomized control­led trial. Lancet 2008; 371(9607): 126– 134. doi: 10.1016/ S0140‑ 6736(08)60105‑ 1.

21. Pandharipande PP, Sanders RD, Girard TD, McGrane S, Thompson JL, Shintani AK et al. Ef­fect of dexmedetomidine versus lorazepam on outcome in patients with sepsis: an a priori‑ designed analysis of the MENDS randomized control­led trial. Crit Care 2010; 14(2): R38. doi: 10.1186/ cc8916.

22. Mitášová A, Bednařík J, Košťálová M, Michalčáková R, Ježková M, Kašpárek T et al. Standardizace české verze The Confusion As­ses­sment Method for the Intensive Care Unit (CAM-ICU.cz). Cesk Slov Neurol N 2010; 73/ 106(3): 258– 266.

23. Girard TD, Pandharipande PP, Carson S­S, Schmidt GA, Wright PE, Canonico AE et al. Feasibility, ef­ficacy, and safety of antipsychotics for intensive care unit delirium: the MIND randomized, placebo‑ control­led trial. Crit Care Med 2010; 38(2): 428– 437.

24. Devlin JW, Roberts RJ, Fong JJ, Skrobik Y, Riker R, Hil­l NS et al. Ef­ficacy and safety of quetiapine in critical­ly il­l patients with delirium: a prospective, multicenter, randomized, double‑ blind, placebo‑ control­led pilot study. Crit Care Med 2010; 38(2): 419– 427. doi: 10.1097/ CCM.0b013e3181b9e302.

25. Van Eijk M­M, Roes KC, Hon­ing ML, Kuiper MA, Karakus A, van der Jagt M et al. Ef­fect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critical­ly il­l patients: a multicentre, double‑blind, placebo‑ control­led, randomized trial. Lancet 2010; 376(9755): 1829– 1837. doi: 10.1016/ S0140‑ 6736(10)61855‑ 7.

26. Skrobik YK, Bergeron N, Dumont M, Gottfried SB. Olanzapine vs. haloperidol: treat­ing delirium in a critical care setting. Intensive Care Med 2004; 30(3): 444– 449.

27. Bathula M, Gonzales JP. The pharmacologic treatment of intensive care unit delirium: a systematic review. An­n Pharmacother 2013; 47(9): 1168– 1174. doi: 10.1177/ 1060028013500466.

28. Devlin JW, Fong JJ, Fraser GL, Riker R. Delirium as­ses­s­­-ment in the critical­ly il­l. Intensive Care Med 2007; 33(6): 929– 940.

29. Haenggi M, Blum S, Brechbuehl R, Brunel­lo A, Jakob SM, Takala J. Ef­fect of sedation level on the prevalence of delirium when as­ses­sed with CAM‑ICU and ICDSC. Intensive Care Med 2013; 39(12): 2171– 2179. doi: 10.1007/ s00134‑ 013‑ 3034‑ 5.

30. Holm S. A simple sequential­ly rejective multiple test procedure. Scand J Statist 1979; 6(2): 65– 70.

31. Schor JD, Levkof­f SE, Lipsitz LA, Reil­ly CH, Cleary PD, Rowe JW et al. Risk factors for delirium in hospitalized elderly. JAMA 1992; 267(6): 827– 831.

Labels
Paediatric neurology Neurosurgery Neurology
Login
Forgotten password

Don‘t have an account?  Create new account

Forgotten password

Enter the email address that you registered with. We will send you instructions on how to set a new password.

Login

Don‘t have an account?  Create new account