Emotional consequences of intensive care unit delirium and delusional memories after intensive care unit admission: a systematic review

Purpose

The aim of this study was to review literature exploring the emotional consequences of delirium and delusional memories in intensive care unit patients.

Methods

A systematic review was performed using PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, and PsychINFO.

Results

Fourteen articles were eligible for this review. Five of them assessed delirium during intensive care unit admission, and the remainder assessed delusional memories during or after admission. No association was found for delirium and adverse emotional outcome. Data regarding delusional memories and emotional outcome were heterogenic. Some studies presented worse scores on posttraumatic stress disorder screening tools in patients with delusional memories, whereas other studies found better scores in patients with delirium or delusional memories.

Conclusions

Based on current literature, no relationship could be shown for delirium and emotional outcome. Regarding delusional memories and adverse emotional outcome, results were in contradiction.     

Cognitive impairment after intensive care unit admission: a systematic review

Purpose

There is increasing evidence that critical illness and treatment in an intensive care unit (ICU) may result in significant long-term morbidity. The purpose of this systematic review was to summarize the current literature on long-term cognitive impairment in ICU survivors.

Methods

PubMed/MEDLINE, CINAHL, Cochrane Library, PsycINFO and Embase were searched from January 1980 until July 2012 for relevant articles evaluating cognitive functioning after ICU admission. Publications with an adult population and a follow-up duration of at least 2 months were eligible for inclusion in the review. Studies in cardiac surgery patients or subjects with brain injury or cardiac arrest prior to ICU admission were excluded. The main outcome measure was cognitive functioning.

Results

The search strategy identified 1,128 unique studies, of which 19 met the selection criteria and were included. Only one article compared neuropsychological test performance before and after ICU admission. The 19 studies that were selected reported a wide range of cognitive impairment in 4–62 % of the patients after a follow-up of 2–156 months.

Conclusion

The results of most studies of the studies reviewed suggest that critical illness and ICU treatment are associated with long-term cognitive impairment. Due to the complexity of defining cognitive impairment, it is difficult to standardize definitions and to reach consensus on how to categorize neurocognitive dysfunction. Therefore, the magnitude of the problem is uncertain.     

Parental satisfaction,involvement, and presence after pediatric intensive care unit admission

Purpose

To describe satisfaction, involvement, presence, and preferences of parents following their child's admission to an intensive care unit (ICU).

Methods

A survey, administered 1 month after their child's ICU admission, described perceptions of parental satisfaction with their interaction with healthcare providers, their presence during resuscitation, involvement in treatment decision-making, and preferences if events were to be re-enacted.

Results

One hundred three parents of 91 patients were enrolled; 64 primary parents (70%) completed the survey at 1 month. The mean (SD) satisfaction rating was 87.6 (± 14.8) and involvement rating was 70.2 (± 34.4) on a scale from 0 (not satisfied/involved) to 100 (completely satisfied/involved). There were no differences in satisfaction (P = .46), involvement (P = .69) and change in preferences (P = .97) between parents who were present and not present. After adjusting for child's baseline illness, receipt of more ICU therapies was associated with worse parental satisfaction (P = .03). Twenty-four (38%) parents reported that if events were repeated, they would have changed their preferences.

Conclusions

Overall, parental satisfaction ratings were high, lower in parents of children receiving more ICU therapies, and not associated with presence during resuscitation. These data contrast the American Heart Association's recommendation and suggestion of benefit from parental presence during periods of intensive therapies.     

Opioid overdose leading to intensive care unit admission: Epidemiology and outcomes

PurposeThere is a scarcity of studies assessing the patient population admitted to the intensive care unit (ICU) with opioid overdose. We sought to characterize the epidemiologic features and outcomes of this patient population.Materials and methodsThis is a retrospective cohort study of adult patients admitted to the ICU at University of Louisville Hospital for opioid overdose. We reviewed each patient's hospital record for demographic data, comorbidities, opioid used, coingestions, and outcomes.ResultsWe included 178 adult patients, of which 107 (60%) were females. The median age was 41 years (interquartile range [IQR], 23). Oxycodone and hydrocodone were the 2 most commonly abused opioids. Benzodiazepines were the most common drug coingested, followed by amphetamines. Tobacco smoking, chronic pain, and alcoholism were the most frequent comorbidities identified. Mental disorders were also common. Most patients required invasive mechanical ventilation (84.8%). Median ICU length of stay was 3 days. Eighteen patients (10.1%) died in the hospital, whereas 6 patients (3.4%) were discharged to a nursing home. Patients who had any coingestion were significantly more likely to undergo invasive mechanical ventilation (91% vs 77%; P = .014) and had longer ICU length of stay (3 [IQR, 2] vs 2 [IQR, 1.8] days; P = .024).ConclusionOpioid overdose is a common cause of ICU admission and affects a relatively young population. Most have respiratory failure requiring mechanical ventilation. It is associated with a relatively high inhospital mortality. Coingestions appear to have an impact on outcomes.     

Influence of a dedicated paediatric cardiac intensive care unit on patient outcomes

Background: The impact of a designated intensive care unit (ICU) for postoperative cardiac care in children is not clear. In our hospital (in the USA), we started a new Paediatric Cardiac Surgery programme 5 years ago, in September 2004. During the first 2 years of the programme, postoperative care was accomplished within the general paediatric ICU (PICU or c‐ICU). Subsequently, in September 2006, a dedicated cardiac ICU (d‐ICU) was established. We looked at our experience during these two periods to determine whether the designation of a separate ICU affected outcomes for these children. Design and Methods: We obtained Institutional Review Board (IRB) approval to review the medical records for all postoperative cardiac admissions to the ICU during the first 4 years of the programme (September 2004–September 2008). Variables collected included age, gender, diagnosis, type of cardiac surgery, Risk Adjustment for Congenital Cardiac Surgery, version 1 (RACHS‐1) classification, ventilator use, hospital stay, invasive line infections, ventilator‐related infections, wound infections, need for cardiopulmonary support, return to the operating room, re‐exploration of the chest, delayed sternal closure, accidental extubations, re‐intubation and mortality rates. These variables were summed and compared for the combined PICU and the dedicated paediatric cardiac ICU. Results: There were 199 cases performed in the first 2 years compared with 244 in the following 2 years. We saw a statistically insignificant increase in the number and complexity of cases during the second period (p = 0·08). However, morbidity declined as evidenced by the decrease in wound infection (p < 0·001) and need for chest re‐exploration (p < 0·001). In addition, mortality declined from 7 of 199 (3·5%) to 2 of 244 (0·8%). p < 0·04 and less children required resuscitation (p < 0·01). Conclusions: We believe the designation of a specific area for postoperative cardiac care was instrumental in the growth and development of our cardiac programme. This rapid change accomplished several crucial elements that lead to accelerated improvement in patient care and a decline in morbidity and mortality.     

Associations between hospital occupancy,intensive care unit transfer delay and hospital mortality

PurposeHospital occupancy (HospOcc) pressures often lead to longer intensive care unit (ICU) stay after physician recognition of discharge readiness. We evaluated the relationships between HospOcc, extended ICU stay, and patient outcomes.Materials and methods7-year retrospective cohort study of 8500 alive discharge encounters from 4 adult ICUs of a tertiary hospital. We estimated associations between i) HospOcc and ICU transfer delay; and ii) ICU transfer delay and hospital mortality.ResultsMedian (IQR) ICU transfer delay was 4.8 h (1.6–11.7), 1.4% (119) suffered in-hospital death, and 4% (341) were readmitted. HospOcc was non-linearly related with ICU transfer delay, with a spline knot at 80% (mean transfer delay 8.8 h [95% CI: 8.24, 9.38]). Higher HospOcc level above 80% was associated with longer transfer delays, (mean increase 5.4% per % HospOcc increase; 95% CI, 4.7 to 6.1; P < .001). Longer ICU transfer delay was associated with increasing odds of in-hospital death or ICU readmission (odds ratio 1.01 per hour; 95% CI 1.00 to 1.01; P = .04) but not with ICU readmission alone (OR 1.01 per hour; 95% CI 1.00 to 1.01, P = .14).ConclusionsICU transfer delay exponentially increased above a threshold hospital occupancy and may be associated with increased hospital mortality.     

Factors associated with persistent delirium after intensive care unit admission in an older medical patient population

Purpose

This study was designed to identify factors associated with persistent delirium in an older medical intensive care unit (ICU) population.

Materials and Methods

This is a prospective cohort study of 309 consecutive medical ICU patients 60 years or older. Persistent delirium was defined as delirium occurring in the ICU and continuing upon discharge to the ward. The Confusion Assessment Method was used to assess for delirium. Patient demographics, severity of illness, and medication data were collected. Univariate and multivariate analysis were used to assess factors associated with persistent delirium.

Results

Of 309 consecutive admissions to the ICU, 173 patients had ICU delirium, survived the ICU stay, and provided ward data. One-hundred patients (58%) had persistent delirium. In a multivariable logistic regression model, factors significantly associated with persistent delirium included age more than 75 years (odds ratio [OR], 2.52; 95% confidence interval [CI], 1.23-5.16), opioid (morphine equivalent) dose greater than 54 mg/d (OR, 2.90; 95% CI, 1.15-7.28), and haloperidol (OR, 2.88; 95% CI, 1.38-6.02); change in code status to “do not resuscitate” (OR, 2.62; 95% CI 0.95-7.35) and dementia (OR, 1.93; 95% CI 0.95-3.93) had less precise associations.

Conclusions

Age, use of opioids, and haloperidol were associated with persistent delirium. Further research is needed regarding the use of haloperidol and opioids on persistent delirium.     

Impact of neurointensivist-managed intensive care unit implementation on patient outcomes after aneurysmal subarachnoid hemorrhage

PurposeThe purpose of the study is to evaluate the impact of neurointensivist-managed intensive care unit (NIM-ICU) implementation for patients admitted with aneurysmal subarachnoid hemorrhage (SAH).MethodsThis study retrospectively evaluated 234 patients (mean age, 61.7 years; male, 67) admitted with SAH between January 1, 2001, and March 31, 2014. Neurologic outcomes between patients admitted from January 2001 to December 2006 (intensivist-managed intensive care unit group) and January 2007 to March 2014 (NIM-ICU group) were compared. The primary outcome was the incidence of a good neurologic outcome at discharge (GO; the modified Ranking Scale score: GO, 0-2; poor neurological outcome, 3-6) at discharge.ResultsNeurointensivist-managed intensive care unit was initiated for 151 (64.5%) of 234 patients. Univariate analysis demonstrated significantly better outcomes for NIM-ICU group vs intensivist-managed intensive care unit group (GOs, 58.3% vs 41.0%, respectively, P = .01). Multivariate logistic regression was used to evaluate NIM-ICU efficacy for SAH patients, but NIM-ICU was not significantly associated with GOs (P = .054). Subgroup analysis of patient grading by Hunt and Kosnik grades I to II showed that NIM-ICU implementation was an independent predictor of GOs (odds ratio, 4.54; 95% confidence interval, 1.08-22.17; P = .04).ConclusionNeurointensivist-managed intensive care unit may improve neurologic outcomes in SAH patients with Hunt and Kosnik grades I to II.     

Communication and end-of-life care in the intensive care unit: patient, family, and clinician outcomes

Even though good communication among clinicians, patients, and family members is identified as the most important factor in end-of-life care in ICUs, it is the least accomplished. According to accumulated evidence, communication about end-of-life decisions in ICUs is difficult and flawed. Poor communication leaves clinicians and family members stressed and dissatisfied, as well as patients' wishes neglected. Conflict and anger both among clinicians and between clinicians and family members also result. Physicians and nurses lack communication skills, an essential element to achieve better outcomes at end of life. There is an emerging evidence base that proactive, multidisciplinary strategies such as formal and informal family meetings, daily team consensus procedures, palliative care team case finding, and ethics consultation improve communication about end-of-life decisions. Evidence suggests that improving end-of-life communication in ICUs can improve the quality of care by resulting in earlier transition to palliative care for patients who ultimately do not survive and by increasing family and clinician satisfaction. Both larger, randomized controlled trials and mixed methods designs are needed in future work. In addition, research to improve clinician communication skills and to assess the effects of organizational and unit context and culture on end-of-life outcomes is essential.     

Pediatric intensive care unit admission tool: a colorful approach

This article discusses the development, implementation, and utilization of our institution's Pediatric Intensive Care Unit (PICU) Color-Coded Admission Status Tool. Rather than the historical method of identifying a maximum number of staffed beds, a tool was developed to color code the PICU's admission status. Previous methods had been ineffective and led to confusion between the PICU leadership team and the administration. The tool includes the previously missing components of staffing and acuity, which are essential in determining admission capability. The PICU tool has three colored levels: green indicates open for admissions; yellow, admission alert resulting from available beds or because staffing is not equal to the projected patient numbers or required acuity; and red, admissions on hold because only one trauma or arrest bed is available or staffing is not equal to the projected acuity. Yellow and red designations require specific actions and the medical director's approval. The tool has been highly successful and significantly impacted nursing with the inclusion of the essential component of nurse staffing necessary in determining bed availability.     

Day of the week of intensive care admission and patient outcomes: a multisite regional evaluation

BACKGROUND: Relationships between day of the week of admission to hospitals and hospital outcomes have been poorly studied. Intensive care units (ICUs) appear to be uniquely suited to examine such a question given the unpredictability of ICU admissions and the clinical instability of their patient populations. METHODS: This retrospective cohort study included 156,136 patients admitted to 38 ICUs in 28 hospitals in a large Midwestern metropolitan area during 1991 to 1997. Demographic and clinical data were collected from patients' medical records and used in multivariable risk-adjustment models that examined the risk for in-hospital death and ICU length of stay. RESULTS: The adjusted odds of in-hospital death were 9% higher (OR 1.09; 95% CI, 1.04-1.15; P <0.001) for weekend admissions (Saturday or Sunday) than in patients admitted midweek (Tuesday through Thursday). However, the adjusted odds of death were also higher (P <0.001) for patients admitted on Monday (OR 1.09) or Friday (OR 1.08). Findings were generally similar in analyses stratified by admission type (medical vs. surgical), hospital teaching status, and illness severity. Adjusted ICU length of stay was 4% longer (P <0.001) for weekend or Friday admissions, compared with midweek admissions. CONCLUSIONS: Patients admitted to an ICU on the weekend have a modestly higher risk for death and ICU length of stay. However, the similar risk for death in patients admitted on Friday and Monday suggests that "weekend effects" may be more related to unmeasured severity of illness and/or selection bias than to differences in quality of care.     

Neopterin as a prognostic biomarker in intensive care unit patients

Purpose

The present study was undertaken to evaluate urinary neopterin in intensive care unit patients.

Materials and Methods

Urinary neopterin levels were determined in systemic inflammatory response syndrome (n = 10), sepsis (n = 18), septic shock (n = 9), and multiple organ dysfunction syndrome (n = 5). It was tested whether neopterin is a differential parameter among the patient groups. Furthermore, the results were also evaluated by comparing with a healthy control group (n = 30), and the relationship between neopterin and mortality or Acute Physiology and Chronic Health Evaluation II scores were investigated.

Results

Neopterin levels of the control group and patients were detected as 111 ± 11 and 3850 ± 1081 μmol/mol creatinine, respectively (P < .05). It was significantly increased in the sepsis and septic shock groups compared to the systemic inflammatory response syndrome group (P < .05). Neopterin levels were significantly higher in the patients with mortality and lower Acute Physiology and Chronic Health Evaluation II scores.

Conclusion

This study showed that monitoring of urinary neopterin profile can be used in intensive care units to show the degree and prognosis of the disease.     

Health care costs,long-term survival,and quality of life following intensive care unit admission after cardiac arrest

Introduction  

The purpose of this study was to investigate the costs and health status outcomes of intensive care unit (ICU) admission in patients who present after sudden cardiac arrest with in-hospital or out-of-hospital cardiopulmonary resuscitation.     

Risk factors and prognostic predictors of unexpected intensive care unit admission within 3 days after ED discharge

Objective

Our objective was to investigate the risk factors and prognostic predictors of unexpected intensive care unit (ICU) admission within 3 days after emergency department (ED) discharge.

Methods

From January 1, 2001, through December 31, 2005, patients admitted to the ICU unexpectedly within 3 days after being discharged from the ED were enrolled. Medical records of these patients were retrospectively reviewed. We categorized each patient's characteristics into dichotomous groups and used the χ² test to identify risk factors for unexpected ICU admission within 3 days after ED discharge. A multiple logistic regression was applied to examine possible independent predictors of poor prognoses.

Results

During the study period, 365 321 patients visited our ED; 241(0.07%) were unexpectedly admitted to the ICU within 3 days after being discharged from the ED. Mean patient age was 74.2 ± 16.4 years. The rate of ICU admissions caused by medical error was 0.019% ± 0.004% of all visits and 29.0% ± 5.7% of all unexpected ICU admissions. The overall mortality rate was 19.9% (48/241). Risk factors for unexpected ICU admission within 3 days after discharge from the ED were age of 65 years or older (odds ratio [OR], 5.4; 95% confidence interval [CI], 4.0-7.4), ambulance transport (OR, 5.1; 95% CI, 3.9-6.5), no accompanying family (OR, 3.5; 95% CI, 2.7-4.5), nonambulatory status (OR, 4.2; 95% CI, 2.9-5.0), not living at home (OR, 2.5; 95% CI, 1.9-3.3), Medicaid insurance (OR, 3.6; 95% CI, 2.8-4.7), and emergency stay of more than 24 hours (OR, 4.4; 95% CI, 3.4-5.7). The independent predictors of mortality were age of 65 years or older (OR, 2.4; 95% CI, 1.7-3.6), multiple comorbidities (OR, 4.0; 95% CI, 1.8-8.5), medical error leading to ICU admission (OR, 3.9; 95% CI, 1.8-8.3), and Acute Physiology and Chronic Health Evaluation II score of 20 or higher (OR, 2.9; 95% CI, 1.1-7.8).

Conclusions

In our study, the risk factors and prognostic predictors of unexpected ICU admission within 3 days after ED discharge were identified. Based on these risk and prognostic prediction factors, further strategies for decreasing the incidence of serious adverse events of ED-discharged patients can be implemented.     

Mode of death after admission to an intensive care unit following cardiac arrest

Objective To determine the mode of death in patients admitted to an intensive care unit (ICU) after cardiac arrest who died before hospital discharge.Design Prospectively defined retrospective review of a database and individual patient medical records and ICU charts.Setting Eleven-bed multidisciplinary intensive care unit in a general hospital in the United Kingdom.Patients and participants All patients admitted to ICU between February 1998 and July 2003 after a cardiac arrest in the previous 24 h.Measurements and results The outcome at hospital discharge and mode of death in non-survivors were recorded. Based on the mode of death, non-survivors were placed in one of three groups: multiple organ failure death, neurological death or cardiovascular death. Two hundred and five patients were admitted to ICU after a cardiac arrest; 113 (55.1%) after out-of-hospital cardiac arrest and 92 (44.9%) after in-hospital cardiac arrest. One hundred and twenty-six (61.5%) patients died before hospital discharge and of these 58 (46.0%) died due to neurological injury. After cardiac arrest, 22.9% of the in-hospital patients and 67.7% of the out-of-hospital patients died due to neurological injury, irrespective of the primary cardiac arrest arrhythmia.Conclusions Two-thirds of the patients dying after out-of-hospital cardiac arrest died due to neurological injury and this proportion was approximately the same for ventricular fibrillation/ventricular tachycardia and pulseless electrical activity/asystole. Approximately a quarter of the patients dying after in-hospital cardiac arrest died due to neurological injury.     

Patients' dreams and unreal experiences following intensive care unit admission

Dreams and unreal experiences occur commonly in critically ill patients admitted to intensive care unit. This study describes 31 patients' dreams and explores the relationship between patients' subjective recall 12-18 months after intensive care unit discharge and their observed behaviour during their intensive care unit stay. Semi-structured interviews revealed that 74% of longer-term ICU patients (> or = 3 days) reported dreaming, with the majority also describing frightening hallucinations. Only two patients reported long-term negative psychological sequelae, but the short-term consequence of hallucinations may also have an undiscovered impact on patients' recovery.     

The performance and customization of SAPS 3 admission score in a Thai medical intensive care unit

Purpose  

The aim of this study was to evaluate the performance of Simplified Acute Physiology Score 3 (SAPS 3) admission scores, both the original and a customized version, in mixed medical critically ill patients.     

Anxiety and depression in intensive care patients six months after admission to an intensive care unit: A cohort study

ObjectivesTo measure the prevalence of anxiety and depression in intensive care patients six months after admission to an intensive care unit and to investigate which variables are associated with anxiety and depression at six months.Research methodologyIn this cohort study, patient-reported outcome measures were collected as soon as possible upon admission and at six months. Two logistic regression models were performed to examine variables associated with reporting anxiety and depression above ≥8 at six months.SettingPatients were recruited from six intensive care units in two Norwegian hospitals between 2018 and 2020.Main outcome measuresThe Hospital Anxiety and Depression Scale.ResultsA total of 145 patients was included in the study. The patients reported a prevalence of 18.6% (n = 27) and 12.4% (n = 18) of anxiety and depression, respectively. Higher baseline anxiety scores were associated with both higher odds of reporting anxiety and depression above ≥8. Younger age was associated with higher odds of reporting anxiety, and being female was associated with lower odds of reporting depression.ConclusionSeveral intensive care survivors reported having symptoms of anxiety and depression six months after admission to the intensive care unit. Younger age, and higher anxiety scores at baseline were variables associated with higher odds of reporting symptoms of either anxiety or depression, while being female was associated with a lower odds of reporting depression.Implications for clinical practiceScreening patients for anxiety and depression may help to identify vulnerable patients. Structured follow-ups with intensive care nurses in an outpatient setting may be useful to help patients to work through some of the experiences from the intensive care unit.