Non-delirious Patients Research Articles

Utilization of NIRS Monitor to Compare the Regional Cerebral Oxygen Saturation Between Dexmedetomidine and Propofol Sedation in Mechanically Ventilated Critically ill Patients with Sepsis- A Prospective Randomized Control Trial.

Delirium frequently occurs in the acute phase of sepsis and is associated with increased ICU and hospital length of stay, duration of mechanical ventilation, and higher mortality rates. We utilized the Near-Infrared Spectroscopy monitor to measure and compare the regional cerebral oxygen saturation in mechanically ventilated patients of sepsis receiving either dexmedetomidine or propofol sedation and assessed the association between delirium and regional cerebral oxygen saturation. A single center prospective randomized control trial conducted over a period of two years, 54 patients were included, equally divided between propofol and dexmedetomidine groups. Patients received a blinded study drug, propofol (10 mg/mL) or dexmedetomidine (5 mcg/mL) via infusion pump according to randomization. Infusion rates were adjusted every 10 min based on weight-based titration tables, aiming for target sedation (RASS -2 to 0). Management components included pain monitoring using the CPOT score and delirium assessment using CAM-ICU score. Dexmedetomidine group showed higher mean regional cerebral oxygen saturation as compared to propofol group (P = .036). No significant differences were found in mechanical ventilation or ICU stay durations, delirium-free days, or sedation cessation reasons. Delirium occurred in 36 patients, with lower mean regional cerebral oxygen saturation as compared to non-delirious patients. The dexmedetomidine group had higher regional cerebral oxygen saturation compared to the propofol group. Delirious patients showed lower cerebral oxygen saturation than non-delirious patients, suggesting a link between sedation type, cerebral oxygenation, and delirium.CTRI registration: REF/2021/11/048655 N.

Diffuse optical tomography for mapping cerebral hemodynamics and functional connectivity in delirium.

Delirium is associated with mortality and new onset dementia, yet the underlying pathophysiology remains poorly understood. Development of imaging biomarkers has been difficult given the challenging nature of imaging delirious patients. Diffuse optical tomography (DOT) offers a promising approach for investigating delirium given its portability and three-dimensional capabilities. Twenty-five delirious and matched non-delirious patients (n=50) were examined using DOT, comparing cerebral oxygenation and functional connectivity in the prefrontal cortex during and after an episode of delirium. Total hemoglobin values were significantly decreased in the delirium group, even after delirium resolution. Functional connectivity between the dorsolateral prefrontal cortex and dorsomedial prefrontal cortex was strengthened post-resolution compared to during an episode; however, this relationship was still significantly weaker compared to controls. These findings highlight DOT's potential as an imaging biomarker to measure impaired cerebral oxygenation and functional dysconnectivity during and after delirium. Future studies should focus on the role of cerebral oxygenation in delirium pathogenesis and exploring the etiological link between delirium and dementias. We developed a portable diffuse optical tomography (DOT) system for bedside three-dimensional functional neuroimaging to study delirium in the hospital. We implemented a novel DOT task-focused seed-based correlation analysis. DOT revealed decreased cerebral oxygenation and functional connectivity strength in the delirium group, even after resolution of delirium.

The impact of delirium on clinical and functional outcomes in hospitalized patients with acute coronary syndrome.

Delirium, which is prevalent in critical care settings, remains underexplored in acute coronary syndrome (ACS) patients in the cardiac intensive care unit (CICU). To investigate the prevalence and clinical significance of delirium in patients with ACS admitted to the CICU. A prospective study (n = 106, mean age 74.2 ± 5.7 years) assessed delirium using the confusion assessment method-intensive care unit (CAM-ICU) tool in 21.7% of ACS patients during their CICU stay. Baseline characteristics, geriatric conditions and clinical procedures were compared between delirious and nondelirious patients. The outcomes included in-hospital mortality, 30-day and 6-month mortality, acute adverse events and length of CICU stay and hospital stay (LOS). Delirious patients who were older and had a higher incidence of coronary artery disease underwent more complex procedures (e.g., pacemaker placement). Multivariate analysis identified central venous catheter insertion, urinary catheterization and benzodiazepine use as independent predictors of delirium. Delirium was correlated with prolonged LOS (p < .001) and increased in-hospital, 30-day and 6-month mortality (p < .001). Delirium in ACS patients in the CICU extends hospitalization and increases in-hospital, 30-day and 6-month mortality. Early recognition and targeted interventions are crucial for mitigating adverse outcomes in this high-risk population. This study highlights the critical impact of delirium on outcomes in hospitalized patients with ACS in the CICU. Delirium, often overlooked in ACS management, significantly extends hospitalization and increases mortality rates. Nurses and physicians must be vigilant in identifying delirium early, particularly in older ACS patients or those with comorbidities. Recognizing independent predictors such as catheterization and benzodiazepine use allows for targeted interventions to reduce delirium incidence. Integrating routine delirium assessments and preventive strategies into ACS management protocols can improve outcomes, optimize resource utilization and enhance overall patient care in the CICU setting.

Former smoking, but not active smoking, is associated with delirium in postoperative ICU patients: a matched case-control study.

To examine the relationship between current and former smoking and the occurrence of delirium in surgical Intensive Care Unit (ICU) patients. We conducted a single center, case-control study involving 244 delirious and 251 non-delirious patients that were admitted to our ICU between 2018 and 2022. Using propensity score analysis, we obtained 115 pairs of delirious and non-delirious patients matched for age and Simplified Acute Physiology Score II (SAPS II). Both groups of patients were further stratified into non-smokers, active smokers and former smokers, and logistic regression was performed to further investigate potential confounders. Our study revealed a significant association between former smoking and the incidence of delirium in ICU patients, both in unmatched (adjusted odds ratio (OR): 1.82, 95% confidence interval (CI): 1.17-2.83) and matched cohorts (OR: 3.0, CI: 1.53-5.89). Active smoking did not demonstrate a significant difference in delirium incidence compared to non-smokers (unmatched OR = 0.98, CI: 0.62-1.53, matched OR = 1.05, CI: 0.55-2.0). Logistic regression analysis of the matched group confirmed former smoking as an independent risk factor for delirium, irrespective of other variables like surgical history (p = 0.010). Notably, also respiratory and vascular surgeries were associated with increased odds of delirium (respiratory: OR: 4.13, CI: 1.73-9.83; vascular: OR: 2.18, CI: 1.03-4.59). Medication analysis showed that while Ketamine and Midazolam usage did not significantly correlate with delirium, Morphine use was linked to a decreased likelihood (OR: 0.27, 95% CI: 0.13-0.55). Nicotine's complex neuropharmacological impact on the brain is still not fully understood, especially its short-term and long-term implications for critically ill patients. Although our retrospective study cannot establish causality, our findings suggest that smoking may induce structural changes in the brain, potentially heightening the risk of postoperative delirium. Intriguingly, this effect seems to be obscured in active smokers, potentially due to the recognized neuroprotective properties of nicotine. Our results motivate future prospective studies, the results of which hold the potential to substantially impact risk assessment procedures for surgeries.

The spectrum of psychological disorders in family members of patients suffering from delirium associated with critical illness: a prospective, observational study

During intensive care unit admission, relatives of critically ill patients can experience emotional distress. The authors hypothesized that families of patients who are diagnosed with intensive care unit (ICU) delirium experience more profound depression and anxiety disorders related to stress than do families of patients without delirium. We performed a prospective observational single-center study including families of adult patients (age above 18 years) hospitalized in a 17-bed ICU of a university hospital for at least 48 h who completed research questionnaires at day 2 after admission and day 30 after initial evaluation using dedicated questionnaires (HADS, CECS, IES, PTSD-C). A total of 98 family members of patients hospitalized in the ICU were included in the final analysis (50 family members whose relatives were CAM-ICU positive (DEL+), and 48 family members of patients without delirium (DEL−)). No statistically significant differences in demographics and psychosocial data were found between the groups. In the follow-up 30 days after the first conversation with a family member, the mean PTSD score for the relatives of patients with delirium was 11.02 (Me = 13.0; SD = 5.74), and the mean score for nondelirious patients' family members was 6.42 (Me = 5.5; SD = 5.50; p < 0.001). A statistically significant increase in IES scores for family members of patients with delirium was observed for total PTSD (p = 0.001), IES—intrusion (p < 0.001), and IES—hyperarousal (p = 0.002). The prevalence of anxiety symptoms, depression, and posttraumatic stress disorder (PTSD) was higher in families of patients diagnosed with ICU delirium within 48 h of admission to the ICU. No factors increasing the depth of these disorders in family members of patients with ICU delirium were identified. Taking appropriate actions and thus providing families with appropriate support will contribute to the understanding of unfavorable emotional states, including anxiety, stress, depression, anger, agitation, or avoidance.

Effect of Atypical Sleep EEG Patterns on Weaning From Prolonged Mechanical Ventilation

Approximately one-third of acute ICU patients display atypical sleep patterns that cannot be interpreted by using standard EEG criteria for sleep. Atypical sleep patterns have been associated with poor weaning outcomes in acute ICUs. Do patients being weaned from prolonged mechanical ventilation experience atypical sleep EEG patterns, and are these patterns linked with weaning outcomes? EEG power spectral analysis during wakefulness and overnight polysomnogram were performed on alert, nondelirious patients at a long-term acute care facility. Forty-four patients had been ventilated for a median duration of 38days at the time of the polysomnogram study. Eleven patients (25%) exhibited atypical sleep EEG. During wakefulness, relative EEG power spectral analysis revealed higher relative delta power in patients with atypical sleep than in patients with usual sleep (53%vs41%; P< .001) and a higher slow-to-fast power ratio during wakefulness: 4.39 vs2.17 (P< .001). Patients with atypical sleep displayed more subsyndromal delirium (36%vs6%; P= .027) and less rapid eye movement sleep (4%vs11%total sleep time; P< .02). Weaning failure was more common in the atypical sleep group than in the usual sleep group: 91%vs45%(P= .013). This study provides the first evidence that patients in a long-term acute care facility being weaned from prolonged ventilation exhibit atypical sleep EEG patterns that are associated with weaning failure. Patients with atypical sleep EEG patterns had higher rates of subsyndromal delirium and slowing of the wakeful EEG, suggesting that these two findings represent a biological signal for brain dysfunction.

Antipsychotic initiation in mechanically ventilated patients in a medical intensive care unit

Objectives: Guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients (PADIS) in the intensive care unit (ICU) promote use of analgosedation to minimize pain, reduce anxiety, and facilitate care. They also suggest against routine use of antipsychotics (APs) for delirium. Our institution’s adaptation incorporates assessment-driven, protocol-based pain, and sedation management and suggests a short course of APs in patients with agitated delirium, defined as Confusion Assessment Method for the ICU (CAM-ICU) positive with Richmond Agitation Sedation Scale (RASS) ≥ +2. While the use of APs in the ICU is typically for delirium, a recent study assessed whether quetiapine reduced sedative requirements among non-delirious patients. The purpose of this study was to assess adherence to our institutional guideline for AP use and to describe sedative and opioid use in relation to AP initiation. Materials and Methods: This retrospective study included patients who were mechanically ventilated and received ≥ 3 new start AP doses. The primary outcome was adherence to our guideline for use of APs in agitated delirium. The secondary outcomes were CAM-ICU and RASS scores in relation to AP initiation and change in sedative and analgesic infusion rates following AP initiation. Results: Thirty-eight patients were included in the study. Five had APs initiated appropriately per our guideline. There was no clinically significant change in continuous infusion rates in the 24 h before and after AP initiation. Conclusion: Overall, AP use was liberal with patients being started on APs who did not have agitated delirium, thus indicating potential alternative indications for initiation. APs did not result in a clinically significant change in continuous infusion requirements in the 24 h following initiation.

Association of perioperative plasma concentration of neurofilament light with delirium after cardiac surgery: a nested observational study

BackgroundNeurofilament light is a blood-based biomarker of neuroaxonal injury that can provide insight into perioperative brain vulnerability and injury. Prior studies have suggested that increased baseline and postoperative concentrations of neurofilament light are associated with delirium after noncardiac surgery, but results are inconsistent. Results have not been reported in cardiac surgery patients, who are among those at highest risk for delirium. We hypothesised that perioperative blood concentrations of neurofilament light (both baseline and change from baseline to postoperative day 1) are associated with delirium after cardiac surgery. MethodsThis study was nested in a trial of arterial blood pressure targeting during cardiopulmonary bypass using cerebral autoregulation metrics. Blood concentrations of neurofilament light were measured at baseline and on postoperative day 1. The primary outcome was postoperative delirium. Regression models were used to examine the associations between neurofilament light concentration and delirium and delirium severity, adjusting for age, sex, race, logistic European System for Cardiac Operative Risk Evaluation, bypass duration, and cognition. ResultsDelirium occurred in 44.6% of 175 patients. Baseline neurofilament light concentration was higher in delirious than in non-delirious patients (median 20.7 pg ml−1 [IQR 16.1–33.2] vs median 15.5 pg ml−1 [IQR 12.1–24.2], P<0.001). In adjusted models, greater baseline neurofilament light concentration was associated with delirium (odds ratio, 1.027; 95% confidence interval, 1.003–1.053; P=0.029) and delirium severity. From baseline to postoperative day 1, neurofilament light concentration increased by 42%, but there was no association with delirium. ConclusionsBaseline neurofilament light concentration, but not change from baseline to postoperative day 1, was associated with delirium after cardiac surgery.

DeltaScan for the Assessment of Acute Encephalopathy and Delirium in ICU and non-ICU Patients, a Prospective Cross-Sectional Multicenter Validation Study

To measure the diagnostic accuracy of DeltaScan: a portable real-time brain state monitor for identifying delirium, a manifestation of acute encephalopathy (AE) detectable by polymorphic delta activity (PDA) in single-channel electroencephalograms (EEGs). Prospective cross-sectional study. Six Intensive Care Units (ICU's) and 17 non-ICU departments, including a psychiatric department across 10 Dutch hospitals. 494 patients, median age 75 (IQR:64-87), 53% male, 46% in ICUs, 29% delirious. DeltaScan recorded 4-minute EEGs, using an algorithm to select the first 96 seconds of artifact-free data for PDA detection. This algorithm was trained and calibrated on two independent datasets. Initial validation of the algorithm for AE involved comparing its output with an expert EEG panel's visual inspection. The primary objective was to assess DeltaScan's accuracy in identifying delirium against a delirium expert panel's consensus. DeltaScan had a 99% success rate, rejecting 6 of the 494 EEG's due to artifacts. Performance showed and an Area Under the Receiver Operating Characteristic Curve (AUC) of 0.86 (95% CI: 0.83-0.90) for AE (sensitivity: 0.75, 95%CI=0.68-0.81, specificity: 0.87 95%CI=0.83-0.91. The AUC was 0.71 for delirium (95%CI=0.66-0.75, sensitivity: 0.61 95%CI=0.52-0.69, specificity: 72, 95%CI=0.67-0.77). Our validation aim was an NPV for delirium above 0.80 which proved to be 0.82 (95%CI: 0.77-0.86). Among 84 non-delirious psychiatric patients, DeltaScan differentiated delirium from other disorders with a 94% (95%CI: 87-98%) specificity. DeltaScan can diagnose AE at bedside and shows a clear relationship with clinical delirium. Further research is required to explore its role in predicting delirium-related outcomes.

Early processed electroencephalography for the monitoring of deeply sedated mechanically ventilated critically ill patients.

Deep sedation may be indicated in the intensive care unit (ICU) for the management of acute organ failure, but leads to sedative-induced delirium. Whether processed electroencephalography (p-EEG) is useful in this setting is unclear. We conducted a single-centre observational study of non-neurological ICU patients sedated according to a standardized guideline of deep sedation (Richmond Agitation Sedation Scale [RASS] between -5 and -4) during the acute phase of respiratory and/or cardio-circulatory failure. The SedLine (Masimo Incorporated, Irvine, California) was used to monitor the Patient State Index (PSI) (ranging from 0 to 100, <25 = very deep sedation and >50 = light sedation to full awareness) during the first 72 h of care. Delirium was assessed with the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). The median duration of PSI monitoring was 43 h. Patients spent 49% in median of the total PSI monitoring duration with a PSI <25. Patients with delirium (n = 41/97, 42%) spent a higher percentage of total monitored time with PSI <25 (median 67% [19-91] vs. 47% [12.2-78.9]) in non-delirious patients (p .047). After adjusting for the cumulative dose of analgesia and sedation, increased time spent with PSI <25 was associated with higher delirium (odds ratio 1.014; 95% CI 1.001-1.027, p = .036). A clinical protocol of deep sedation targeted to RASS at the acute ICU phase may be associated with prolonged EEG suppression and increased delirium. Whether PSI-targeted sedation may help reducing sedative dose and delirium deserves further clinical investigation. Patients requiring deep sedation are at high risk of being over-sedated and developing delirium despite the application of an evidence-based sedation guideline. Development of early objective measures are essential to improve sedation management in these critically ill patients.

Quantitative electroencephalography predicts postoperative delirium in cardiac surgical patients after cardiopulmonary bypass: a prospective observational study.

Despite its frequency and associated negative effect, delirium remains poorly recognized in postoperative patients after ICU admission, especially among those who have undergone cardiac surgery with cardiopulmonary bypass. Postoperative delirium is triggered by a wide variety of acute medical conditions associated with impaired neuronal network connectivity. The lack of objective biomarkers primarily hinders the early detection of delirium. Seeking early biomarkers for tracking POD could potentially assist in predicting the onset of delirium and assessing the severity of delirium and response to interventions. QEEGs were taken from 46 sedated postoperative patients, with 24 of them having undergone cardiac surgery. The assessment of delirium was performed twice daily using the Confusion Assessment Method for the ICU (CAM-ICU) to screen for postoperative delirium (POD). QEEG data were interpreted clinically by neurophysiologists and processed by open-source EEGLAB to identify features in patients who had or did not have POD after cardiac or non-cardiac surgery. The incidence of delirium in patients after undergoing cardiac surgery was nine times greater than in those after non-cardiac surgeries (41.7% vs. 4.5%; p = 0.0046). Patients with delirium experienced longer use of mechanical ventilation (118 h (78,323) compared to 20 h (18,23); p < 0.0001) and an extended ICU length of stay (7 days (6, 20) vs. 2 days (2, 4); p < 0.0001). The depth of anesthesia, as measured by RASS scores (p = 0.3114) and spectral entropy (p = 0.1504), showed no significant difference. However, notable differences were observed between delirious and non-delirious patients in terms of the amplitude-integrated EEG (aEEG) upper limit, the relative power of the delta band, and spectral edge frequency 95 (SEF95) (p = 0.0464, p = 0.0417, p = 0.0337, respectively). In a homogenous population of sedated postoperative patients, robust qEEG parameters strongly correlate with delirium and could serve as valuable biomarkers for early detection of delirium and assist in clinical decision-making.

Concurrence of seizures and peri-ictal delirium in the critically ill - its frequency, associated characteristics, and outcomes

BackgroundTo assess the frequency, clinical features, and outcome of peri-ictal delirium in adult patients experiencing seizures during intensive care.MethodsThis observational study was conducted at a Swiss intensive care unit from 2015 to 2020. Patients aged ≥ 18 years with seizures were categorized as peri-ictal delirious (Intensive Care Delirium Screening Checklist [i.e., ICDSC] ≥ 4) or not (i.e., ICDSC < 4) within 24 h of seizures. The frequency of peri-ictal delirium and in-hospital death were defined as the primary endpoints. Illness severity and treatment characteristics between delirious and non-delirious patients were secondary endpoints. Logistic regression was used to compare in-hospital death and differences regarding clinical characteristics between delirious and non-delirious patients.Results48% of 200 patients had peri-ictal delirium for a median of 3 days. Delirious patients were older (median age 69 vs. 62 years, p = 0.002), had lower Simplified Acute Physiology Scores II (SAPS II; median 43 vs. 54, p = 0.013), received neuroleptics more frequently (31 vs. 5%, p < 0.001), were mechanically ventilated less often (56% vs. 73%, p = 0.013) and shorter (median 3 vs. 5 days, p = 0.011), and had decreased odds for in-hospital death with delirium (OR = 0.41, 95% CI 0.20–0.84) in multivariable analyses.ConclusionsDelirium emerged in every second patient experiencing seizures and was associated with lower SAPS II, shorter mechanical ventilation, and better outcomes, contradicting assumptions that altered cerebral function, from seizures and delirium, are linked to unfavorable outcomes.

Nurses’ experiences of managing cognitive problems in intensive care unit patients: A qualitative study

ObjectivesNurses hold a key position in identifying symptoms and initiating preventive strategies for cognitive impairment in delirious and non-delirious intensive care unit patients. However, it remains unclear whether nurses consider cognitive impairment as a distinct concern from delirium. By understanding nurses’ perspectives, we may identify barriers and facilitators in caring for patients with cognitive challenges in the intensive care unit.The objective of this study was to explore nurses’ experiences of cognitive problems in patients admitted to an intensive care unit. Research methodologyA phenomenological-hermeneutic study of interviews with ten nurses from intensive care units. Data were collected in March-April 2022 and analysed using a Ricœur-inspired method of interpretation. FindingsThree themes related to nurses’ experiences of cognitive problems emerged through analysis; 1) Cognitive problems and delirium are seen as two sides of the same coin, 2) Searching for the person behind the patient, and 3) Maintaining a sense of normality in a confusing environment. ConclusionsThe interconnected concept of cognitive impairment and delirium syndrome meant that nurses assessed and managed cognitive problems in intensive care unit patients by focusing on preventing delirium. Apart from delirium screening, nurses relied on relatives’ knowledge to assess patients’ cognition. Most significantly, our study revealed a previously unexplored approach by nurses to manage patients’ cognition, which involved “shielding” patients from the noisy and disruptive intensive care unit environment. Implications for clinical practiceEffective communication methods, coupled with family involvement may aid nurses in identifying patients’ cognitive problems. In the acute phase of critical illness, distinguishing between delirium and cognitive problems may not be clinically relevant, as delirium protocols may protect patients’ cognition.Further investigating the concept of shielding may reveal previously unexplored nursing approaches to manage cognitive problems.

Forecasting Caseload of Critically Ill Patients Who Are Alert and Without Delirium for at Least Two Consecutive Days for the Assessment of Their Psychological Distress.

One-quarter of alert, non-delirious patients in critical care units report significant psychological distress. Treatment of this distress depends upon identifying these high-risk patients. Our aim was to characterize how many critical care patients remain alert and without delirium for at least two consecutive days and could thus predictably undergo evaluation for distress. This retrospective cohort study used data from a large teaching hospital in the United States of America, from October 2014 to March 2022. Patients were included ifthey were admitted to one of three intensive care units, and for >48 hours all delirium and sedation screenings were negative (Riker sedation-agitation scalefour, calm and cooperative, and no delirium based on all Confusion Assessment Method for the Intensive Care Unit scores negative and all Delirium Observation Screening Scale less than three).Means and standard deviations of means for counts and percentages are reported among the most recent six quarters. Means and standard deviations ofmeans for lengths of stay were calculated among all N=30 quarters.The Clopper-Pearson method was used to calculate the lower 99% confidence limit for the percentages of patients who would have had atmost one assessment ofdignity-related distress before intensive care unit discharge orchange in mental status. An average of 3.6 (standard deviation 0.2) new patients met the criteria daily. The percentages of all critical care patients (20%, standard deviation 2%) and hours (18%, standard deviation 2%) meeting criteria decreased slightly over the 7.5 years. Patients spent a mean of 3.8(standard deviation 0.1) days awake incritical care before their condition or site changed. In the context of assessing distress and potentially treating it before the date ofchange ofcondition (e.g., transfer), 66% (6818/10314) ofpatients would have zero or one assessment, lower 99% confidence limit of 65%. Approximately one-fifth of critically ill patients are alert and without delirium and thus could be evaluated for distress during their intensive care unit stay, mostly during a single visit. These estimates can be used to guide workforce planning.

68 Using the Cornell Assessment of Pediatric Delirium Score to Identify Delirium in Pediatric Burn Patients

Abstract Introduction Delirium rates in pediatric critical care range from 18-40% and its development is associated with baseline cognitive dysfunction, primary diagnosis, and mechanical ventilation. The Cornell Assessment of Pediatric Delirium (CAPD) is a tool used to detect delirium in children of all ages, but has not been validated in burn patients. Our study aimed to use CAPD score to determine the frequency of delirium in pediatric burn patients and assess the association of delirium with burn demographics. Methods We conducted a retrospective review of patients aged 2.5 weeks to 18 years who were admitted to our ABA-verified pediatric burn center from 2018-2021 and who underwent delirium screening with the CAPD tool (CAPD ≥9 indicates a diagnosis of delirium). Injury mechanism, patient demographics, hospitalization details, and CAPD score were collected and χ2, Fisher’s exact test, and univariate analyses performed. Results 389 patients with documented CAPD scores were included in our cohort, with median age of 2 years at the time of burn injury. Delirium was identified in 42 (10.8%) patients. Delirious patients were generally older compared to non-delirious patients (4 years (IQR 2, 11) vs 2 years (IQR 1, 6), P &amp;lt; 0.0005) and had higher TBSA burned (21.63% (IQR 9, 42) vs 3.5% (IQR 1.75, 6), P &amp;lt; 0.0001). Odds of developing delirium with increasing age was 1.08 (95% CI: 1.02-1.15, P = 0.0068) and 1.16 (95% CI: 1.11-1.20, P = &amp;lt; 0.0001) for each percent increase in TBSA burned. Delirium diagnosis did not vary significantly with gender or race/ethnicity. Though it did not reach statistical significance, percent probability of developing delirium was highest among fire burns (26.53% (95% CI: 17.79-35.27)), and lowest among chemical burns (1.49% (95%CI: 0-4.40), P &amp;gt; 0.05). Patients who underwent 6 or more Anesthesia Events (AE) were 74.43 times more likely to develop delirium than patients who underwent 0 AEs (P &amp;lt; 0.001). Compared to non-delirious patients, patients with delirium were 81.02 times more likely to have an ICU admission (95% CI: 38.79-169.22, P &amp;lt; 0.0001) and 11.37 times more likely to have a longer hospital admission (95% CI: 7.74-16.72, P &amp;lt; 0.0001). Conclusions Screening with the CAPD tool identified delirium in pediatric burn patients with known risk factors for delirium including higher TBSA burned, greater number of AEs, and longer ICU course or hospital admission. Delirium increased with age in our study group. There are few validated tools for measuring delirium in pediatric burn patients, and further studies are needed determine whether CAPD accurately captures delirium in younger burn patients. Applicability of Research to Practice Knowing associations between clinical burn characteristics and delirium can help predict which patients are at highest risk. Early identification of these patients can enable extra precautions to prevent delirium and to treat it early if it develops.

Association Between Postoperative Delirium and Long-Term Subjective Cognitive Decline in Older Patients Undergoing Cardiac Surgery: A Secondary Analysis of the Minimizing Intensive Care Unit Neurological Dysfunction with Dexmedetomidine-Induced Sleep Trial

This study aimed to evaluate whether a measure of subjective cognitive decline (SCD), the Patient-Reported Outcomes Measurement Information System (PROMIS) Applied Cognition-Abilities questionnaire, was associated with postoperative delirium. It was hypothesized that delirium during the surgical hospitalization would be associated with a decrease in subjective cognition up to 6 months after cardiac surgery. This was a secondary analysis of data from the Minimizing Intensive Care Unit Neurological Dysfunction with Dexmedetomidine-induced Sleep randomized, placebo-controlled, parallel-arm superiority trial. Data from patients recruited between March 2017 and February 2022 at a tertiary medical center in Boston, Massachusetts were analyzed in February 2023. Data from 337 patients aged 60 years or older who underwent cardiac surgery with cardiopulmonary bypass were included. Patients were assessed preoperatively and postoperatively at 30, 90, and 180 days using the subjective PROMIS Applied Cognition-Abilities and telephonic Montreal Cognitive Assessment. Postoperative delirium occurred within 3 days in 39 participants (11.6%). After adjusting for baseline function, participants who developed postoperative delirium self-reported worse cognitive function (mean difference [MD] -2.64 [95% CI -5.25, -0.04]; p=0.047) up to 180 days after surgery, as compared with nondelirious patients. This finding was consistent with those obtained from objective t-MoCA assessments (MD -0.77 [95% CI -1.49, -0.04]; p=0.04). In this cohort of older patients undergoing cardiac surgery, in-hospital delirium was associated with SCD up to 180 days after surgery. This finding suggested that measures of SCD may enable population-level insights into the burden of cognitive decline associated with postoperative delirium.

Prognostic significance of delirium subtypes in critically ill medical and surgical patients: a secondary analysis of a prospective multicenter study

BackgroundThe prognostic implication of delirium subtypes in critically ill medical and surgical patients is scarcely investigated. The objective was to determine how delirium subtypes are associated with hospital mortality and other clinical outcomes.MethodsWe performed a secondary analysis on data from a prospective multicenter study aimed at implementation of delirium-oriented measures, conducted between 2012 and 2015 in The Netherlands. We included adults (≥ 18 years) admitted to the medical or surgical intensive care unit (ICU). Exclusion criteria were neurological admission diagnosis, persistent coma or ICU readmissions. Delirium was assessed using the Confusion Assessment Method-ICU or Intensive Care Delirium Screening Checklist, and delirium subtypes (hypoactive, hyperactive, or mixed) were classified using the Richmond Agitation–Sedation Scale. The main outcome was hospital mortality. Secondary outcomes were ICU mortality, ICU length of stay, coma, mechanical ventilation, and use of antipsychotics, sedatives, benzodiazepines and opioids.ResultsDelirium occurred in 381 (24.4%) of 1564 patients (52.5% hypoactive, 39.1% mixed, 7.3% hyperactive). After case-mix adjustment, patients with mixed delirium had higher hospital mortality than non-delirious patients (OR 3.09, 95%CI 1.79–5.33, p = 0.001), whereas hypoactive patients did not (OR 1.34, 95%CI 0.71–2.55, p = 0.37). Similar results were found for ICU mortality. Compared to non-delirious patients, both subtypes had longer ICU stay, more coma, increased mechanical ventilation frequency and duration, and received more antipsychotics, sedatives, benzodiazepines and opioids. Except for coma and benzodiazepine use, the most unfavourable outcomes were observed in patients with mixed delirium.ConclusionsPatients with mixed delirium had the most unfavourable outcomes, including higher mortality, compared with no delirium. These differences argue for distinguishing delirium subtypes in clinical practice and future research.Trial registration ClinicalTrials.gov NCT01952899.

Discomfort improvement for critically ill patients using electronic relaxation devices: results of the cross-over randomized controlled trial E-CHOISIR (Electronic-CHOIce of a System for Intensive care Relaxation)

PurposeTo assess the impact of different electronic relaxation devices on common stressful patient symptoms experienced in intensive care unit (ICU).MethodsSixty critically ill patients were enrolled in four relaxation sessions using a randomized cross-over design: standard relaxation (TV/radio), music therapy (MUSIC-CARE©), and two virtual reality systems using either real motion pictures (DEEPSEN©) or synthetic motion pictures (HEALTHY-MIND©). The goal was to determine which device was the best to reduce overall patient discomfort intensity (0–10 Numeric Rating Scale (NRS); primary endpoint). Secondary endpoints were specific stressful symptoms (pain, anxiety, dyspnea, thirst, and lack of rest feeling) and stress response measured by Analgesia/Nociception Index (ANI). Multivariate mixed-effect analysis was used, taking into account patient characteristics and multiple measurements.ResultsFifty patients followed the full research protocol, and ten patients did at least one research planned session of relaxation. HEALTHY-MIND© was associated with a significant decrease in overall discomfort, the primary endpoint (median NRS = 4[2–6] vs. 2[0–5]; p = 0.01, mixed-effect model), accompanied by a significant decrease in stress response (increase in ANI, secondary endpoint; p < 0.01). Regarding other secondary endpoints, each of the two virtual reality systems was associated with a decrease in anxiety (p < 0.01), while HEALTHY-MIND© was associated also with a decrease in pain (p = 0.001) and DEEPSEN© with a decrease in lack of rest (p = 0.01). Three incidents (claustrophobia/dyspnea/agitation) were reported among 109 virtual reality sessions. Cybersickness was rare (NRS = 0[0–0]).ConclusionElectronic relaxation therapy is a promising, safe, and effective non-pharmacological solution that can be used to improve overall discomfort in alert and non-delirious ICU patients. Its effectiveness depends on technical characteristics (virtual reality using a synthetic imagined world versus a real world or music therapy alone without virtual reality), as well as the type of symptoms.

Delirium Leads to Poor In‐Hospital and 90‐Day Outcomes Among Patients With Acute Ischemic Stroke With and Without Intravenous Thrombolysis or Intraarterial Therapy

Background Delirium experienced poststroke is known to be associated with poor prognosis; however, the outcomes and functional consequences among patients with acute ischemic stroke (AIS) undergoing intravenous thrombolysis (intravenous tissue plasminogen activator) or intraarterial therapy are not well characterized. Methods Using data from 7 stroke centers with standardized delirium screening protocols, delirium was determined by a positive modified “Arousal, Attention, Abbreviated Mental‐Test, Acute Change Test” or Confusion Assessment Method for the Intensive Care Unit screen including diagnosis codes. Multivariable models were fit to estimate likelihoods of in‐hospital mortality, unfavorable discharge disposition, and longer length of stay among delirious patients with AIS, reported as adjusted odds ratios (aORs), adjusted incident rate ratios, and 95% CIs. A subset of patients with AIS with 90‐day modified Rankin scale (mRS) including those receiving intravenous tissue plasminogen activator or intraarterial therapy were analyzed for shifts in mRS scores associated with delirium, via ordinal logistic regression models. Results Between May 2016 and June 2021, AIS was the primary diagnosis in 12 409 hospitalization encounters representing 10 874 unique patients. Delirium was documented in 41.6% of AIS encounters, compared with 26.5% of age and mild cognitive impairment– or dementia‐matched non‐AIS encounters. Delirious (versus nondelirious) patients with AIS were older (median: 75 years versus 65 years), more frequently women (53.3% versus 48.7%), with a higher comorbidity burden (median Charlson Comorbidity Index: 7 versus 5). Delirious patients with AIS had higher odds of in‐hospital mortality (aOR, 2.66; [95% CI, 1.62–4.49]), unfavorable discharge disposition (aOR, 3.68; [95% CI, 3.15–4.30]), and longer length of stay (adjusted incidence rate ratio, 1.67; CI, 1.61–1.73). In the cohort of 2784 patients with treated and untreated AIS with 90‐day mRS, adjusted models indicated lower mRS (aOR, 0.54; CI, 0.46–0.63) associated with treatment, and higher mRS for delirious patients with AIS (aOR, 3.09; CI, 2.58–3.71). Among the subcohort of 948 patients with treated AIS, delirium remained significantly associated with higher mRS (aOR, 2.82; CI, 2.08–3.83). Conclusion Delirium is common among patients with AIS including those receiving intravenous tissue plasminogen activator or undergoing intraarterial therapy and prognosticates poor in‐hospital and 90‐day outcomes. Active screening and management of delirium may lead to improved stroke outcomes.

The relationship of acute delirium with cognitive and psychiatric symptoms after stroke: a longitudinal study

ObjectiveDelirium, a common complication after stroke, is often overlooked, and long-term consequences are poorly understood. This study aims to explore whether delirium in the acute phase of stroke predicts cognitive and psychiatric symptoms three, 18 and 36 months later.MethodAs part of the Norwegian Cognitive Impairment After Stroke Study (Nor-COAST), 139 hospitalized stroke patients (49% women, mean (SD) age: 71.4 (13.4) years; mean (SD) National Institutes of Health Stroke Scale (NIHSS) 3.0 (4.0)) were screened for delirium with the Confusion Assessment Method (CAM). Global cognition was measured with the Montreal Cognitive Assessment (MoCA), while psychiatric symptoms were measured using the Hospital Anxiety and Depression Scale (HADS) and the Neuropsychiatric Inventory-Questionnaire (NPI-Q). Data was analyzed using mixed-model linear regression, adjusting for age, gender, education, NIHSS score at baseline and premorbid dementia.ResultsThirteen patients met the criteria for delirium. Patients with delirium had lower MoCA scores compared to non-delirious patients, with the largest between-group difference found at 18 months (Mean (SE): 20.8 (1.4) versus (25.1 (0.4)). Delirium was associated with higher NPI-Q scores at 3 months (Mean (SE): 2.4 (0.6) versus 0.8 (0.1)), and higher HADS anxiety scores at 18 and 36 months, with the largest difference found at 36 months (Mean (SE): 6.2 (1.3) versus 2.2 (0.3)).ConclusionsSuffering a delirium in the acute phase of stroke predicted more cognitive and psychiatric symptoms at follow-up, compared to non-delirious patients. Preventing and treating delirium may be important for decreasing the burden of post-stroke disability.