Intensive Care Delirium Screening Checklist Score Research Articles

Brain functional magnetic resonance imaging in ICU patients who developed delirium

ObjectiveTo detect brain alterations in intensive care unit (ICU) patients who develop delirium using functional magnetic resonance imaging (fMRI) and diffusion tensor imaging (DTI) and to determine their predictive value.MethodsFifty-two patients who were admitted to the ICU of the Affiliated Hospital of Zunyi Medical University between June 2021 and June 2022 were enrolled. Fifteen patients who were diagnosed with delirium by the Intensive Care Delirium Screening Checklist (ICDSC) after MRI were selected as the delirium group, and 15 healthy volunteers who were examined during the same period served as the control group. Both groups underwent fMRI and DTI. Quantitative fMRI and DTI data were compared between the two groups to detect abnormal structural and functional brain damage. The relationships between MRI outliers and clinical indicators in the delirium group were also assessed.ResultsDemographic characteristics and imaging indicators before delirium were not correlated with ICDSC scores after delirium. Compared with the healthy control group, the delirium group had significantly lower regional homogeneity (ReHo) values in the left caudate nucleus and frontal lobe on fMRI. The amplitude of the low-frequency fluctuations (ALFF) values of the delirium group were significantly increased in the hippocampus but significantly decreased in the frontal lobe. Compared with the healthy control group, the delirium group showed reduced mean diffusivity (MD) values, mainly in the right cerebellum and right middle temporal gyrus; reduced radial diffusivity (RD) values, mainly in the anterior cerebellum and right middle temporal gyrus; reduced fractional anisotropy (FA) values, only in the corpus callosum; and reduced axial diffusivity (AD) values, mainly in the anterior cerebellar lobe, right middle temporal gyrus, and left middle frontal gyrus on DTI. The statistical thresholds for quantitative DTI measurements were p < 0.005 at the voxel level and a cluster size > 5.ConclusionAbnormal resting-state brain activity in the left superior frontal gyrus and structural changes in the frontal lobe, temporal lobe, corpus callosum, hippocampus, and cerebellum were observed in ICU patients who developed delirium during hospitalization. Early-brain fMRI and DTI examinations are recommended for the prediction of delirium according to unique quantitative indicators to facilitate early intervention for critically ill patients, reduce the length of hospital stay, and improve patient prognosis.

Comparison of the effectiveness of delirium evaluation tools in intensive care patients: pre-deliric versions 1 and 2, E-pre-deliric and ICDSC.

This study's objective was to compare the effectiveness of the delirium prediction model (pre-deliric) and the early prediction model (E-pre-deliric) in delirium prediction in an intensive care unit (ICU) according to the Intensive Care Delirium Screening Checklist (ICDSC). Our aim was to determine these models' usability and cut-off values for ICU patients. We classified the studied patients based on their highest ICDSC scores (tested twice daily) during ICU hospitalization. ICDSC scores of 4 or higher indicated positive results for delirium, whereas a score of 0 represented a negative result. We recorded the patients' demographic and clinical details and characteristics and calculated their E-pre-deliric and pre-deliric version 1 and version 2 scores. To evaluate the effectiveness of the models, we used receiver operating characteristic (ROC) curve analysis. Two hundred fifty patients (55.6% males, mean age 60.6±18.7 years) participated in this study. Their mean Acute Physiology and Chronic Health Evaluation II (APACHE-II) score was 17.0±9.1. Delirium was more common in men, patients of older ages, those with high APACHE-II scores, those who had undergone urgent admissions, those with histories of trauma, those with high urea or creatinine values and those who had undergone sedation or mechanical ventilation. Compared to patients who did not develop delirium, those who did had longer ICU stays and hospital stays, as well as greater mortality risk. The cutoff values for the patients' pre-deliric version 1, pre-deliric version 2 and E-pre-deliric scores were 38% [area under ROC (AUROC)=1], 22% (AUROC=1) and 28% (AUROC=1), respectively. This study is the first to compare the pre-deliric and E-pre-deliric prediction models. These models' validity and reliability were acceptable. They were clinically useful, and we identified their cut-off values. These models provide options for early detection of delirium and are easily applicable in the ICU.

Effects of Opioids, Steroids, Benzodiazepines, Anticholinergics, and Antihistamines on the Efficacy of Antipsychotics for Treating Delirium in End-of-Life Adult Patients Undergoing Palliative Care

The purpose of the study was to determine the effect of combination therapy involving opioids, steroids, benzodiazepines, anticholinergics, and antihistamines on antipsychotics efficacy for delirium. The study included adult inpatients receiving end-of-life palliative care and diagnosed with hyperactive delirium. Changes in delirium symptoms were assessed using the Intensive Care Delirium Screening Checklist (ICDSC). A retrospective analysis was conducted on 97 patients with ICDSC scores of ≥4, comparing the scores before and after antipsychotic administration. A mean score <4 sustained for 3 days after antipsychotics administration was considered effective. The mean days with ICDSC <4 within a 3-day period were evaluated as well. The efficacy of antipsychotics was compared between cases with and without the use of opioids, steroids, benzodiazepines, anticholinergics, and antihistamines. The results revealed no significant differences in the efficacy of antipsychotics for delirium when used in conjunction with opioids (odds ratio 0.614, 95% CI [0.179-2.105]), benzodiazepines (0.387, [0.108-1.390]), steroids (1.258, [0.276-5.746]), or anticholinergics (2.085, [0. 148-29.458]). Additionally, no significant differences were observed in the mean days with ICDSC <4 within 3-day period. Although opioids, benzodiazepines, steroids, anticholinergics, and antihistamines are recognized as delirium risk factors, their use for symptom relief in patients with delirium may not affect antipsychotic efficacy.

Orexin receptor antagonists versus antipsychotics for the management of delirium in intensive care unit patients with cardiovascular disease: A retrospective observational study

ObjectiveAlthough antipsychotics are often used in the pharmacological treatment of delirium, recent reports suggest the efficacy of orexin receptor antagonists. This study investigated whether orexin receptor antagonists could be a possible treatment option for delirium. MethodA nonblinded nonrandomized routine clinical treatment was performed. Patients treated in intensive care units (ICU) for cardiovascular disease and receiving psychiatric intervention were studied retrospectively. The scores from the Intensive Care Delirium Screening Checklist (ICDSC) were compared between patients treated with orexin receptor antagonists and those treated with antipsychotics. ResultsThe mean (standard deviation) ICDSC scores were 4.5 (1.8) at day −1 and 2.6 (2.6) at day 7 for orexin receptor antagonist group (n = 25) and 4.6 (2.4) at day −1 and 4.1 (2.2) at day 7 for antipsychotic group (n = 28). The orexin receptor antagonist group showed significantly lower ICDSC scores than the antipsychotic group (p = 0.021). ConclusionWhile precise efficacy cannot be determined from our retrospective, observational, and uncontrolled pilot study, this analysis encourages a future double-blind randomized placebo-controlled trial of orexin-antagonists for delirium treatment.

Acoustocerebrography in septic patients: A randomized and controlled pilot study.

Sepsis-associated encephalopathy (SAE) is a common organ dysfunction in patients with severe sepsis or septic shock and leads to higher mortality and longer hospital stay. The diagnosis remains an exclusion process; none of the available measurements are specific for SAE. The aim of the presented prospective and controlled clinical study was to evaluate the possible role of molecular acoustics in determining acute brain injury in septic patients using an acoustocerebrography (ACG) system. ACG is a multifrequency, transcranial ultrasound method that measures the attenuation and time of flight to detect changes in the brain tissue. After approval from the local research ethics committee (of the University Hospital of Rostock: Reg. No.: A 2016-0026), 20 patients were included in two study groups: septic shock group (SG) and control group (CG; postoperative nonseptic patients). All patients were screened several times with the ACG on different days. Blood parameters of organ function, sepsis-related organ failure assessment score, and delirium scores [Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and Intensive Care Delirium Screening Checklist (ICDSC)] were obtained as well. A neurologist examined all patients at inclusion. Predictive analysis was done using a data-driven statistical method and by deriving a parameter from the ACG data. The study was registered under “clinicaltrials.gov” (Reg. No.: NCT03173196). All patients in the SG were CAM-ICU-positive at inclusion (ICDSC: in mean 4.0) and had clinical signs of SAE. In contrast, all patients in the CG were CAM-ICU-negative, with an ICDSC score of 0. Predictive analysis using the ACG data presented an accuracy of 83.4% with a specificity of 89.0% and a sensitivity of 75.1%. The ACG method may be helpful for the monitoring and diagnosing acute brain injury; however, the results of this first report should be verified by further clinical studies. Further investigations should include long-established instruments of SAE diagnosis, e.g., electroencephalography, MRI, and biomarkers, to compare the results with the ACG measurements.

Risk factors for postoperative delirium on oxygen delivery-guided perfusion

BackgroundStudies have demonstrated the efficacy of oxygen delivery-guided perfusion (ODGP) in preventing postoperative acute kidney injury, but the benefit of ODGP for delirium has not been confirmed. We retrospectively investigated the risk factors for postoperative delirium in patients who underwent ODGP (with oxygen delivery index [DO2i] > 300 mL/min/m2).MethodsConsecutive patients who underwent on-pump cardiovascular surgery with ODGP from January 2018 to December 2020 were retrospectively analyzed. In addition to examining patients’ DO2i during cardiopulmonary bypass (CPB), we quantified the two primary DO2 components-hematocrit (Hct) and pump flow. Delirium was defined based on the Intensive Care Delirium Screening Checklist (ICDSC). Patients were divided into three groups: no delirium (ICDSC score = 0), subsyndromal delirium (ICDSC score = 1–3), and clinical delirium (ICDSC score ≥ 4).ResultsMultivariate analysis identified only the number of red blood cell (RBC) units transfused, intubation time, and the cumulative time below the Hct threshold of 25% as predictive factors of postoperative delirium. Although patients with higher ICDSC scores had greater hemodilution during CPB, ODGP resulted in a higher pump flow, and DO2i was maintained above 300 mL/min/m2, with no significant difference between the three groups.ConclusionsA low Hct level during CPB with ODGP, the number of RBC units transfused, and intubation time were associated with postoperative delirium. Further investigations are needed to determine the ability of ODGP to prevent low Hct during CPB.

A retrospective comparison of haloperidol and hydroxyzine combination therapy with haloperidol alone in the treatment of overactive delirium

For the treatment of delirium, antipsychotics such as haloperidol are used as standard treatments. However, haloperidol has a little sedative effect and may not be sufficiently effective in controlling overactive delirium. Hydroxyzine, an antihistamine, may be used in combination with haloperidol to supplement its sedative effect. The aim of this study was to investigate the effect of haloperidol alone or in combination with hydroxyzine on the improvement of overactive delirium retrospectively. Delirium was assessed from medical records using the Intensive Care Delirium Screening Checklist (ICDSC). The number of patients and days with an ICDSC score of < 4, indicating an absence of delirium after haloperidol alone or haloperidol and hydroxyzine was surveyed for 6days. A total of 157 patients were diagnosed with delirium from April 2019 to July 2021, of which 18 patients received haloperidol alone, and 21 patients received the combination of haloperidol and hydroxyzine for overactive delirium. The number of patients with a mean ICDSC score of < 4 on days 1-6 was two patients (11%) in the haloperidol groups and two patients (10%) in the combination of haloperidol and hydroxyzine group (P = 0.999). The days within < 4 of the ICDSC score on days 1-6 were 0.8 (1.3) and 0.8 (1.5), respectively (P = 0.848). Haloperidol alone and haloperidol plus hydroxyzine are both effective in the treatment of overactive delirium. However, the concomitant use of hydroxyzine with haloperidol may not improve the efficacy of treatment of overactive delirium compared to haloperidol alone.

Availability of preoperative neutrophil-lymphocyte ratio to predict postoperative delirium after head and neck free-flap reconstruction: A retrospective study.

Postoperative delirium (POD) is a well-recognized postoperative complication and is associated with increased morbidity and mortality. We investigated whether the preoperative neutrophil-lymphocyte ratio (NLR) could be an effective predictor of POD after head and neck free-flap reconstruction. This was a single-center, retrospective, observational study. We analyzed the perioperative data of patients who had undergone elective head and neck free-flap reconstruction surgery. POD was assessed with the Intensive Care Delirium Screening Checklist (ICDSC) during admission to our intensive care unit (ICU). POD was defined as an ICDSC score ≥4. Risk factors for POD were evaluated by univariate and multivariate logistic regression analysis. We included 97 patients. The incidence of POD was 20.6% (20/97). Significantly longer ICU stays were observed in the patients with POD compared to those without POD (median [interquartile range]: 5 [4–6] vs. 4 [4–5], p = 0.031). Higher preoperative NLR values (3 <NLR ≤4 and 4 <NLR) were significantly associated with higher ICDSC scores compared to NLR ≤1 (4 [2–4] vs. 1 [1–1], p = 0.027 and 4 [1–4] vs. 1 [1–1], p = 0.038, respectively). The multivariable logistic regression analysis revealed that only a preoperative NLR >3.0 (adjusted Odds Ratio: 23.6, 95% Confidence Interval: 6.6–85.1; p<0.001) was independently associated with POD. The multivariate area under the receiver operator curve was significantly greater for the E-PRE-DELIRIC model with NLR compared to the E-PRE-DELIRIC model (0.87 vs. 0.60; p<0.001). The preoperative NLR may be a good predictor of POD in patients undergoing head and neck free-flap reconstruction.

Adaptation and Validation of a Chart-Based Delirium Detection Tool for the ICU (CHART-DEL-ICU).

OBJECTIVETo adapt and validate a chart‐based delirium detection tool for use in critically ill adults.DESIGNValidation study.SETTINGMedical‐surgical intensive care unit (ICU) in an academic hospital.MEASUREMENTSA chart‐based delirium detection tool (CHART‐DEL) was adapted for use in critically ill adults (CHART‐DEL‐ICU) and compared with prospective delirium assessments (i.e., clinical assessments (reference standard) by a research nurse trained by a neuropsychiatrist and routine delirium screening tools Confusion Assessment Method (CAM‐ICU)) and (Intensive Care Delirium Screening Checklist (ICDSC)). The original CHART‐DEL tool was adapted to include physician‐reported ICDSC score (for probable delirium) and Richmond‐Agitation Sedation Scale score (for altered level of consciousness and agitation). Two trained chart abstractors blinded to all delirium assessments manually abstracted delirium‐related information from medical charts and electronic medical records and rated if delirium was present (four levels: uncertain, possible, probable, definite) or absent (no evidence).RESULTSCharts were manually abstracted for delirium‐related information for 213 patients who were included in a prospective cohort study that included prospective delirium assessments. The CHART‐DEL‐ICU tool had excellent interrater reliability (kappa = 0.90). Compared to the reference standard, the sensitivity was 66.0% (95% CI = 59.3–72.3%) and specificity was 82.1% (95% CI = 78.0–85.7%), with a cut‐point that included definite, probable, possible, and uncertain delirium. The AUC of the CHART‐DEL‐ICU alone is 74.1% (95% CI = 70.4–77.8%) compared with the addition of the CAM‐ICU and ICDSC (CAM‐ICU/CHART‐DEL‐ICU: 80.9% (95% CI = 77.8–83.9%), P = .01; ICDSC/CHART‐DEL‐ICU: 79.2% (95% CI = 75.9–82.6%), P = .03).CONCLUSIONA chart‐based delirium detection tool has improved diagnostic accuracy when combined with routine delirium screening tools (CAM‐ICU and ICDSC), compared to a chart‐based method on its own. This presents a potential for retrospective detection of delirium from medical charts for research or to augment routine delirium screening methods to find missed cases of delirium.

The CAM-ICU-7 and ICDSC as measures of delirium severity in critically ill adult patients.

BackgroundIn clinical practice, a dichotomous approach to delirium identification may no longer be relevant when existing delirium screening tools measure a range of scores. The objective of this study was to compare the Confusion Assessment Method for the Intensive Care Unit 7-item (CAM-ICU-7) and the Intensive Care Delirium Screening Checklist (ICDSC) as measures of the spectrum of delirium severity in critically ill adult patients.MethodsIn this cross-sectional study, 218 patients underwent 641 paired assessments by bedside nurses (ICDSC, as per usual care) and trained research assistants (CAM-ICU-7). Correlation between the CAM-ICU-7 and ICDSC scores was evaluated. Logistic regression was used to explore associations between CAM-ICU-7 or ICDSC score and length of ICU stay and mechanical ventilation (receipt, ≥96 hours).ResultsDelirium prevalence evaluated by the CAM-ICU-7 and ICDSC were 46.3% (95% CI:39.7–53.0) and 34.4% (95% CI:28.3–41.0). Prevalence of less than clinical threshold symptoms of delirium evaluated by the CAM-ICU-7 (score: 1–2) and ICDSC (score: 1–3) were 30.3% (95%CI:24.5–36.7) and 50.9% (95%CI:44.3–57.6). The CAM-ICU-7 and ICDSC had significant positive correlation (0.58, p<0.001). Agreement between the tools as measures of delirium was moderate (kappa = 0.51) and as measures of less than clinical threshold symptoms of delirium was fair (kappa = 0.21). Less than clinical threshold symptoms of delirium identified by the ICDSC, not CAM-ICU-7, were associated with prolonged length of ICU stay (≥7 days) in patients <65 years of age [Odds Ratio (OR) 9.2, 95% CI:2.5–34.0] and mechanical ventilation (receipt: OR 2.8, 95% CI:1.3–6.4; ≥96 hours: OR 6.6, 95% CI:1.9–22.9), when compared to patients with no delirium.ConclusionsThe CAM-ICU-7 and ICDSC are measures of the spectrum of delirium severity that are closely correlated. Less than clinical threshold symptoms of delirium measure by the ICDSC is a better predictor of outcomes, when compared with the CAM-ICU-7.

Hospital‐wide evaluation of delirium incidence in adults under 65 years of age

Hospital‐wide evaluation of delirium incidence in adults under 65 years of age

Psychometric properties of the intensive care delirium screening checklist when used by bedside nurses in clinical practice: a prospective descriptive study

BackgroundThe Intensive Care Delirium Screening Checklist (ICDSC) demonstrates good psychometric characteristics in research settings. However, evidence about these characteristics in pragmatic ICU settings is inconsistent. This study evaluated psychometric properties and user-friendliness of the ICDSC when administered by ICU nurses in daily practice.MethodsThis prospective study included 77 patients from a surgical intensive care unit. To examine the psychometric characteristics, the scores on the ICDSC (performed by bedside nurses) were compared with the scores on the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) (performed by researchers as gold standard). The user-friendliness was evaluated by 34 ICU nurses with a 20-item questionnaire.ResultsThe ICDSC had an area under the curve of 0.843. It showed a good diagnostic accuracy with a sensitivity of 81.0%, a specificity of 87.7%, and a 53.1% positive and 96.4% negative predictive value. The overall Cronbach’s alpha coefficient for all ICDSC scores was high (0.839). Overall, ICU nurses experienced the ICDSC as easy-to-use. The scale was usable in most surgical ICU patients. Yet, some nurses (11.8%) had problems to score the items ‘inappropriate speech’ and ‘symptom fluctuation’ in intubated patients.ConclusionsThe ICDSC is a valid and user-friendly tool for delirium screening in daily ICU nursing practice. Yet, some problems were reported in intubated patients. Therefore, validation studies with specific focus on intubated patients are needed.

Diffusion tensor imaging and resting-state functional magnetic resonance imaging in patients with delirium in intensive care unit

To analyze the brain function of patients with delirium in intensive care unit (ICU) using resting-state functional magnetic resonance imaging (fMRI), further analyze the structural changes in the brain using diffusion tensor imaging (DTI), and explore the correlations of brain function with structural changes in patients with delirium in ICU from a new perspective of functional imaging, provide visual evidence for the diagnosis of delirium. Patients with delirium admitted to ICU of the Affiliated Hospital of Zunyi Medical University from January 1st to December 31st in 2017 were enrolled as subjects. During the same period, the healthy volunteers who matched the gender, age and education level of the patients with delirium were enrolled as control group. The intensive care delirium screening checklist (ICDSC) scores within 24 hours after ICU admission were recorded. All the subjects were scanned by fMRI and DTI. The abnormal changes in resting-state brain function of the patients with delirium were evaluated by cerebral regional homogeneity (ReHo) data analysis. The DTI data were processed by the FSL software, and the fractional anisotropy (FA) and mean diffusivity (MD) of the brain were extracted, respectively, to evaluate the damage to brain structure. The values of ReHo, FA and MD were compared between the two groups. The ReHo value of brain region with reduced ReHo value of patients with delirium as compared with the healthy volunteers was extracted for Pearson correlation analysis with ICDSC scores. A total of 22 patients with delirium were included. Seven patients who did not cooperate in the examination, used sedatives or had false images in scanning, were excluded. Finally, 15 patients were enrolled in the delirium group, and 15 healthy volunteers in the healthy control group. (1) No statistically significant difference was found in gender, age or education time between the two groups. ICDSC score of the delirium group was significantly higher than that of the healthy control group (6.07±1.28 vs. 1.07±0.88, P < 0.01). (2) fMRI scanning and analysis results: compared with the healthy control group, the ReHo values of the cerebellum, right hippocampus, striatum, midbrain and pons in the delirium group were significantly increased (all P < 0.05, AlphaSim correction), while the ReHo values of bilateral superior frontal gyrus, bilateral median frontal gyrus, left inferior frontal gyrus, temporal lobe and parietal lobe were significantly lowered (all P < 0.05, AlphaSim correction). Correlation analysis showed that the ReHo value of the left superior frontal gyrus was negatively correlated with ICDSC score in the patients with delirium (r = -0.794, P < 0.05), indicating that the changes in the functional area of the medial frontal gyrus was most closely related to delirium. (3) DTI scanning and analysis results: compared with the healthy control group, the FA values of the left cerebellum, bilateral frontal lobes, left temporal lobe, corpus callosum and left hippocampus in the delirium group were decreased significantly (all P < 0.05, AlphaSim correction), while the MD values of the medial frontal gyrus, right superior temporal gyrus, anterior cingulate gyrus, bilateral insular lobes and left caudate nucleus were enhanced significantly (all P < 0.05, AlphaSim correction), suggesting that the structural and functional damage was found in multiple brain regions in patients with delirium. Multiple brain regions of patients with delirium present abnormal resting-state brain function. The abnormal resting-state brain function of the left superior frontal gyrus is closely related to the occurrence of delirium. Structural damage is found in multiple brain regions of patients with delirium. The structural changes in the frontal lobe, temporal lobe, corpus callosum, hippocampus and cerebellum and their abnormal functions can be used as preliminary imaging indexes for the diagnosis of delirium.

Risk Factors of Delirium in ICU Patients with Acute Poisoning

Purpose: This study estimated the incidence of delirium and associated risk factors and outcomes in ICU patients with acute poisoning. Methods: Data were collected from ICU patients over 18 years of age that were admitted via the emergency center after presenting with poisoning from 2010 to 2015. Delirium was assessed retrospectively using the Intensive Care Delirium Screening Checklist (ICDSC). Risk factors were evaluated by univariate and multivariate analysis. Results: A total of 199 patients participated in this study and 68 (34.2%) were diagnosed with delirium based on the ICDSC score. The delirium group showed a significantly higher association with prolonged length of stay in the hospital and ICU in comparison with the non-delirium group. The delirium group was associated with greater use of physical restraint. A statistically greater number of patients with pharmaceutical substance poisoning developed delirium over a short period of time than those with non-pharmaceutical substance poisoning. There was no significant difference between the two groups with respect to age, sex, past history, GCS score, vital signs, application of ventilator care and renal replacement therapy. Conclusion: The finding that the delirium group had a greater length of stay in both the hospital and the ICU is consistent with the results of previous worldwide studies of the effects of delirium on the prognosis of patients who were admitted to the ICU, suggesting the possibility for domestic application. Additionally, use of physical restraint was positively related to the incidence of delirium. Thus, interventions for minimizing the use of physical restraints and considering alternatives are needed.

A hospital-wide evaluation of delirium prevalence and outcomes in acute care patients - a cohort study

BackgroundDelirium is a well-known complication in cardiac surgery and intensive care unit (ICU) patients. However, in many other settings its prevalence and clinical consequences are understudied. The aims of this study were: (1) To assess delirium prevalence in a large, diverse cohort of acute care patients classified as either at risk or not at risk for delirium; (2) To compare these two groups according to defined indicators; and (3) To compare delirious with non-delirious patients regarding hospital mortality, ICU and hospital length of stay, nursing hours and cost per case.MethodsThis cohort study was performed in a Swiss university hospital following implementation of a delirium management guideline. After excluding patients aged < 18 years or with a length of stay (LOS) < 1 day, 29′278 patients hospitalized in the study hospital in 2014 were included.Delirium period prevalence was calculated based on a Delirium Observation Scale (DOS) score ≥ 3 and / or Intensive Care Delirium Screening Checklist (ICDSC) scores ≥4.ResultsOf 10′906 patients admitted, DOS / ICDSC scores indicated delirium in 28.4%. Delirium was most prevalent (36.2–40.5%) in cardiac surgery, neurosurgery, trauma, radiotherapy and neurology patients. It was also common in geriatrics, internal medicine, visceral surgery, reconstructive plastic surgery and cranio-maxillo-facial surgery patients (prevalence 21.6–28.6%). In the unadjusted and adjusted models, delirious patients had a significantly higher risk of inpatient mortality, stayed significantly longer in the ICU and hospital, needed significantly more nursing hours and generated significantly higher costs per case. For the seven most common ICD-10 diagnoses, each diagnostic group’s delirious patients had worse outcomes compared to those with no delirium.ConclusionsThe results indicate a high number of patients at risk for delirium, with high delirium prevalence across all patient groups. Delirious patients showed significantly worse clinical outcomes and generated higher costs. Subgroup analyses highlighted striking variations in delirium period-prevalence across patient groups. Due to the high prevalence of delirium in patients treated in care centers for radiotherapy, visceral surgery, reconstructive plastic surgery, cranio-maxillofacial surgery and oral surgery, it is recommended to expand the current focus of delirium management to these patient groups.

Abstract WP355: Evaluation of a Checklist to Identify Early Signs of Hyperperfusion Syndrome After Carotid Endarterectomy

Background and purpose: Hyperperfusion syndrome (HPS) occurs in only 1-3% of patients after carotid endarterectomy (CEA). However, it can cause severe cerebral hemorrhage and may be lethal. Therefore, nurses need to be able to recognize the early signs of HPS and report them to the physician. In this study, we aimed to investigate the applicability of using the Intensive Care Delirium Screening Checklist (ICDSC) to discover early signs of postoperative HPS after CEA, allowing nurses to report the signs and possibly prevent disease progression. Method: The study included 96 Japanese patients average age 71.9 ± 8.3 years old undergoing CEA from May 2008 to May 2017. There were 9 patients in the HPS group and 87 in the non-HPS group. Research design was a methodological study. To analyze differences between normally distributed continuous variables, the average value ± standard deviation was calculated and a t test used to compare between groups. For non-normally distributed continuous variables, the median and the range were calculated, and the Wilcoxon rank sum test was used to compare between groups. Ethical approval was granted by the Ethics Review Committee of the research execution facility. Result: There was no significant difference in the patient characteristics in both groups. There was also no significant difference in the number of patients exhibiting signs of delirium (&gt;4 points in total on the ICDSC) between the HPS group (n=8) and the non-HPS group (n=10). However, patients in the HPS group were unable to engage in conversation, while those in the non-HPS group responded to the nurses’ questions and several patients were able to engage in lucid conversation. The HPS group thus scored significantly higher than the non-HPS group on the "inappropriate speech or mood" ICDSC item (100% in the HPS group vs. 20% in the non-HPS group, P &lt;0.001). In addition, on the "symptom fluctuation" item, the non-HPS group scored significantly higher than the HPS group (0% in the HPS group vs. 100% in the non-HPS group, P &lt;0.001). Conclusion: A total ICDSC score &gt;4 and the presence of "inappropriate speech or mood" or "symptom fluctuation" strongly suggest the presence of HPS. In conclusion suggest that ICDSC is effective in identifying the early clinical signs of HPS after CEA.

A novel scoring system to predict delirium and its relationship with the clinical course in patients with acute decompensated heart failure

BackgroundDelirium is known to be a poor prognostic factor in patients with acute decompensated heart failure (ADHF). The purpose of this study was to determine predictors of delirium on admission of ADHF patients, and to establish a scoring formula to identify patients at high risk for delirium. Methods and resultsWe recorded the Intensive Care Delirium Screening Checklist (ICDSC) score in 120 ADHF patients during their stay in the coronary care unit (CCU). Patients with a highest ICDSC score of 4 or more were diagnosed with delirium. We examined independent candidate predictors of delirium using multivariate logistic regression analysis and developed the following scoring formula, the delirium prediction score (DPS), using independent predictors of delirium and their regression coefficients: DPS=inferior vena cava diameter+C-reactive protein (and additionally +10 for patients with a history of cerebral infarction). Receiver operating curve analysis indicated that evaluation using this scoring system at the time of admission was able to predict delirium with high accuracy (C-statistic: 0.885). In addition, the calculated scores had significantly positive correlations with duration of CCU stay and overall length of hospital stay. ConclusionsWe established a novel scoring system to predict on admission the likelihood of development of delirium in ADHF patients; this system also predicts prolongation of intensive care and hospital stay.

Effect of ABCDE Bundle Implementation on Prevalence of Delirium in Intensive Care Unit Patients.

The ABCDE bundle incorporates multidisciplinary measures to improve and/or preserve patients' physical, functional, and neurocognitive status through awakening and breathing coordination, delirium prevention and management, and early physical mobility. To quantify the prevalence and duration of delirium in patients in the intensive care unit (ICU) before and after implementation of the ABCDE bundle. Delirium prevalence was defined as the percentage of patients who had at least 1 positive delirium score on the Intensive Care Delirium Screening Checklist (ICDSC) during the ICU stay; delirium duration was the number of days during the ICU stay that a positive ICDSC score was noted. Retrospective data were collected from before and after implementation of the ABCDE bundle. Of the 159 records reviewed (80 before and 79 after bundle implementation), most were for white men (mean age, 66.3 years). After implementation of the ABCDE bundle, the prevalence of delirium decreased significantly (from 38% to 23%, P = .01) and the mean number of days of delirium decreased significantly (from 3.8 to 1.72 days, P < .001). The number of patients with delirium-free stays increased after bundle implementation. Implementation of the ABCDE bundle led to significant decreases in the prevalence and duration of delirium in ICU patients.

Efficacy of Ramelteon for delirium after lung cancer surgery.

The aim of the study was to evaluate the feasibility of Ramelteon for the prevention of delirium after lung cancer surgery in elderly patients. Medical records of patients over 70 years old, who underwent anatomical pulmonary resection for lung cancer at our institution from January 2013 to December 2015, were reviewed. Patients treated in 2013 and 2014 were used as a control group. Ramelteon was administered daily for 7 days after surgery. The incidence of delirium was determined based on the Intensive Care Delirium Screening Checklist (ICDSC). Scores of ≥4 and 1-3 points were used for the diagnoses of delirium and a pre-delirious state, respectively. There were 24 patients in the Ramelteon group and 58 patients in the control group. ICDSC scores of ≥4 points were found for no patients in the Ramelteon group and 5 (9%) in the control group, whereas 21 (88%) and 49 (85%) patients, in the respective groups, had ICDSC scores of 0 points. The average incidence of events, associated with delirium, showed a trend of being lower in the Ramelteon group (0.25 ± 0.74 vs 1.58 ± 4.93, P = 0.061), and all events in the Ramelteon group occurred on the day of surgery. Thus, only one day was required for complete recovery from delirium in the Ramelteon group, whereas 8 days were needed in the control group. The peak delirious state occurred after 5 days in the control group. Ramelteon is likely to reduce the incidence and intensity of delirium after surgery for lung cancer in elderly patients.

An Evaluation of Adverse Drug Reactions Associated With Antipsychotic Use for the Treatment of Delirium in the Intensive Care Unit

Purpose: This investigation evaluated the incidence, severity, and harm of adverse drug reactions (ADRs) associated with antipsychotic use for intensive care unit (ICU) delirium. Methods: In this prospective, observational study patients were screened for development of delirium with the Intensive Care Delirium Screening Checklist (ICDSC). An ICDSC score of ≥4 was considered delirious. Patients with delirium were screened daily for ADRs. Suspected ADRs were evaluated for drug causality using 3 published, objective assessment tools. Suspected ADRs were considered positive when 2 of 3 instruments had an agreement rating of “possible” or greater. ADR severity was defined as “mild/moderate” or “severe” using the National Cancer Institute’s Common Terminology Criteria for Adverse Events scale. A modified National Coordinating Council Medication Error Reporting Index for Categorizing Errors categorized ADRs into “no harm” or “harmful.” Results: Of 90 patients with delirium, 56 received antipsychotics. Ten suspected ADRs occurred attributed to antipsychotic use. QTc prolongation was the most observed ADR (50%). Patients with ADRs had higher mean Acute Physiology and Chronic Health Evaluation II (APACHE II) scores (P = .038). Patients who received haloperidol experienced more severe (P = .048) ADRs. Conclusions: ADRs were observed in 18% of patients having delirium treated with antipsychotics with about half considered severe or harmful. A risk versus benefit assessment is needed before initiating antipsychotic therapy in ICU patients.