Delirium in Intensive Care Patients – a Prospective Study

Czech version

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

Overview

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

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

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

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

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

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

Sources

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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