Duration Of Intensive Care Unit Delirium Research Articles

Prophylactic melatonin for delirium in critically ill patients: A systematic review and meta-analysis with trial sequential analysis.

Up to 80% of patients in the intensive care unit (ICU) suffer from delirium. Studies on the preventative use of melatonin in the ICU have produced mixed results. We performed a systematic review and meta-analysis to evaluate whether early administration of melatonin reduces the prevalence of delirium in critically ill patients. We searched Medline, Embase, and the Cochrane Library for randomized controlled trials comparing melatonin or melatonin agonists to placebo in ICU setting. The population included adult patients in the ICU. The primary outcome was the prevalence of delirium. Secondary outcomes included duration of delirium, delirium-free day, serum melatonin concentration, need for sedation, duration of mechanical ventilation, hospital and ICU length of stay (LOS), all-cause mortality, sleep quality, and adverse events. Trial sequential analysis (TSA) was performed on the primary outcome to prevent the risk of random error and multiplicity phenomenon as a result of repeated significance testing across all the included trials. Twelve trials with a total of 2538 patients were analyzed. When all trials were pooled, the incidence of delirium in ICU patients who received melatonin was significantly lower than in those who received placebo (risk ratio, 0.77; 95% confidence interval: 0.61-0.96; I2 = 56%). There were no significant differences in secondary outcomes including duration of delirium, duration of mechanical ventilation, ICU LOS, hospital LOS, and mortality. TSA indicated that Z-curve crossed the traditional boundary, but did not cross the monitoring boundary for benefit, which indicated that it is still inconclusive that melatonin affects the incidence of delirium. This meta-analysis found that early administration of melatonin may result in a decreased delirium prevalence in critically ill patients. However, the sensitivity analysis of high-quality studies did not support this finding. In addition, TSA demonstrated that the result may have false-positive error. Therefore, this finding should be interpreted with caution. Further studies are needed to examine the effectiveness of prophylactic melatonin on the prevalence and duration of ICU delirium in the future.

Risk factors for delirium in intensive care unit and its duration

To screen risk factors for delirium and its duration in intensive care unit (ICU) patients. 1 200 patients admitted to ICU of the Second Hospital of Shanxi Medical University from May 2017 to May 2019 were enrolled. The gender, age, anesthesia mode, duration of mechanical ventilation and hypoxia, acute physiology and chronic health evaluation II (APACHE II) score, sedative drug use, and length of ICU stay were recorded. The occurrence and duration of ICU delirium were recorded. Multivariate Logistic regression analysis and multiple linear regression analysis were used to analyze the factors with statistical significance differences between the groups for screening the risk factors for delirium and its duration in ICU patients. 397 of 1 200 patients developed delirium, the incidence of ICU delirium was 33.1%. The duration of delirium in 189 patients (47.6%) was 1.0 day, and the duration of delirium in 397 delirium patients was 2.0 (1.5, 2.5) days. (1) Analysis of risk factors for delirium: univariate analysis showed that there was no significant difference in the incidence of ICU delirium among patients with different genders or ages. The incidence of ICU delirium in patients with duration of mechanical ventilation or hypoxia 4-9 days and ≥ 10 days was higher than that in patients with ≤ 3 days. The incidence of ICU delirium of general anesthesia and internal medicine patients was higher than that of patients with lumbar anesthesia. The incidence of ICU delirium in patients with APACHE II score ≥ 20 was higher than that in patients with ≤ 10 and 11-19. The patients with length of ICU stay > 9 days had a higher ICU delirium incidence than those ≤ 8 days. Increased incidence of ICU delirium in sedative patients was found as compared with those who did not use sedatives. Multivariate Logistic regression analysis showed that APACHE II score [odds ratio (OR) = 5.491, 95% confidence interval (95%CI) was 4.361-6.913, P < 0.001], the length of ICU stay (OR = 2.679, 95%CI was 1.822-3.941, P < 0.001) and the use of sedatives (OR = 2.479, 95%CI was 1.821-3.374, P < 0.001) were risk factors for ICU delirium. (2) Analysis of risk factors of ICU delirium duration: univariate analysis showed that there was no significant difference in ICU delirium duration in patients with different genders or ages. The duration of ICU delirium in patients with duration of mechanical ventilation or hypoxia ≥ 10 days was longer than that in patients with ≤ 3 days and 4-9 days. The duration of ICU delirium in general anesthesia and non-surgical patients was higher than that in patients with spinal anesthesia. The ICU delirium duration in patients with APACHE II score ≥ 20 was longer than that in patients with ≤ 10 and 11-19. The duration of ICU delirium in patients with the length of ICU stay > 9 days was longer than that in patients with ≤ 8 days. The duration of ICU delirium in patients on sedatives was longer than those not taking sedatives. Multiple linear regression analysis showed that the duration of ICU delirium increased by an average of 0.061 days (β = 0.061, 95%CI was 0.032-0.090, P < 0.001) for each additional day of hypoxia (hypoxia duration was divided into three grades of ≤ 3, 4-9 and ≥ 10 days). For every one increase in APACHE II score (APACHE II score was divided into three grades of ≤ 10, 11-19 and ≥ 20), duration of ICU delirium extended an average of 0.058 days (β = 0.058, 95%CI was 0.048-0.068, P < 0.001). ICU delirium duration increased by an average of 0.065 days in patients with length of ICU stay > 9 days as compared with those ≤ 8 days (β = 0.065, 95%CI was 0.056-0.075, P < 0.001). On average, the duration of ICU delirium was prolonged by 0.362 days in patients on sedatives as compared with those who did not use sedatives (β = 0.362, 95%CI was 0.234-0.490, P < 0.001). APACHE II score, the length of ICU stay and the use of sedatives were common risk factors for ICU delirium and its duration. The hypoxic duration was risk factors for ICU delirium duration.

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

BackgroundTo determine the preventive and therapeutic effect of dexmedetomidine on intensive care unit (ICU) delirium.MethodsThe 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.ResultsThe 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.ConclusionFindings 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.

Antipsychotics, Delirium, and Acute Respiratory Distress Syndrome: What Is the Link?

Acute respiratory distress syndrome (ARDS) is an acute inflammatory process that impairs the ability of the lungs to oxygenate and ultimately leads to respiratory failure. Patients who develop ARDS often have prolonged and complicated hospital courses putting them at risk for intensive care unit (ICU) delirium. Patients with ICU delirium often need chemical sedation, mechanical ventilation, prolonged duration of ICU and hospital stays, and they experience long-term cognitive impairment and increased mortality. In a patient with ARDS, ICU delirium further complicates the hospital course and increases the risk of morbidity and mortality. Antipsychotics are prescribed to decrease the severity and duration of ICU delirium, thus potentially decreasing their risk of morbidity and mortality. However, antipsychotics are associated with many adverse effects including respiratory failure. Given the long-term sequelae associated with the development of ICU delirium and the risks associated with antipsychotic use, clinicians must weigh the risks and benefits of antipsychotic use. This review investigates the interrelationship between ARDS, delirium, and antipsychotic use. In addition to discussing relevant studies evaluating antipsychotics for the prevention and treatment of delirium, we investigate safety concerns with the use of antipsychotics, especially as they relate to ARDS. Using the data compiled in this review, clinicians can make an informed decision about the use of antipsychotics for the prevention or treatment of delirium, with special consideration for their patients with ARDS. Future studies are needed to critically evaluate antipsychotic timing, dose, and duration for the prevention and treatment of ICU delirium and specifically evaluate the impact in special populations, particularly patients with ARDS.

Clinical effectiveness of a sedation protocol minimizing benzodiazepine infusions and favoring early dexmedetomidine: a before-after study.

IntroductionRandomized controlled trials suggest clinical outcomes may be improved with dexmedetomidine as compared with benzodiazepines; however, further study and validation are needed. The objective of this study was to determine the clinical effectiveness of a sedation protocol minimizing benzodiazepine use in favor of early dexmedetomidine.MethodsWe conducted a before-after study including adult surgical and medical intensive care unit (ICU) patients requiring mechanical ventilation and continuous sedation for at least 24 hours. The before phase included consecutive patients admitted between 1 April 2011 and 31 August 31 2011. Subsequently, the protocol was modified to minimize use of benzodiazepines in favor of early dexmedetomidine through a multidisciplinary approach, and staff education was provided. The after phase included consecutive eligible patients between 1 May 2012 and 31 October 2012.ResultsA total of 199 patients were included, with 97 patients in the before phase and 102 in the after phase. Baseline characteristics were well balanced between groups. Use of midazolam as initial sedation (58% versus 27%, P <0.0001) or at any point during the ICU stay (76% versus 48%, P <0.0001) was significantly reduced in the after phase. Dexmedetomidine use as initial sedation (2% versus 39%, P <0.0001) or at any point during the ICU stay (39% versus 82%, P <0.0001) significantly increased. Both the prevalence (81% versus 93%, P =0.013) and median percentage of days with delirium (55% (interquartile range (IQR), 18 to 83) versus 71% (IQR, 45 to 100), P =0.001) were increased in the after phase. The median duration of mechanical ventilation was significantly reduced in the after phase (110 (IQR, 59 to 192) hours versus 74.5 (IQR, 42 to 148) hours, P =0.029), and significantly fewer patients required tracheostomy (20% versus 9%, P =0.040). The median ICU length of stay was 8 (IQR, 4 to 12) days in the before phase and 6 (IQR, 3 to 11) days in the after phase (P =0.252).ConclusionsImplementing a sedation protocol that targeted light sedation and reduced benzodiazepine use led to significant improvements in the duration of mechanical ventilation and the requirement for tracheostomy, despite increases in the prevalence and duration of ICU delirium.

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Introduction: Delirium in the intensive care unit (ICU) is associated with increased mortality and long term cognitive dysfunction. Recent guidelines provide recommendations for nonpharmacologic, but not pharmacologic prevention due to variable outcomes when antipsychotics are used for prevention. Importantly, the majority of this research was conducted in non-ICU patients. The purpose of this retrospective study is to evaluate the incidence of delirium in ICU patients who received antipsychotics. Methods: This was a single center retrospective cohort study. Patients admitted to medical, surgical, and cardiothoracic surgery ICUs who received either haloperidol or quetiapine and were Confusion Assessment Method for the ICU (CAM-ICU) negative upon initiation of either medication were included. Patients were divided into four groups: scheduled haloperidol, prn haloperidol, scheduled quetiapine, and prn quetiapine. The primary outcome measure was to compare the incidence and duration of delirium. Secondary outcome measures included: 1) characterization of adverse effects and 2) description of risk factors associated with delirium. Results:: Eighty patients were included in the study. The majority received either scheduled quetiapine (35%) or as needed haloperidol (55%) while 10% received prn quetiapine and no patients received scheduled haloperidol. APACHE II score was higher in the prn haloperidol group (17.1 vs 11.5 vs 14.0; p = 0.02). Incidence of delirium was 39% in the scheduled quetiapine group compared with 50% in the prn quetiapine group and 36% in the prn haloperidol group (p = 0.79). There was no difference in delirium-free days between groups (11.6 vs 8.7 vs 7.2; p = 0.15). The scheduled quetiapine group had a slightly longer time to first episode of delirium, but this was not statistically significant (11 days vs 4.8 days vs 5.6 days; p = 0.20). Hospital length of stay (LOS) was longer in the scheduled quetiapine group (27 days vs 15.1 days vs 15.5 days; p = 0.02). There was no difference in 30-day mortality (7.1% vs 12.5% vs 18.2%; p = 0.39) and incidence of QTc prolongation (34.8% vs 0% vs 22.2%; p = 0.22). In the multivariate analysis, ICU LOS was identified as a risk factor for delirium. Conclusions: There was no difference in overall incidence or duration of ICU delirium between scheduled quetiapine, prn quetiapine, or prn haloperidol. Safety outcomes, including mortality and QTc prolongation, were similar between groups. ICU LOS was associated with increased incidence of delirium. Additionally, longer hospital length of stay was observed with the use of scheduled quetiapine.

Benzodiazepine and opioid use and the duration of intensive care unit delirium in an older population*

There is a high prevalence of delirium in older medical intensive care unit (ICU) patients and delirium is associated with adverse outcomes. We need to identify modifiable risk factors for delirium, such as medication use, in the ICU. The objective of this study was to examine the impact of benzodiazepine or opioid use on the duration of ICU delirium in an older medical population. Prospective cohort study. Fourteen-bed medical intensive care unit in an urban university teaching hospital. 304 consecutive admissions age 60 and older. None. The main outcome measure was duration of ICU delirium, specifically the first episode of ICU delirium. Patients were assessed daily for delirium with the Confusion Assessment Method for the ICU and a validated chart review method. Our main predictor was receiving benzodiazepines or opioids during ICU stay. A multivariable model was developed using Poisson rate regression. Delirium occurred in 239 of 304 patients (79%). The median duration of ICU delirium was 3 days with a range of 1-33 days. In a multivariable regression model, receipt of a benzodiazepine or opioid (rate ratio [RR] 1.64, 95% confidence interval [CI] 1.27-2.10) was associated with increased delirium duration. Other variables associated with delirium duration in this analysis include preexisting dementia (RR 1.19, 95% CI 1.07-1.33), receipt of haloperidol (RR 1.35, 95% CI 1.21-1.50), and severity of illness (RR 1.01, 95% CI 1.00-1.02). The use of benzodiazepines or opioids in the ICU is associated with longer duration of a first episode of delirium. Receipt of these medications may represent modifiable risk factors for delirium. Clinicians caring for ICU patients should carefully evaluate the need for benzodiazepines, opioids, and haloperidol.