Differences in 90-day mortality of delirium subtypes in the intensive care unit: A retrospective cohort study

This article by Rood and colleagues was published online in the “Journal of Critical Care” during June 2019
Introduction:  Many intensive care unit (ICU) patients suffer from delirium which is associated with deleterious short-term and long-term effects, including mortality. We determined the association between different delirium subtypes and 90-day mortality.
Materials and methods:  Retrospective cohort study in ICU patients admitted in 2015–2017. Delirium, including its subtypes, was determined using the confusion assessment method-ICU (CAM-ICU) and Richmond agitation sedation scale (RASS). Exclusion criteria were insufficient assessments and persistent coma. Cox-regression analysis was used to determine associations of delirium subtypes with 90-day mortality, including relevant covariates (APACHE-IV, length of ICU stay and mechanical ventilation).
Results:  7362 ICU patients were eligible of whom 6323 (86%) were included. Delirium occurred in 1600 (25%) patients (stratified for delirium subtype: N = 571–36% mixed, N = 485–30% rapidly reversible, N = 433–27% hypoactive, N = 111–7% hyperactive). The crude hazard ratio (HR) for overall prevalent delirium with 90-day mortality was 2.84 (95%CI: 2.32–3.49), and the adjusted HR 1.29 (95%CI: 1.01–1.65). The adjusted HR for 90-day mortality was 1.57 (95%CI: 1.51–2.14) for the mixed subtype, 1.40 (95%CI: 0.71–2.73) for hyperactive, 1.31 (95%CI: 0.93–1.84) for hypoactive and 0.95 (95%CI: 0.64–1.42) for rapidly reversible delirium.
Conclusion:  After adjusting for covariates, including competing risk factors, only the mixed delirium subtype was significantly associated with 90-day mortality.
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Efficacy of music on sedation, analgesia and delirium in critically ill patients. A systematic review of randomized controlled trials

This article by Gonzalo and colleagues was published online in June 2019 in the Journal of Critical Care.
Purpose:  To systematically synthesize randomized controlled trial data on the efficacy of music to provide sedation and analgesia, and reduce incidence of delirium, in critically ill patients.
Material and methods:  Relevant databases (Medline, PubMed, Embase, CINAHL, Cochrane, Alt Healthwatch, LILACS, PsycINFO, CAIRSS, RILM) were searched from inception to April 26, 2018. We also searched the reference lists of included publications and for ongoing trials. The selection of relevant articles was conducted by two researchers at two levels of screening.
Data collection followed the recommendations from the Cochrane Systematic Reviews Handbook. We used the Cochrane Collaboration’s tool for assessing risk of bias. Quality of the evidence was rated according to GRADE.
Results:  The review identified six adult studies and no neonatal or pediatric studies. A descriptive analysis of study results was performed. Meta-analysis was not feasible due to heterogeneity. One study reported a reduction in sedation requirements with the use of music while the other five did not find any significant differences across groups.
Conclusions:  This systematic review revealed limited evidence to support or refute the use of music to reduce sedation/analgesia requirements, or to reduce delirium in critically ill adults, and no evidence in pediatric and neonatal critically ill patients.
The full text of this article is available to subscribers via this link to the journal’s homepage.  The full text of articles from issues older than sixty days is available via this link to an archive of issues of Journal of Critical Care.  A Rotherham NHS Athens password is required.  Eligible staff can register for an Athens password via this link.  Please speak to the library staff for more details.

Current practice and perceptions regarding pain, agitation and delirium management in patients receiving venovenous extracorporeal membrane oxygenation

This article by Dzierba and colleagues was first published in the Journal of Critical Care during May 2019.
Purpose:  To characterize monitoring of pain, agitation, and delirium; investigate opioid and sedative choices; and describe prevention and treatment of delirium in adults receiving venovenous extracorporeal membrane oxygenation (vv-ECMO) for respiratory failure.
Materials and methods:  International, cross-sectional survey distributed January 2018 to members of the Society of Critical Care Medicine.
Results:  Respondents were predominately physicians (58%) from North America (89%). Fentanyl (77%) and hydromorphone (48%) were the most common intravenous opioids used to manage pain. A deep level of sedation was targeted in the first 24-h after initiation of vv-ECMO 64% of the time. When deep sedation was targeted, propofol (70%) and benzodiazepines (41%) were the most common sedatives. The most common sedatives for light sedation were dexmedetomidine (45%) and propofol (39%). Delirium prevention included avoidance of benzodiazepines (73%), whereas the most common treatment strategy was scheduled atypical antipsychotics (83%). Centers that extubated patients during vv-ECMO used dexmedetomidine as the second preferred sedative as compared to benzodiazepines at non-extubating centers (p = 0.04).
Conclusions:  Most respondents use validated scales and protocols to assess and manage pain, agitation/sedation, and delirium. The majority of respondents reported targeting a deep level of sedation with propofol being used for both deep and light levels of sedation.
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Do health care professionals worry about delirium? Relatives’ experience of delirium in the intensive care unit: A qualitative interview study

This research by Bohart and colleagues was published online in “Intensive and Critical Care Nursing” during May 2019.
Objectives:  In intensive care units, there is a high incidence of delirium, which relates to the risk of complications. Engagement of relatives is an acknowledged part of handling delirium, but knowledge of relatives’ perspectives is lacking.
Aim:  To explore relatives’ experiences of delirium in the critically ill patient admitted to an intensive care unit.Research design:  A qualitative design with a phenomenological approach. Semi-structured interviews with eleven relatives of critically ill patients who had delirium during admission to the intensive care unit.Setting:  An intensive care unit in Denmark.
Findings:  Three categories emerged: ‘Delirium is not the main concern’, ‘Communication with health-care professionals is crucial’, and ‘Delirium impacts on relatives’. Relatives had a lack of knowledge of delirium. Symptoms of delirium were thought of as a natural consequence of critical illness and seemed to be a secondary problem. Health-care professionals did not talk about delirium and information was requested. Delirium and the manifestation of it was experienced in different ways and brought different ways of coping.
Conclusion:  Findings give a new insight into relatives’ experience of delirium in the intensive care unit. Relatives need more information to better understand delirium. Future research must investigate the potential in helping relatives to cope with delirium, to the benefit of both patient and relatives.
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Haloperidol for the management of delirium in adult intensive care unit patients: A systematic review and meta-analysis of randomized controlled trials

This article by Zayed et al was published online in the Journal of Critical Care during January 2019.
Purpose:  Delirium commonly presents as a complication in critically ill patients. Our aim is to perform a meta-analysis investigating the role of haloperidol versus placebo in management (treatment and prophylaxis), of delirium in intensive care unit (ICU).
Materials and methods:  Our study is a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing haloperidol versus placebo for treatment and/or prophylaxis of ICU-related delirium.
Results:  Six RCTs representing 2552 patients. There was no significant difference between haloperidol and placebo-treated patients in short-term all-cause mortality (risk ratio [RR] 0.96; 95% confidence interval [CI] 0.81–1.14; P = 0.67), incidence of delirium (RR 0.93; 95% CI 0.65–1.34; P = 0.70), ICU length of stay (Mean difference [MD] 0.00 days; 95% CI -0.82-0.83; P = 0.99), or delirium/coma-free days (MD 0.09; 95% CI -0.05-0.24; P = 0.21). Haloperidol was not associated with increased risk for serious adverse events (RR 0.65; 95% CI 0.23–1.88; P = 0.43), QTc prolongation (RR 0.87; 95% CI 0.63–1.19; P = 0.38), or extrapyramidal symptoms (RR 0.84; 95% CI 0.57–1.23; P = 0.37).
Conclusion:  Among critically ill patients, haloperidol administration compared with placebo does not significantly affect short-term mortality, incidence of delirium, ICU length of stay, or delirium or coma-free days. Additionally, there was no increased risk of adverse events.
The full text of this article is available to subscribers via this link to the journal’s homepage The full text of articles from issues older than sixty days is available via this link to an archive of issues of Journal of Critical Care.  A Rotherham NHS Athens password is required.  Eligible staff can register for an Athens password via this link.  Please speak to the library staff for more details.

Dexmedetomidine in prevention and treatment of postoperative and intensive care unit delirium: a systematic review and meta-analysis

This article by Flukiger et al was published in Annals of intensive care September 2018.
Background:  To determine the preventive and therapeutic effect of dexmedetomidine on intensive care unit (ICU) delirium.
Methods:  The literature search using PubMed and the Cochrane Central Register of Controlled Trials was performed (August 1, 2018) to detect all randomized controlled trials (RCTs) of adult ICU patients receiving dexmedetomidine. Articles were included if they assessed the influence of dexmedetomidine compared to a sedative agent on incidence of ICU delirium or treatment of this syndrome. Accordingly, relevant articles were allocated to the following two groups: (1) articles that assessed the delirium incidence (incidence comparison) or articles that assessed the treatment of delirium (treatment comparison). Incidence of delirium and delirium resolution were the primary outcomes. We combined treatment effects comparing dexmedetomidine versus (1) placebo, (2) standard sedatives, and (3) opioids in random-effects meta-analyses. Risk of bias for each included RCT was assessed following Cochrane standards.
Results:  The literature search resulted in 28 articles (25 articles/4975 patients for the incidence comparison and three articles/166 patients for the treatment comparison). In the incidence comparison, heterogeneity was present in different subgroups. Administration of dexmedetomidine was associated with significantly lower overall incidence of delirium when compared to placebo (RR 0.52; 95% CI 0.39-0.70; I2 = 37%), standard sedatives (RR 0.63; 95% CI 0.46-0.86; I2 = 69%), as well as to opioids (RR 0.61; 95% CI 0.44-0.83; I2 = 0%). Use of dexmedetomidine significantly increased the risks of bradycardia and hypotension. Limited data were available on circulatory insufficiency and mortality. In the treatment comparison, the comparison drugs in the three RCTs were placebo, midazolam, and haloperidol. The resolution of delirium was measured differently in each study. Two out of the three studies indicated clear favorable effects for dexmedetomidine (i.e., compared to placebo and midazolam). The study comparing dexmedetomidine with haloperidol was a pilot study (n = 20) with high variability in the results.
Conclusions:  Findings suggest that dexmedetomidine reduces incidence and duration of ICU delirium. Furthermore, our systematic searches show that there is limited evidence if a delirium shall be treated with dexmedetomidine.
The full text of the article is available via this link.

Delirium prediction in the intensive care unit: comparison of two delirium prediction models

This article by Wassenaar and others was published in the May 2018 issue of Critical Care.
Background:  Accurate prediction of delirium in the intensive care unit (ICU) may facilitate efficient use of early preventive strategies and stratification of ICU patients by delirium risk in clinical research, but the optimal delirium prediction model to use is unclear. We compared the predictive performance and user convenience of the prediction model for delirium (PRE-DELIRIC) and early prediction model for delirium (E-PRE-DELIRIC) in ICU patients and determined the value of a two-stage calculation.
Methods:  This 7-country, 11-hospital, prospective cohort study evaluated consecutive adults admitted to the ICU who could be reliably assessed for delirium using the Confusion Assessment Method-ICU or the Intensive Care Delirium Screening Checklist. The predictive performance of the models was measured using the area under the receiver operating characteristic curve. Calibration was assessed graphically. A physician questionnaire evaluated user convenience. For the two-stage calculation we used E-PRE-DELIRIC immediately after ICU admission and updated the prediction using PRE-DELIRIC after 24 h.
Results:  In total 2178 patients were included. The area under the receiver operating characteristic curve was significantly greater for PRE-DELIRIC (0.74 (95% confidence interval 0.71-0.76)) compared to E-PRE-DELIRIC (0.68 (95% confidence interval 0.66-0.71)) (z score of - 2.73 (p < 0.01)). Both models were well-calibrated. The sensitivity improved when using the two-stage calculation in low-risk patients. Compared to PRE-DELIRIC, ICU physicians (n = 68) rated the E-PRE-DELIRIC model more feasible.
Conclusions:  While both ICU delirium prediction models have moderate-to-good performance, the PRE-DELIRIC model predicts delirium better. However, ICU physicians rated the user convenience of E-PRE-DELIRIC superior to PRE-DELIRIC. In low-risk patients the delirium prediction further improves after an update with the PRE-DELIRIC model after 24h.
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