Diagnosis and management of delirium in critical care patients: a French national survey

Purpose

Delirium has severe consequences on hospital mortality, length of stay, costs, and long-term cognitive function. No study has ever investigated French intensivists?? attitude, a basis for management improvement. We conducted a national survey to describe the attitudes of French intensivists toward delirium screening and management.

Methods

A questionnaire was sent by e-mail to the intensivists of the French intensive care society. Up to three e-mails have been sent to nonrespondents during a 75-day period.

Results

The response rate was 25.7% (n = 283). Twenty-eight respondents (10%) reported screening for delirium with a validated screening tool. Among respondents, 60% estimated that delirium occurs in less than 25% of intubated patients. Antipsychotics, benzodiazepines, and hydroxizine were prescribed as first-line therapy in 77%, 53%, and 36% of the cases, respectively. Mobilization of intubated patients occurred less frequently than estimated as possible. Physicians who screened for delirium had a higher estimation of its severity and occurrence than physicians who did not.

Conclusions

Respondents among French intensivists rarely screen for delirium with a dedicated tool. Treatments reported as used in that setting are often different from the guidelines.     

Intensive care unit environment may affect the course of delirium

Purpose

Delirium is a common disorder in intensive care unit (ICU) patients. It is unclear whether ICU environment affects delirium. We investigated the influence of ICU environment on the number of days with delirium during ICU admission.

Methods

In this prospective before–after study, ICU delirium was compared between a conventional ICU with wards and a single-room ICU with, among others, improved daylight exposure. We included patients admitted for more than 24 h between March and June 2009 (ICU with wards) or between June and September 2010 (single-room ICU). Patients who remained unresponsive throughout ICU admission were excluded. The presence of delirium in the preceding 24 h was assessed daily with the confusion assessment method for the ICU (CAM-ICU) by research physicians combined with evaluation of medical and nursing charts. The number of days with delirium was investigated with Poisson regression analysis.

Results

We included 55 patients (449 observation days) in the ICU with wards and 75 patients (468 observation days) in the single-room ICU. After adjusting for confounding, the number of days with delirium decreased by 0.4 days (95 % confidence interval 0.1–0.7) in the single-room ICU (p = 0.005). The incidence of delirium during ICU stay was similar in the ICU with wards (51 %) and in the single-room ICU (45 %, p = 0.53).

Conclusions

This study is the first to show that ICU environment may influence the course of delirium in ICU patients.     

Pregabalin for Alcohol Dependence: A Critical Review of the Literature

Introduction

Alcohol dependence represents a severe pathological disorder associated with a significant rate of morbidity and mortality. To date, limited pharmacological agents exist to treat this disorder, and there is a growing interest for new therapies. In this context, pregabalin represents a promising strategy. Pregabalin, like gabapentin, selectively binds to the ??²??subunit of voltage-gated calcium channels, inhibiting release of excessive levels of excitatory neurotransmitters. The main focus of this review is the clinical use of pregabalin in alcoholic patients, but the authors also reported some data about chemistry, pharmacology, and pharmacokinetics of this drug.

Methods

The authors conducted a PubMed search of clinical human studies published in English from January 2000 to August 2012 using the following search terms: pregabalin alcohol dependence, pregabalin alcohol withdrawal, pregabalin alcoholism.

Results

The search revealed a total of five studies: two trials for the treatment of alcohol relapse and three articles for the management of alcohol withdrawal syndrome with pregabalin. The critical review of the literature suggests that pregabalin could be a novel and effective treatment option for the management of alcohol relapse in detoxified patients, whereas until now there have been mixed results for the treatment of alcohol withdrawal syndrome. In particular, pregabalin showed a greater beneficial effect on patients with comorbid conditions such as alcoholism and generalized anxiety disorders. The exact mechanism of action of pregabalin in the management of alcoholism is not well understood but it is thought to be due mainly to the modulation of neurotransmitters such as glutamate and norepinephrine by inhibiting activity-dependent calcium influx in nerve terminals.

Conclusion

Pregabalin, within a dosage of 150?C450 mg/day, showed beneficial effects for alcohol relapse prevention and contrasting results for the treatment of the withdrawal syndrome. Its use appears to be safe and well tolerated.     

How to implement monitoring tools for sedation, pain and delirium in the intensive care unit: an experimental cohort study

Purpose

Systematic monitoring of sedation, pain and delirium in the ICU is of paramount importance in delivering adequate patient care. While the use of systematic monitoring instruments is widely agreed upon, these tools are infrequently implemented into daily ICU care. The aim of this study is to compare the effectiveness of two different training strategies (training according to the local standard vs. modified extended method) on the implementation rate of scoring instruments on the ICU.

Methods

In this experimental cohort study we analyzed the frequency of scoring on three surgical ICUs before and after training, and in a 1?year follow-up. A modified extended training included establishing a local support team helping to resolve immediate problems. In addition we evaluated the impact on patients’ outcome.

Results

ICUs trained by the modified extended method showed increased documentation rates of all scores per patient and day. In a 1?year follow-up, increased scoring rates for all scores were maintained. Scoring rates with training according to the local standard training protocol did not increase significantly. Implementation of delirium and pain monitoring were associated with a decrease in mortality [odds ratio (OR) 0.451; 95?% confidence interval (CI): 0.22–0.924, and, respectively, OR 0.348; 95?% CI: 0.140–0.863]. Monitoring had no significant influence on ventilation time or ICU length of stay.

Conclusions

A modified extended training strategy for ICU monitoring tools (sedation, pain, delirium) leads to higher intermediate and long-term implementation rates and is associated with improved patient outcome. However, these findings may have been biased by unmeasured confounders.     

Recalibration of the delirium prediction model for ICU patients (PRE-DELIRIC): a multinational observational study

Purpose

Recalibration and determining discriminative power, internationally, of the existing delirium prediction model (PRE-DELIRIC) for intensive care patients.

Methods

A prospective multicenter cohort study was performed in eight intensive care units (ICUs) in six countries. The ten predictors (age, APACHE-II, urgent and admission category, infection, coma, sedation, morphine use, urea level, metabolic acidosis) were collected within 24 h after ICU admission. The confusion assessment method for the intensive care unit (CAM-ICU) was used to identify ICU delirium. CAM-ICU screening compliance and inter-rater reliability measurements were used to secure the quality of the data.

Results

A total of 2,852 adult ICU patients were screened of which 1,824 (64 %) were eligible for the study. Main reasons for exclusion were length of stay <1 day (19.1 %) and sustained coma (4.1 %). CAM-ICU compliance was mean (SD) 82 ± 16 % and inter-rater reliability 0.87 ± 0.17. The median delirium incidence was 22.5 % (IQR 12.8–36.6 %). Although the incidence of all ten predictors differed significantly between centers, the area under the receiver operating characteristic (AUROC) curve of the eight participating centers remained good: 0.77 (95 % CI 0.74–0.79). The linear predictor and intercept of the prediction rule were adjusted and resulted in improved re-calibration of the PRE-DELIRIC model.

Conclusions

In this multinational study, we recalibrated the PRE-DELIRIC model. Despite differences in the incidence of predictors between the centers in the different countries, the performance of the PRE-DELIRIC-model remained good. Following validation of the PRE-DELIRIC model, it may facilitate implementation of strategies to prevent delirium and aid improvements in delirium management of ICU patients.     

Effect of sedation level on the prevalence of delirium when assessed with CAM-ICU and ICDSC

Purpose

We hypothesized that reduced arousability (Richmond Agitation Sedation Scale, RASS, scores ?2 to ?3) for any reason during delirium assessment increases the apparent prevalence of delirium in intensive care patients. To test this hypothesis, we assessed delirium using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and Intensive Care Delirium Screening Checklist (ICDSC) in intensive care patients during sedation stops, and related the findings to the level of sedation, as assessed with RASS score.

Methods

We assessed delirium in 80 patients with ICU stay longer than 48 h using CAM-ICU and ICDSC during daily sedation stops. Sedation was assessed using RASS. The effect of including patients with a RASS of ?2 and ?3 during sedation stop (“light to moderate sedation”, eye contact less than 10 s or not at all, respectively) on prevalence of delirium was analyzed.

Results

A total of 467 patient days were assessed. The proportion of CAM-ICU-positive evaluations decreased from 53 to 31 % (p < 0.001) if assessments from patients at RASS ?2/?3 (22 % of all assessments) were excluded. Similarly, the number of positive ICDSC results decreased from 51 to 29 % (p < 0.001).

Conclusions

Sedation per se can result in positive items of both CAM-ICU and ICDSC, and therefore in a diagnosis of delirium. Consequently, apparent prevalence of delirium is dependent on how a depressed level of consciousness after sedation stop is interpreted (delirium vs persisting sedation). We suggest that any reports on delirium using these assessment tools should be stratified for a sedation score during the assessment.     

Associations of markers of inflammation and coagulation with delirium during critical illness

Purpose

To assess the associations between a?priori-selected markers of inflammation and coagulation and delirium during critical illness.

Methods

In this prospective cohort study, we collected blood from mechanically ventilated medical intensive care unit (ICU) patients and measured nine plasma markers of inflammation and coagulation. We assessed patients daily for delirium using the Confusion Assessment Method for the ICU and used multivariable regression to analyze the associations between plasma markers and subsequent delirium, after adjusting for age, severity of illness, and sepsis.

Results

Among the 138 patients studied, with median age of 66?years and median Acute Physiology and Chronic Health Evaluation (APACHE)?II of 27, 107 (78?%) were delirious at some point during the study. Two markers of inflammation and one of coagulation were significantly associated with delirium. After adjusting for covariates, lower plasma concentrations of matrix metalloproteinase-9 (MMP-9) and protein?C were associated with increased probability of delirium (p?=?0.04 and 0.01, respectively), and higher concentrations of soluble tumor necrosis factor receptor-1 (sTNFR1) were associated with increased probability of delirium (p?<?0.01). Concentrations of C-reactive protein (p?=?0.82), myeloperoxidase (p?=?0.11), neutrophil gelatinase-associated lipocalin (p?=?0.70), D-dimer (p?=?0.83), plasminogen activator inhibitor type?1 (p?=?0.98), and Von Willebrand factor antigen (p?=?0.65) were not associated with delirium.

Conclusions

In this study, MMP-9, protein?C, and sTNFR1 were independently associated with subsequent ICU delirium. These results suggest that specific aspects of inflammation and coagulation may play a role in the evolution of delirium during critical illness and that these markers should be examined in larger studies of ICU patients.     

Nu-DESC DK: the Danish version of the nursing delirium screening scale (nu-DESC)

Background

Delirium is one of the most common complications among elderly hospitalized patients, postoperative patients and patients on intensive care units with a prevalence between 11 and 80%. Delirium is associated with higher morbidity and mortality. Reliable instruments are required to detect delirium at an early time point. The Nursing-Delirium Screening Scale (Nu-DESC) is a screening tool with high sensitivity and good specificity. However, there is currently no official translation after ISPOR guidelines of any Danish delirium assessment tools available. Thereby hampering the implementation of 2017 ESA-Guidelines on postoperative Delirium in the clinical routine. The aim of this study is to provide an official translation and evaluation of the Nu-DESC into Danish following the ISPOR process.

Methods

The Nu-DESC was translated after International Society for Pharmacoecomonics and Outcome Research (ISPOR) guidelines to Danish after permission of the original author, and is evaluated by medical staff and finally approved by the original author.

Results

All steps of the ISPOR guideline were consecutively followed, without any major problems. The evaluation of the Nu-DESC DK regarding its intelligibility and feasibility showed no statistically significant differences between nurses and medical doctors ratings. The translation was authorized and approved by the original author.

Conclusion

This study provides the Nu-DESC DK, an official Danish delirium screening instrument, which can detect all psychomotor types of delirium.

     

Delirium epidemiology in critical care (DECCA): an international study

Introduction

Delirium is a frequent source of morbidity in intensive care units (ICUs). Most data on its epidemiology is from single-center studies. Our aim was to conduct a multicenter study to evaluate the epidemiology of delirium in the ICU.

Methods

A 1-day point-prevalence study was undertaken in 104 ICUs from 11 countries in South and North America and Spain.

Results

In total, 975 patients were screened, and 497 fulfilled inclusion criteria and were enrolled (median age, 62 years; 52.5% men; 16.7% and 19.9% for ICU and hospital mortality); 64% were admitted to the ICU because of medical causes, and sepsis was the main diagnosis (n = 76; 15.3%). In total, 265 patients were sedated with the Richmond agitation and sedation scale (RASS) deeper than -3, and only 232 (46.6%) patients could be evaluated with the confusion-assessment method for the ICU. The prevalence of delirium was 32.3%. Compared with patients without delirium, those with the diagnosis of delirium had a greater severity of illness at admission, demonstrated by higher sequential organ-failure assessment (SOFA (P = 0.004)) and simplified acute physiology score 3 (SAPS3) scores (P < 0.0001). Delirium was associated with increased ICU (20% versus 5.7%; P = 0.002) and hospital mortality (24 versus 8.3%; P = 0.0017), and longer ICU (P < 0.0001) and hospital length of stay (LOS) (22 (11 to 40) versus 7 (4 to 18) days; P < 0.0001). Previous use of midazolam (P = 0.009) was more frequent in patients with delirium. On multivariate analysis, delirium was independently associated with increased ICU mortality (OR = 3.14 (1.26 to 7.86); CI, 95%) and hospital mortality (OR = 2.5 (1.1 to 5.7); CI, 95%).

Conclusions

In this 1-day international study, delirium was frequent and associated with increased mortality and ICU LOS. The main modifiable risk factors associated with the diagnosis of delirium were the use of invasive devices and sedatives (midazolam).     

Intensive care unit delirium is an independent predictor of longer hospital stay: a prospective analysis of 261 non-ventilated patients

Introduction

Delirium occurs in most ventilated patients and is independently associated with more deaths, longer stay, and higher cost. Guidelines recommend monitoring of delirium in all intensive care unit (ICU) patients, though few data exist in non-ventilated patients. The study objective was to determine the relationship between delirium and outcomes among non-ventilated ICU patients.

Method

A prospective cohort investigation of 261 consecutively admitted medical ICU patients not requiring invasive mechanical ventilation during hospitalization at a tertiary-care, university-based hospital between February 2002 and January 2003. ICU nursing staff assessed delirium and level of consciousness at least twice per day using the Confusion Assessment Method for the ICU (CAM-ICU) and Richmond Agitation-Sedation Scale (RASS). Cox regression with time-varying covariates was used to determine the independent relationship between delirium and clinical outcomes.

Results

Of 261 patients, 125 (48%) experienced at least one episode of delirium. Patients who experienced delirium were older (mean ± SD: 56 ± 18 versus 49 ± 17 years; p = 0.002) and more severely ill as measured by Acute Physiology and Chronic Health Evaluation II (APACHE II) scores (median 15, interquartile range (IQR) 10–21 versus 11, IQR 6–16; p < 0.001) compared to their non-delirious counterparts. Patients who experienced delirium had a 29% greater risk of remaining in the ICU on any given day (compared to patients who never developed delirium) even after adjusting for age, gender, race, Charlson co-morbidity score, APACHE II score, and coma (hazard ratio (HR) 1.29; 95% confidence interval (CI) 0.98–1.69, p = 0.07). Similarly, patients who experienced delirium had a 41% greater risk of remaining in the hospital after adjusting for the same covariates (HR 1.41; 95% CI 1.05–1.89, p = 0.023). Hospital mortality was higher among patients who developed delirium (24/125, 19%) versus patients who never developed delirium (8/135, 6%), p = 0.002; however, time to in-hospital death was not significant the adjusted (HR 1.27; 95% CI 0.55–2.98, p = 0.58).

Conclusion

Delirium occurred in nearly half of the non-ventilated ICU patients in this cohort. Even after adjustment for relevant covariates, delirium was found to be an independent predictor of longer hospital stay.     

Alcohol and injury in Poland: review and training recommendations

Background

Alcohol plays a significant role in accidents, injuries, and their outcomes. According to the World Health Organization (WHO), there are 76.3 million people with alcohol use disorders worldwide; in 2000, 1.8 million deaths and loss of 58.3 million disability-adjusted life years were attributed to alcohol.

Methods

Although the association between alcohol consumption and trauma-related morbidity and mortality is well-documented, particularly in the US, there is much less information on trauma and alcohol in Poland, a country undergoing unprecedented economic and cultural changes stemming from entry into the European Union (EU) in the midst of a global recession.

Results

Injury is the third leading cause of death in Poland. Rates for all injuries in Poland are higher than in the rest of the EU. Alcohol is one of the greatest risk factors for disease and injury among men and one of the top ten health and injury risk factors for women. In this paper we review the last 10 years of research on injury and alcohol in Poland.

Conclusion

Recommendations are provided for next steps with regard to training health care professionals in emergency medical settings to address this serious and growing problem.     

Impact of pneumonia on hyperactive delirium in end-stage lung cancer patients

Purpose

Patients with incurable lung cancer often receive palliative care. Hyperactive delirium is a burden not only for the patient??s family but also for caregivers. There are no reports describing the risk factors for delirium among lung cancer patients. The present study investigated the frequency of incidence and risk factors for hyperactive delirium among end-stage lung cancer patients.

Methods

Patients who died of lung cancer in our institute from January 2010 to December 2010 were retrospectively investigated. Information was obtained from medical records, and patients who developed hyperactive delirium (delirium group, group D) were compared with patients who did not (control group, group C) based on clinical and laboratory data.

Results

A total of 146 patients (median age, 70?years; 80?% male) died of lung cancer. Thirty-one (21.2?%) patients developed hyperactive delirium. Sex (P?=?0.0093) and pneumonia (P?=?0.023) were statistically significant variables in univariate analysis. Pneumonia occurred in 27.4?% of all patients. The incidence of pneumonia was 45.2?% in group D and 22?% in group C. Only pneumonia (odds ratio, 2.89; 95?% confidence interval, 1.22?C6.85; P?=?0.016) was identified as a significant factor for predicting hyperactive delirium in multivariate analysis.

Conclusions

Pneumonia was identified as a significant risk factor for the development of hyperactive delirium among end-stage lung cancer patients.     

Triage of intensive care patients: identifying agreement and controversy

Rationale

Intensive care unit (ICU) resources are limited in many hospitals. Patients with little likelihood of surviving are often admitted to ICUs. Others who might benefit from ICU are not admitted.

Objective

To provide an updated consensus statement on the principles and recommendations for the triage of patients for ICU beds.

Design

The previous Society of Critical Care Medicine (SCCM) consensus statement was used to develop drafts of general and specific principles and recommendations. Investigators and consultants were sent the statements and responded with their agreement or disagreement.

Setting

The Eldicus project (triage decision making for the elderly in European intensive care units).

Participants

Eldicus investigators, consultants, and experts consisting of intensivists, users of ICU services, ethicists, administrators, and public policy officials.

Interventions

Consensus development was used to grade the statements and recommendations.

Measurements and main results

Consensus was defined as 80 % agreement or more. Consensus was obtained for 54 (87 %) of 62 statements including all (19) general principles, 31 (86 %) of the specific principles, and 10 (71 %) of the recommendations. Inconsistencies in responses were noted for ICU admission and discharge. Despite agreement for guidelines applying to individual patients and an objective triage score, there was no agreement for a survival cutoff for triage, not even for a chance of survival of 0.1 %.

Conclusions

Consensus was reached for most general and specific ICU triage principles and recommendations. Further debate and discussion should help resolve the remaining discrepancies.     

Prevalence and risk factors related to haloperidol use for delirium in adult intensive care patients: the multinational AID-ICU inception cohort study

Purpose

We assessed the prevalence and variables associated with haloperidol use for delirium in ICU patients and explored any associations of haloperidol use with 90-day mortality.

Methods

All acutely admitted, adult ICU patients were screened during a 2-week inception period. We followed the patient throughout their ICU stay and assessed 90-day mortality. We assessed patients and their variables in the first 24 and 72 h in ICU and studied their association together with that of ICU characteristics with haloperidol use.

Results

We included 1260 patients from 99 ICUs in 13 countries. Delirium occurred in 314/1260 patients [25% (95% confidence interval 23–27)] of whom 145 received haloperidol [46% (41–52)]. Other interventions for delirium were benzodiazepines in 36% (31–42), dexmedetomidine in 21% (17–26), quetiapine in 19% (14–23) and olanzapine in 9% (6–12) of the patients with delirium. In the first 24 h in the ICU, all subtypes of delirium [hyperactive, adjusted odds ratio (aOR) 29.7 (12.9–74.5); mixed 10.0 (5.0–20.2); hypoactive 3.0 (1.2–6.7)] and circulatory support 2.7 (1.7–4.3) were associated with haloperidol use. At 72 h after ICU admission, circulatory support remained associated with subsequent use of haloperidol, aOR 2.6 (1.1–6.9). Haloperidol use within 0–24 h and within 0–72 h of ICU admission was not associated with 90-day mortality [aOR 1.2 (0.5–2.5); p?=?0.66] and [aOR 1.9 (1.0–3.9); p?=?0.07], respectively.

Conclusions

In our study, haloperidol was the main pharmacological agent used for delirium in adult patients regardless of delirium subtype. Benzodiazepines, other anti-psychotics and dexmedetomidine were other frequently used agents. Haloperidol use was not statistically significantly associated with increased 90-day mortality.

     

Safety of nicotine replacement therapy in critically ill smokers: a retrospective cohort study

Purpose

Nicotine replacement therapy (NRT) has been used to ameliorate nicotine withdrawal in the intensive care unit (ICU). Previous cohort studies have suggested an increased mortality with NRT use: methodological problems may call into question the validity of these findings. We undertook a retrospective cohort study to determine if NRT use was associated with adverse outcomes.

Methods

This retrospective cohort study was conducted in a 30-bed, university affiliated, teaching hospital ICU.

Results

We identified 423 smokers admitted over 2?years, of whom 73 received transdermal NRT. Cox proportional hazard regression models, with NRT modelled as a time-varying covariate, were used to test the hypothesis that NRT was associated with an altered ICU or hospital mortality. A second analysis utilized propensity scores. The unadjusted ICU and hospital mortalities were lower for the NRT group; although both differences were non-significant. The Cox models showed that, after adjustment for APACHE risk, age, sex and alcohol use, risk associated with NRT administration was not statistically different than non-administration for both ICU (hazard ratio 0.50, [95?% CI 0.20–1.24], p?=?0.14) and hospital (hazard ratio 0.95, [95?% CI 0.52–1.75], p?=?0.88) mortality. Similar findings occurred with the propensity matched analysis.

Conclusion

We were unable to demonstrate any harm associated with NRT, with the ICU model actually trending towards benefit. We conclude that a randomised, blinded, placebo controlled trial is required to assess adequately the safety and efficacy of NRT as a treatment in critically ill smokers.     

Effect of organisational factors on the variation in incidence of delirium in intensive care unit patients: A systematic review and meta-regression analysis

Background

Delirium occurs frequently in intensive care unit (ICU) patients and is associated with numerous deleterious outcomes. There is a large variation in reported delirium occurrence rates, ranging from 4% to 89%. Apart from patient and treatment-related factors, organisational factors could influence delirium incidence, but this is currently unknown.

End-of-life decisions in an Indian intensive care unit

Background

There is a paucity of data on end-of-life decisions (EOLD) for patients in Indian intensive care units (ICUs).

Objective

To document the end-of-life and full-support (FS) decisions among patients dying in an ICU, to compare the respective patient characteristics and to describe the process of decision-making.

Design

Retrospective, observational.

Patients

Consecutive patients admitted to a 12-bed closed medical-surgical ICU.

Exclusions

Patients with EOLD discharged home or transferred to another hospital.

Measurements and results

Demographic profile, APACHE IV at 24 h, ICU outcome, type of limitation, disease category, pre-admission functional status, reasons for EOLD, interventions and therapies within 3 days of death, time to EOLD, time to death after EOLD and ICU length of stay. Out of 88 deaths among 830 admissions, 49% were preceded by EOLD. Of these 58% had withholding of treatment, 35% had do-not-resuscitate orders (DNR) and 7% had a withdrawal decision. Mean age and APACHE IV scores were similar between EOLD and FS groups. Functional dependence before hospitalization favored EOLD. Patients receiving EOLD as opposed to FS had longer stays. Fifty-three percent of limitations were decided during the first week of ICU stay well before the time of death. Escalation of therapy within 3 days of death was less frequent in the EOLD group.

Conclusions

Despite societal and legal barriers, half the patients dying in the ICU received a decision to limit therapy mostly as withholding or DNR orders. These decisions evolved early in the course of stay and resulted in significant reduction of therapeutic burdens.     

Detecting pediatric delirium: development of a rapid observational assessment tool

Objective

Development of a novel screening tool for the detection of delirium in pediatric intensive care unit (PICU) patients of all ages by comparison with psychiatric assessment based on the reference standard Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria.

Methods

This was a prospective blinded pilot study investigating the feasibility of the Cornell Assessment of Pediatric Delirium (CAP-D) performed in a PICU at a university hospital. Fifty patients, ages 3?months to 21?years, admitted to the PICU over a 6-week period were included. No interventions were performed.

Results

After informed consent was obtained, two study teams independently assessed for delirium by completing the CAP-D and by conducting psychiatric evaluation based on the DSM-IV criteria. Concordance between the CAP-D and DSM-IV criteria was excellent, at 97%. Prevalence of delirium in this sample was 29%.

Conclusion

The CAP-D may be a valid screen for identification of delirium in PICU patients of all ages. Further studies are required to explore its validity, inter-rater reliability, and feasibility of use as a nursing screen.     

Abstracts for ESICM-Barcelona 2014

Background

Intensive care unit (ICU) patients are exposed to many sources of discomfort. Although increasing attention is being given to the detection and treatment of pain, very little is given to the detection and treatment of dyspnea (defined as “breathing discomfort”).

Methods

Published information on the prevalence, mechanisms, and potential negative impacts of dyspnea in mechanically ventilated patients are reviewed. The most appropriate tools to detect and quantify dyspnea in ICU patients are also assessed.

Results/Conclusions

Growing evidence suggests that dyspnea is a frequent issue in mechanically ventilated ICU patients, is highly associated with anxiety and pain, and is improved in many patients by altering the ventilator settings.

Conclusions

Future studies are needed to better delineate the impact of dyspnea in the ICU and to define diagnostic, monitoring and therapeutic protocols.     

The ultra-early protective effect of ulinastatin on rabbit acute lung injury induced by paraquat

Background

Identification of delirium in emergency departments (ED) is often underestimated; within EDs, studies on delirium assessment and relation with patient outcome in Intermediate Care Units (IMCU) appear missing in European hospital settings. Here we aimed to determine delirium prevalence in an EDIMCU (Hospital de Braga, Braga, Portugal) and assessed routine biochemical parameters that might be delirium indicators.

Methods

The study was prospective and observational. Sedation level was assessed via the Richmond Agitation-Sedation Scale and delirium status by the Confusion Assessment Method for the ICU. Information collected included age and gender, admission type, Charlson Comorbidity Index combined condition score (Charlson score), systemic inflammatory response syndrome criteria (SIRS), biochemical parameters (blood concentration of urea nitrogen, creatinine, hemoglobin, sodium and potassium, arterial blood gases, and other parameters as needed depending on clinical diagnosis) and EDIMCU length of stay (LOS). Statistical analyses were performed as appropriate to determine if baseline features differed between the ‘Delirium’ and ‘No Delirium’ groups. Multivariate logistic regression was performed to assess the effect of delirium on the 1-month outcome.

Results

Inclusion and exclusion criteria were met in 283 patients; 238 were evaluated at 1-month for outcome follow-up after EDIMCU discharge (“good” recovery without complications requiring hospitalization or institutionalization; “poor” institutionalization in permanent care-units/assisted-living or death). Delirium was diagnosed in 20.1% patients and was significantly associated with longer EDIMCU LOS. At admission, Delirium patients were significantly older and had significantly higher blood urea, creatinine and osmolarity levels and significantly lower hemoglobin levels, when compared with No Delirium patients. Delirium was an independent predictor of increased EDIMCU LOS (odds ratio 3.65, 95% CI 1.97-6.75) and poor outcome at 1-month after discharge (odds ratio 3.51, CI 1.84-6.70), adjusted for age, gender, admission type, presence of SIRS criteria, Charlson score and osmolarity at admission.

Conclusions

In an EDIMCU setting, delirium was associated with longer LOS and poor outcome at1-month post-discharge. Altogether, findings support the need for delirium screening and management in emergency settings.