ICU转出患者认知障碍发生现状及影响因素分析

目的 了解ICU转出患者认知障碍的发生现状并分析其影响因素,为早期识别认知障碍和构建针对性的护理措施提供参考。 方法 2021年1月—8月,采用便利抽样法,选取福建省某三级甲等综合性医院的245例ICU转出患者作为调查对象,采用一般资料调查表、蒙特利尔认知量表、理查兹-坎贝尔睡眠量表等进行调查,将单因素分析有统计学意义的变量纳入Logistic回归方程,分析ICU转出患者认知障碍的影响因素。 结果 共220例ICU转出患者完成调查且资料完整,其认知障碍的发生率为38.18%。Logistic回归结果显示,年龄、受教育程度、谵妄发生次数、理查兹-坎贝尔睡眠量表评分是ICU转出患者发生认知障碍的影响因素（P<0.05）。 结论 ICU转出患者认知障碍发生率较高,年龄大、受教育程度低、谵妄发生次数多、睡眠质量差的ICU转出患者发生认知障碍的风险较高。护理人员应密切关注高风险患者,积极探索有效的预防措施,以降低认知障碍的发生率。     

Incidence,risk factors,and cumulative risk of delirium among ICU patients: A case-control study

ObjectivesDelirium is a common acute cognitive impairment syndrome among intensive care unit (ICU) patients. This study was aimed to investigate the incidence, risk factors, and cumulative risk of delirium among ICU patients.MethodsA case-control study including clinical records of 452 patients were retrospectively analyzed. Delirium was assessed using the Confusion Assessment Method for the ICU and Richmond Agitation–Sedation Scale.ResultsWe found that 163 out of the 452 patients (36.1%) had delirium. Multivariate analysis showed that use of sedatives, length of ICU hospitalization, and physical restraint were independent risk factors for delirium. The additive effect of all three factors resulted to an odds ratio of 30.950.ConclusionThe incidence of delirium remained high. Thus, nurses shall strengthen the monitoring of delirium, regularly access the patient's level of calmness, and limit the use of physical restraint.     

Differences in long-term outcomes between ICU patients with persistent delirium,non-persistent delirium and no delirium: A longitudinal cohort study

PurposeDetermine differences in physical, mental and cognitive outcomes 1-year post-ICU between patients with persistent delirium (PD), non-persistent delirium (NPD) and no delirium (ND).Materials and methodsA longitudinal cohort study was performed in adult ICU patients of two hospitals admitted between July 2016–February 2020. Questionnaires on physical, mental and cognitive health, frailty and QoL were completed regarding patients' pre-ICU health status and 1-year post-ICU. Delirium data were from patients' total hospital stay. Patients were divided in PD (≥14 days delirium), NPD (<14 days delirium) or ND patients.Results2400 patients completed both questionnaires, of whom 529 (22.0%) patients developed delirium; 35 (6.6%) patients had PD and 494 (93.4%) had NPD. Patients with delirium (PD or NPD) had worse outcomes in all domains compared to ND patients. Compared to NPD, more PD patients were frail (34.3% vs. 14.6%, p = 0.006) and fatigued (85.7% vs. 61.1%, p = 0.012). After adjustment, PD was significantly associated with long-term cognitive impairment only (aOR 3.90; 95%CI 1.31–11.63).ConclusionsPatients with PD had a higher likelihood to develop cognitive impairment 1-year post-ICU compared to NPD or ND. Patients with PD and NPD were more likely to experience impairment on all health domains (i.e. physical, mental and cognitive), compared to ND patients.     

Risk factors for post–intensive care syndrome: A systematic review and meta-analysis

ObjectiveThe objective of this study was to identify the risk factors for each area of post–intensive care syndrome (PICS) and to determine their effect size.Review method usedThis study used systematic review and meta-analysis.Data sourcesPubMed, CINAHL, EMBASE, PsycINFO, and Cochrane Library were searched.Review methodsEighty-nine studies were selected for the review based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The PICS areas and risk factors reported in the individual studies were reviewed and categorised. We used the Newcastle–Ottawa Scale to evaluate the quality of studies. The effect size of each risk factor was calculated as odds ratio (OR).ResultsThere were 33 mental health studies, 15 cognitive impairment studies, 32 physical impairment studies, eight studies on two areas, and one study on all three areas. Sixty risk factors were identified, including 33 personal and 27 intensive care unit (ICU)–related factors. Significant risk factors for mental health included female sex (odds ratio [OR] = 3.37, 95% confidence interval [CI]: 1.12–10.17), previous mental health problems (OR = 9.45, 95% CI: 2.08–42.90), and negative ICU experience (OR = 2.59, 95% CI: 2.04–3.28). The only significant risk factor for cognitive impairment was delirium (OR = 2.85, 95% CI: 1.10–7.38). Significant risk factors for physical impairment included older age (OR = 2.19, 95% CI: 1.11–4.33), female sex (OR = 1.96, 95% CI: 1.32–2.91), and high disease severity (OR = 2.54, 95% CI: 1.76–3.66).ConclusionsAlthough PICS is a multidimensional concept, each area has been studied separately. Significant risk factors for PICS included older age, female sex, previous mental health problems, disease severity, negative ICU experience, and delirium. To prevent PICS, the multidisciplinary team should pay attention to modifiable risk factors such as delirium and patients’ ICU experience.     

La familia en la prevención del delirium en la unidad de cuidados intensivos: scoping review

IntroductionDelirium is cognitive impairment related to negative inpatient outcomes in the Intensive Care Unit (ICU), family interventions have been shown to be effective in reducing the incidence of this condition.ObjectiveTo identify strategies that include the family in the prevention of delirium in the adult intensive care unit that can be integrated into ABCDEF. Inclusion criteria: Studies describing actions and interventions involving caregivers and family members in the ICU for the prevention of delirium, conducted in the last five years, available in full text, in English and Spanish, Portuguese and in adults.MethodsA scope review was conducted using the keywords “Critical Care, Delirium, Family, Primary Prevention” in 11 databases (PubMed, Virtual Health Library, Cochrane Library, TRIP Data base, EBSCO, Ovid Nursing, Springer, Scopus, Dialnet, Scielo, Lilacs) and other sources (Open Gray, Google Scholar), between August - October 2019; 8 studies were considered relevant and were analysed.ResultsThe results were described in 3 categories: flexibility vs. restriction of visits in the ICU, Reorientation as a prevention strategy and post-ICU syndrome in the family.ConclusionExtended visits, development of family-mediated activities, and redirection are non-pharmacological strategies that reduce the incidence of delirium in the ICU and offer multiple benefits to the patient and family/caregiver.     

Self-Reported Physical Symptoms in Intensive Care Unit (ICU) Survivors: Pilot Exploration Over Four Months Post-ICU Discharge

ContextSurvivors of critical illness must overcome persistent physical and psychological challenges. Few studies have longitudinally examined self-reported physical symptoms in intensive care unit (ICU) survivors.ObjectivesTo describe prevalence and severity of self-reported symptoms in 28 adult medical ICU survivors during the first four months post-ICU discharge and their associations with family caregiver responses.MethodsPatients completed the Modified Given Symptom Assessment Scale. Caregivers completed the Shortened 10-item Center for Epidemiologic Studies Depression Scale, Brief Zarit Burden Score, Pittsburgh Sleep Quality Index, and the Caregiver Health Behavior form. Data at ICU discharge (two weeks or less), and two and four months post-ICU discharge were analyzed.ResultsAcross the time points, most patients reported one or more symptoms (88.5–97%), with sleep disturbance, fatigue, weakness, and pain the most prevalent. For these four symptoms with the highest prevalence, there were: 1) moderate correlations among symptom severity at two and four months post-ICU discharge; and 2) no difference in prevalence or severity by patients' disposition (home vs. institution), except worse fatigue in patients at home at two weeks or less post-ICU discharge. Patients' overall symptom burden showed significant correlation with caregivers' depressive symptoms two weeks or less post-ICU discharge. There were trends of moderate correlations between patients' overall symptom burden and caregivers' health risk behaviors and sleep quality at two and four months post-ICU discharge.ConclusionIn our sample, sleep disturbance, fatigue, weakness, and pain were the four key symptoms during first four months post-ICU discharge. Future studies focusing on these four symptoms are necessary to promote quality in post-ICU symptom management.     

Long-term outcome of delirium during intensive care unit stay in survivors of critical illness: a prospective cohort study

Introduction

Delirium is associated with impaired outcome, but it is unclear whether this relationship is limited to in-hospital outcomes and whether this relationship is independent of the severity of underlying conditions. The aim of this study was to investigate the association between delirium in the intensive care unit (ICU) and long-term mortality, self-reported health-related quality of life (HRQoL), and self-reported problems with cognitive functioning in survivors of critical illness, taking severity of illness at baseline and throughout ICU stay into account.

Methods

A prospective cohort study was conducted. We included patients who survived an ICU stay of at least a day; exclusions were neurocritical care patients and patients who sustained deep sedation during the entire ICU stay. Delirium was assessed twice daily with the Confusion Assessment Method for the ICU (CAM-ICU) and additionally, patients who received haloperidol were considered delirious. Twelve months after ICU admission, data on mortality were obtained and HRQoL and cognitive functioning were measured with the European Quality of Life – Six dimensions self-classifier (EQ-6D). Regression analyses were used to assess the associations between delirium and the outcome measures adjusted for gender, type of admission, the Acute Physiology And Chronic Health Evaluation IV (APACHE IV) score, and the cumulative Sequential Organ Failure Assessment (SOFA) score throughout ICU stay.

Results

Of 1101 survivors of critical illness, 412 persons (37%) had been delirious during ICU stay, and 198 (18%) died within twelve months. When correcting for confounders, no significant association between delirium and long-term mortality was found (hazard ratio: 1.26; 95% confidence interval (CI) 0.93 to 1.71). In multivariable analysis, delirium was not associated with HRQoL either (regression coefficient: -0.04; 95% CI -0.10 to 0.01). Yet, delirium remained associated with mild and severe problems with cognitive functioning in multivariable analysis (odds ratios: 2.41; 95% CI 1.57 to 3.69 and 3.10; 95% CI 1.10 to 8.74, respectively).

Conclusions

In this group of survivors of critical illness, delirium during ICU stay was not associated with long-term mortality or HRQoL after adjusting for confounding, including severity of illness throughout ICU stay. In contrast, delirium appears to be an independent risk factor for long-term self-reported problems with cognitive functioning.     

Predicting hospital mortality and length of stay: A prospective cohort study comparing the Intensive Care Delirium Screening Checklist versus Confusion Assessment Method for the Intensive Care Unit

ObjectiveThe objective of this study was to compare two tools, the Intensive Care Delirium Screening Checklist (ICDSC) and Confusion Assessment Method for the intensive care unit (ICU) (CAM-ICU), for their predictive validity for outcomes related to delirium, hospital mortality, and length of stay (LOS).MethodsThe prospective study conducted in six medical ICUs at a tertiary care hospital in Taiwan enrolled consecutive patients (≥20 years) without delirium at ICU admission. Delirium was screened daily using the ICDSC and CAM-ICU in random order. Arousal was assessed by the Richmond Agitation–Sedation Scale (RASS). Participants with any one positive result were classified as ICDSC- or CAM-ICU-delirium groups.ResultsDelirium incidence evaluated by the ICDSC and CAM-ICU were 69.1% (67/97) and 50.5% (49/97), respectively. Although the ICDSC identified 18 more cases as delirious, substantial concordance (κ = 0.63; p < 0.001) was found between tools. Independent of age, Acute Physiology and Chronic Health Evaluation II score, and Charlson Comorbidity Index, both ICDSC- and CAM-ICU-rated delirium significantly predicted hospital mortality (adjusted odds ratio: 4.93; 95% confidence interval [CI]:1.56 to 15.63 vs. 2.79; 95% CI: 1.12 to 6.97, respectively), and only the ICDSC significantly predicted hospital LOS with a mean of 17.59 additional days compared with the no-delirium group. Irrespective of delirium status, a sensitivity analysis of normal-to-increased arousal (RASS≥0) test results did not alter the predictive ability of ICDSC- or CAM-ICU-delirium for hospital mortality (adjusted odds ratio: 2.97; 95% CI: 1.06 to 8.37 vs. 3.82; 95% CI: 1.35 to 10.82, respectively). With reduced arousal (RASS<0), neither tool significantly predicted mortality or LOS.ConclusionsThe ICDSC identified more delirium cases and may have higher predictive validity for mortality and LOS than the CAM-ICU. However, arousal substantially affected performance. Future studies may want to consider patients’ arousal when deciding which tool to use to maximise the effects of delirium identification on patient mortality.     

The validity and reliability of the Arabic version of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU): A prospective cohort study

BackgroundAccurate diagnosis for Arabic speaking critically ill patients suffering from delirium is limited by the need for a valid/reliable translation of a standardized delirium instrument such as the Confusion Assessment Method for the ICU (CAM-ICU).ObjectiveTo determine the validity and reliability of the Arabic version of the CAM-ICU.DesignA prospective cohort study design was used to conduct the current study.SettingsData collection took place in Geriatric, Emergency and Surgical intensive care units.ParticipantsFifty-eight adult patients met the inclusion criteria and participated in the study. Among the participants 22(38%) patients were on mechanical ventilation.MethodsAfter translating the CAM-ICU into Arabic language, the Arabic CAM-ICU was administered by two well-trained critical care nurses and compared with reference standard assessments by delirium experts using the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM -IV-TR), along with assessment of severity of illness using Sequential Organ Failure Assessment (SOFA). Concurrent validity was assessed by calculating sensitivity, specificity and positive and negative predictive value (PPV and NPV) for the two Arabic CAM-ICU raters, where calculations were based on considering the DSM-IV-TR criterion as the reference standard. The convergent validity of the Arabic CAM-ICU was explored by comparing the Arabic CAM-ICU ratings and the total score of SOFA (severity of illness) and MMSE (cognitive impairment).ResultsA total of 58 ICU patients were included, of whom 27 (47%) were diagnosed with delirium during their ICU stay via DSM-IV criteria. Interrater reliability for the Arabic CAM-ICU, overall and for mechanically ventilated patients assessed using Cohen's kappa (κ) were 0.82 and 1, respectively, p < 0.001. The sensitivities (95% CI) for the two critical care nurses when using the Arabic CAM-ICU compared with the reference standard were 81% (60%–93%) and 85% (65%–95%), respectively, whereas specificity (95% CI) was 81%(62%–92%) for both nurses. High sensitivity and specificity measures were also observed across subgroups; 100% for mechanically ventilated patients, 88% (60%–98%) and 79% (49%–94%) for those aged 65 years or older and 82% (56%–95%) and 75% (43%–93%) for those with SOFA scores at or above the median value.ConclusionsThe Arabic CAM-ICU appeared to be valid and reliable tool for diagnosing delirium. Future investigations may lead to a better understanding of the prevalence, predictors, and consequences of delirium among critically ill Arabic speaking patients.     

Incidence and short-term consequences of delirium in critically ill patients: A prospective observational cohort study

BackgroundDelirium is a serious and frequent psycho-organic disorder in critically ill patients. Reported incidence rates vary to a large extent and there is a paucity of data concerning delirium incidence rates for the different subgroups of intensive care unit (ICU) patients and their short-term health consequences.ObjectivesTo determine the overall incidence and duration of delirium, per delirium subtype and per ICU admission diagnosis. Furthermore, we determined the short-term consequences of delirium.DesignProspective observational study.Participants and settingAll adult consecutive patients admitted in one year to the ICU of a university medical centre.MethodsDelirium was assessed using the Confusion Assessment Method-ICU three times a day. Delirium was divided in three subtypes: hyperactive, hypoactive and mixed subtype. As measures for short-term consequences we registered duration of mechanical ventilation, re-intubations, incidence of unplanned removal of tubes, length of (ICU) stay and in-hospital mortality.Results1613 patients were included of which 411 (26%) developed delirium. The incidence rate in the neurosurgical (10%) and cardiac surgery group (12%) was the lowest, incidence was intermediate in medical patients (40%), while patients with a neurological diagnosis had the highest incidence (64%). The mixed subtype occurred the most (53%), while the hyperactive subtype the least (10%). The median delirium duration was two days [IQR 1–7], but significantly longer (P < 0.0001) for the mixed subtype. More delirious patients were mechanically ventilated and for a longer period of time, were more likely to remove their tube and catheters, stayed in the ICU and hospital for a longer time, and had a six times higher chance of dying compared to non-delirium ICU patients, even after adjusting for their severity of illness score. Delirium was associated with an extended duration of mechanical ventilation, length of stay in the ICU and in-hospital, as well as with in-hospital mortality.ConclusionsThe delirium incidence in a mixed ICU population is high and differs importantly between ICU admission diagnoses and the subtypes of delirium. Patients with delirium had a significantly higher incidence of short-term health problems, independent from their severity of illness and this was most pronounced in the mixed subtype of delirium. Delirium is significantly associated with worse short-term outcome.     

Barriers to rehabilitation after critical illness: a survey of multidisciplinary healthcare professionals caring for ICU survivors in an acute care hospital

BackgroundThere is scant literature on the barriers to rehabilitation for patients discharged from the intensive care unit (ICU) to acute care wards.ObjectivesThe objective of this study was to assess ward-based rehabilitation practices and barriers and assess knowledge and perceptions of ward clinicians regarding health concerns of ICU survivors.Methods, design, setting, and participantsThis was a single-centre survey of multidisciplinary healthcare professionals caring for ICU survivors in an Australian tertiary teaching hospital.Main outcome measuresThe main outcome measures were knowledge of post–intensive care syndrome (PICS) amongst ward clinicians, perceptions of ongoing health concerns with current rehabilitation practices, and barriers to inpatient rehabilitation for ICU survivors.ResultsThe overall survey response rate was 35% (198/573 potential staff). Most respondents (66%, 126/190) were unfamiliar with the term PICS. A majority of the respondents perceived new-onset physical weakness, sleep disturbances, and delirium as common health concerns amongst ICU survivors on acute care wards. There were multifaceted barriers to patient mobilisation, with inadequate multidisciplinary staffing, lack of medical order for mobilisation, and inadequate physical space near the bed as common institutional barriers and patient frailty and cardiovascular instability as the commonly perceived patient-related barriers. A majority of the surveyed ward clinicians (66%, 115/173) would value education on health concerns of ICU survivors to provide better patient care.ConclusionThere are multiple potentially modifiable barriers to the ongoing rehabilitation of ICU survivors in an acute care hospital. Addressing these barriers may have benefits for the ongoing care of ICU survivors.     

An exploration of the reliability and usability of two delirium screening tools in an Australian intensive care unit: A pilot study

ObjectiveTo compare the inter-rater reliability and usability of two delirium screening tools designed for use in ICU; the Confusion Assessment Method for ICU and the Intensive Care Delirium Screening Checklist.Research methodology/designA multiple methods design was used. The intra and inter rater reliability of the tools were evaluated using Kappa statistics and intra class correlation coefficients. Focus groups were conducted to explore ICU staff perceptions of the usability of the tools and feasibility of delirium screening.SettingPrivate hospital ICU, Melbourne Australia.Results66 patients were assessed for delirium; median age of 71 (IQR 62–75) years. Seventeen patients (26%) scored positive for delirium using the screening tools and 11 (17%) had delirium confirmed on the medical ICU discharge summary. Ten nurse assessors performed 99 paired assessments using the two tools sequentially, demonstrating the intra and inter-rater agreement and reliability of the tools was moderate to high.Four focus groups were conducted with 16 participants. Content analysis identified three themes: (i) current recognition of delirium, (ii) benefits of delirium screening, and (iii) future directions for delirium management. Time and medical staff indifference were identified as barriers to screening, facilitators were education and having a follow-up plan.ConclusionThis study found that the reliability and usability of the CAM-ICU and ICDSC were acceptable and that using structured delirium screening was feasible as part of a wider, multi-disciplinary delirium management plan.     

Dimensions of physical frailty and cognitive function in older adults with amnestic mild cognitive impairment

ObjectiveThe objective of this study was to examine relationships between dimensions of physical frailty and severity of cognitive impairment in older adults with amnestic mild cognitive impairment (aMCI).Patients and methodsThe prevalence of physical frailty dimensions including slow gait speed, low physical activity, and low grip strength was examined among 201 sedentary older adults with aMCI. Associations between dimensions of physical frailty and severity of cognitive impairment, as measured with the Alzheimer's Disease Assessment Scale-Cognitive Subscale (ADAS-Cog) and individual dimensions of cognitive function were examined using multiple linear regression models.ResultsGreater than 50% of participants met physical frailty criteria on dimensions of slow gait speed, low physical activity and low grip strength. Slower gait speed was associated with elevated severity of cognitive impairment. Both gait speed and physical activity were associated with individual dimensions cognitive function.ConclusionsDimensions of physical frailty, particularly gait speed, were associated with severity of cognitive impairment, after adjusting for age, sex and age-related factors. Further studies are needed to investigate mechanisms and early intervention strategies that assist older adults with aMCI to maintain function and independence.     

The association between nurse-administered midazolam following cardiac surgery and incident delirium: An observational study

BackgroundPost-operative delirium after cardiac surgery is an adverse event that affects patients’ recovery and complicates the delivery of nursing care. Numerous risk factors for delirium are uncontrollable; however, nurses’ pro re nata drug administration of sedatives may be a controllable risk factor.ObjectivesThis study examined the relationship between nurses’ pro re nata administration of midazolam hydrochloride to cardiac surgery patients and the development of post-operative delirium.DesignObservational study.SettingCardiac surgery intensive care and nursing units of a tertiary care center in Vancouver, Canada. Participants: 122 male and female patients requiring non-emergent surgery for coronary artery disease or valvular heart disease who did not have pre-existing cognitive impairment, severe hearing or visual impairment, substance misuse, alcohol intake exceeding 7 drinks per week, or renal impairment requiring hemodialysis.MethodsPatients were assessed for delirium, on three occasions, with the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) during the first 72 h after surgery and through reviews of physicians’ notes. Risk factor and midazolam dosage data were collected from medical records.Results77.9% of the patients in this sample received midazolam hydrochloride post-operatively. The prevalence of delirium ranged from 37.7% to 44.3%. Almost all of the dosages of midazolam (85–87%) were given before the first indication of delirium; that is, most of the patients had received their entire dosage before the first signs of delirium were detected. Bivariate analysis with logistic regression models revealed that for every additional milligram of midazolam administered, the patients were 7–8% more likely to develop delirium. Multivariate logistic regression models demonstrated that the magnitude of the association between midazolam dosage and delirium was not confounded by established risk factors including age and peripheral vascular disease.ConclusionNurses play an important role in the prediction, assessment and prevention of post-operative delirium. Sedatives should be administered with caution because they increase a patient's risk of developing delirium. Nurses’ decisions regarding sedation administration must be informed by empirical knowledge, accurate assessment data and clear rationale with consideration of how these actions may contribute to the development of delirium.     

ICU患者亚谵妄综合征患病率及危险因素的系统评价

目的 系统评价ICU患者亚谵妄综合征患病率现状及危险因素,为早期识别ICU患者亚谵妄综合征的发生风险提供证据支持。 方法 检索PubMed、Embase、PsycINFO、Cochrane Library、中国生物医学文献服务系统、中国知网、维普和万方数据库,检索时间为建库至2019年6月,纳入评价ICU患者亚谵妄综合征患病率及其影响因素的文献,应用Stata 14.0软件对亚谵妄综合征发生率进行单组Meta分析,采用固定效应或随机效应模型进行数据合并,用Begg秩相关和漏斗图判定发表偏倚。对影响因素采取描述性分析。 结果 共纳入13篇文献,涉及5 396例ICU患者,发表时间为2007年—2019年。Meta分析结果显示,ICU患者亚谵妄综合征发生率为36.9%[95%CI（0.22~0.52）],亚组分析显示,女性、老年ICU、亚洲地区患者亚谵妄综合征患病率更高;描述性分析显示,影响ICU患者亚谵妄综合征发生的因素包括年龄、基础疾病、认知障碍、药物镇静等。 结论 ICU患者亚谵妄综合征发生率较高,高龄、基础疾病、认知障碍以及应用药物镇静等可增加患者发生亚谵妄综合征的风险。但纳入文献整体研究样本量不大,研究质量不高,建议后续开展多中心大样本研究,进一步探索ICU亚谵妄综合征患病率和危险因素。     

Missing link or not,mobilise against delirium

Delirium is known to be a predictor of adverse outcomes. In a prospective study Abelha and colleagues showed that postoperative delirium was an independent risk factor for deterioration in functional capacity following discharge. While evidence for causality remains elusive, there is no doubt that patients who develop delirium are left with new functional and cognitive impairment. Finding a pharmacological treatment for the prevention and treatment of delirium is a priority in delirium research and the results of ongoing trials are awaited. Early mobilisation of ICU patients has been demonstrated to decrease delirium and improve functional outcomes. Resources should be directed to appropriate, progressive mobilisation of all critically ill patients as a priority.Abelha and colleagues explored the quality of life for postoperative patients surviving an ICU admission as a secondary outcome, showing that patients who develop delirium take longer to return to premorbid functionality with perceived quality of life worsening as dependency increases [1]. The authors were able to assess functional capacity before ICU admission in order to accurately determine any deterioration. Unsurprisingly, patients who subsequently developed delirium were more likely to be dependent with regard to at least one activity before surgery. This is a relatively large critical care study with a total of 562 patients, although the average Acute Physiology and Chronic Health Evaluation score was 8 and only 89 patients developed delirium. The risk of functional deterioration would be expected to be even higher in a sicker patient population admitted acutely to a general mixed ICU.This finding is consistent with the results of a large multicentre cognitive outcome trial establishing that, after critical illness, patients are left with new and clinically important cognitive impairment linked to duration of delirium [2]. There is an ever-increasing body of scientifically robust evidence regarding critically ill patients, delirium and outcomes [3]. Animal studies support the hypothesis that delirium in a vulnerable patient is a key determinant rather than a predictor of adverse outcomes [4,5]. There is clearly an association between developing delirium and adverse outcomes, in this case functional status, although causality is yet to be established – the missing link.The return rate of follow-up questionnaires was 73%; the authors point out that nonresponders were more likely to have a different type of anaesthesia, lower temperature on return to surgical ICU and red cell transfusion [1]. No-one would suggest that keeping patients warmer would make them more likely to return a follow-up form; this is illustrative because some intensivists consider delirium in the same light as temperature – that is, as a sign, not itself something to be targeted to improve outcomes. The missing link enables negative opinions ranging from delirium being no more than an epiphenomenon through to pessimism that anything can be done to modify delirium.So is it possible to modify delirium, prevent delirium or decrease the duration or severity? As critical care clinicians we look to drugs as the most feasible intervention in our very dependent debilitated and delirious patient population. However, the findings of a recent randomised controlled trial into whether early haloperidol can prevent or reduce delirium as opposed to placebo in mechanically ventilated patients did not support the drug’s use [6]. More research is needed and additional studies exploring the use of antipsychotics and alternative targets for drug intervention (for example, neuroinflammation) are ongoing [7].A study into early mobilisation demonstrated that 59% of those patients who underwent a safe and well-tolerated programme of physiotherapy from admission returned to independent functional status, as opposed to 35% of those undergoing standard care [8]. The intervention group had a shorter duration of delirium. This is an area for improvement in the majority of ICUs where resources are limited by investment in practitioners, time and working practices. In 2008 a UK study found that approximately 25% of patients were not mobilised on any given day because of shortage of physiotherapy staff or because it was a weekend [9]. This observation is supported by an updated systematic review into physiotherapy in intensive care, which concludes with the suggestion that early progressive mobilisation should be implemented as a matter of priority in all adult ICUs and as an area of clinical focus for ICU physiotherapists [10].Bearing in mind the outcomes impacting on quality of life that many of our patients are left to manage in the short term or for the rest of their lives, delirium cannot be ignored. In units such as our own where delirium is monitored on a daily basis, we see hypoactive delirium holding up patients’ clinical progress. At the very least, this tells us we have not treated the underlying cause. Why wait when we can make a difference today? Let us get our patients moving on course to a better quality of life. Independent activities of daily living are the least we want for our patients, to be continent, to wash and to be able to eat a meal without assistance.     

Care and treatments related to intensive care unit–acquired muscle weakness: A cohort study

BackgroundIntensive care unit–acquired muscle weakness (ICUAW) has an incidence of 40–46%. Early mobilisation is known to be a protective factor.ObjectiveThe aim of the study was to identify the incidence of ICUAW in Spain and to evaluate variables likely to contribute to the development of ICUAW.MethodsA 4-month, prospective observational multicentre cohort study was conducted on patients receiving invasive mechanical ventilation for at least 48 h. Data were collected from ICU day 3 until ICU discharge. The primary outcome was presence of ICUAW (diagnosed using the Medical Research Council [MRC] scale). The secondary outcome was nurse–patient ratio, physiotherapist availability, analgesia, sedation and delirium management, glycaemic control, and daily level of mobility during the ICU stay as per the ICU Mobility Scale. A logistic regression model was constructed based exclusively on days 3–5 of the ICU stay.ResultsThe data of 642 patients were analysed from 80 ICUs, accounting for 35% of all ICUs in Spain. The incidence of ICUAW was 58% (275 of 474 patients; 95% confidence interval [CI] [53–62]). The predictors for ICUAW were older age (odds ratio [OR] = 1.01; 95% CI [1.00–1.03]) and more days with renal replacement therapy (OR = 1.01; 95% CI [1.00–1.02]). The protective factors for ICUAW were male gender (OR = 0.58; 95% CI [0.38–0.89]), higher Barthel Index (showing prehospital functional independence) (OR = 0.97; 95% CI [0.95–0.99]), more days of being awake and cooperative (defined by a feasible MRC assessment) (OR = 0.98; 95% CI [0.97–0.99]), presence of delirium (OR = 0.98; 95% CI [0.97–0.99]), and more days with active mobilisation (ICU Mobility Scale ≥ 4) (OR = 0.98; 95% CI [0.97–0.99]).ConclusionsThe risk factors for ICUAW were functional dependence before admission, female gender, older age, and more days on renal replacement therapy. The protective factors for ICUAW were feasibility of MRC assessment, the presence of delirium, and being actively mobilised during the first 5 days in the ICU.     

Prediction of delirium in critically ill patients with elevated C-reactive protein

Background and Purpose

Delirium is thought to be associated with systemic inflammatory response. However, its association with the most widely used inflammatory biomarker C-reactive protein (CRP) has not been well established. We aimed to examine whether CRP on intensive care unit (ICU) entry was associated with subsequent development of delirium.

Design and Setting

This prospective observational study was conducted in a mixed 24-bed ICU in a tertiary teaching hospital.

Methods

All patients admitted to the ICU from February 2011 to June 2012 were screened for eligibility. Demographic data and clinical characteristics of included patients were recorded. Patients were screened for the presence of delirium by using the tool Confusion Assessment Method for the ICU (CAM-ICU). C-reactive protein was obtained on ICU entry and 24 hours thereafter. Eligible patients were followed up for 28 days or until death. Univariate and multivariate analyses were performed to evaluate independent risk factors for delirium. Clinical outcome included the length of stay (LOS) in the ICU, 28-day mortality, and duration of mechanical ventilation. Two-tailed P < .05 was considered statistically significant.

Results

A total of 223 patients were included during study period. In univariate analysis, patients with delirium showed significantly higher CRP values than those without (120.5 vs 57.5 mg/L; P = .0001). By adjusting for confounding variables (including age, sex, Acute Physiology and Chronic Health Evaluation II, intubation, living alone, physical restraint, alcohol drinking, smoking, type of medical condition, and hospital LOS before ICU admission) in logistic regression model, CRP remained an independent predictor of delirium (odds ratio, 1.07; 95% confidence interval, 1.01-1.15). As compared with nondelirious patients, those with delirium showed longer LOS in ICU (13 vs 5 days; P < .001) and duration of mechanical ventilation (6 vs 1 days; P < .001). An increase in CRP greater than 8.1 mg/L within 24 hours was associated with 4-fold increase in the risk of delirium (odds ratio: 4.47, 95% confidence interval, 1.28-15.60).

Conclusion

C-reactive protein measured on ICU entry and its changes within 24 hours are risk indicators of delirium. Further studies exploring the treatment of delirium according to CRP levels are warranted.