Delirium in Cardiac Intensive Care Unit.

Sukrut Pagad,Vanessa May,Bilal Haider Malik,Ashley A Arnold,Saruja Nanthakumaran,Saijanakan Sridharan,Manoj R Somagutta

doi:10.7759/cureus.10096

Abstract

Delirium is a multifactorial syndrome and is described as an acute brain dysfunction seen commonly in post-cardiac surgery patients. The prevalence of post-operative Delirium (POD) ranges from 11.4% to 55%, depending on the diagnostic tool and type of study. Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) are the two most used and recommended tools by the Society of Intensive Care Medicine. Annual delirium-related healthcare costs in the United States (US) range from 6.6 to 20.4 billion USD in ICU patients. However, delirium in cardiac ICU (CICU) is underdiagnosed and warrants vigorous workup. The risk factors for delirium in CICU can be classified as modifiable, non-modifiable, and cardiac surgical causes. After cardiac procedures, delirium is associated with increased mortality, increased length of hospital stay, loss of functional independence, increased hospital costs, and an independent predictor of death 10 years postoperatively. Non-pharmacological measures such as avoiding delirium-risk medications, early physical rehabilitation, occupational therapy, and sleep improvement strategies have shown significant benefits in decreasing delirium. Pharmacological options are limited for use in CICU, and a need for future studies in this topic is in demand.

Highlights

BackgroundAccording to the Diagnostic and Statistical Manual of Mental Disorders (DSM 5), delirium is characterized by a disturbance in attention, awareness or cognition [1]
According to American Psychiatric Association, the diagnosis needs to be supplemented by observational assessment tools like Confusion Assessment Method (CAM), Confusion Assessment Method - Intensive care unit (CAM-ICU), and Intensive Care Delirium Screening Checklist (ICDSC)
Recent studies exhibit the vital role of microglial activation mediates the pro-inflammatory response, subsequently leading to intense neurological inflammation resulting in post-operative delirium (POD) in cardiac surgery patients [6,17,21]

Summary

Introduction

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM 5), delirium is characterized by a disturbance in attention (i.e., reduced ability to direct, focus, sustain, and shift attention), awareness (reduced orientation to the environment) or cognition (e.g., disorientation, language, visuospatial ability, or perception) [1]. POD is associated with cognitive decline, prolonged hospital stay, increased hospital costs, institutionalization, physical and emotional stress These patients have a higher risk of mortality within the first years after cardiac surgery [11,16]. Recent studies exhibit the vital role of microglial activation mediates the pro-inflammatory response, subsequently leading to intense neurological inflammation resulting in POD in cardiac surgery patients [6,17,21]. In another prospective cohort study, CAM-ICU and ICDSC were evaluated versus the DSM-IV-TR in delirium diagnosis concerning their validity and psychometric properties They noticed CAM-ICU showed only modest concurrent validity (Cohen's κ = 0.44) and sensitivity (50%) but high specificity (95%).

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Disclosures

17. Brown CH

Findings

21. Cunningham C