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Medicina
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Delirium in Critically Ill Patients
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Delirium in Critically Ill Patients

A special issue of Medicina (ISSN 1648-9144). This special issue belongs to the section "Intensive Care/ Anesthesiology".

Deadline for manuscript submissions: closed (31 July 2020) | Viewed by 33199

Special Issue Editor

Dr. Katarzyna Kotfis

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Guest Editor
Department of Anesthesiology, Intensive Care and Pain Management, Pomeranian Medical University, 70-111 Szczecin, Poland
Interests: ICU delirium; post-operative delirium; pain; post-intensive care syndrome; delirium biomarkers; frailty; cognitive dysfunction; perioperative safety
Special Issues, Collections and Topics in MDPI journals

Special Issue Information

Dear Colleagues,

Delirium is a highly frequent problem both in the ICU and in post-operative care settings, affecting many hospitalized patients around the world. Therefore, it has attracted global interest and a vast amount of research regarding this subject has been conducted.

Despite a growing number of studies regarding different aspects of delirium in critically ill patients, the understanding of the phenomenon itself, regarding biochemical mechanisms and its functional outcome, remains poorly understood. Therefore, a better understanding of the available data as well as a further investigation of the molecular mechanisms responsible for delirium are imperative for significant improvements in its prevention, detection, and therapy.

Experts in the field have constantly suggested that only systematic interventions implemented through a team-based multicomponent approach may lead to a reduction in the incidence, duration, and severity of delirium. Thus, early diagnosis, identification of risk factors and populations at risk, as well as adequate treatment of delirium are major health concerns worldwide.

Given the importance of delirium in the field of medicine and research, the journal Medicina is launching this Special Issue entitled “Delirium in Critically Ill Patients”. We encourage you and your co-workers to submit your articles reporting on this topic. Reviews or original articles dealing with epidemiology, diagnosis, biochemical, and molecular aspects associated with delirium pathogenesis in experimental models and humans, as well as articles providing an up-to-date overview of the use of team-based multicomponent approaches in early diagnosis and management of delirium are particularly welcome. We warmly invite you to submit articles reporting on evidence from innovative therapeutics, with a special focus on non-pharmacological approaches.

Dr. Katarzyna Kotfis
Guest Editor

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Medicina is an international peer-reviewed open access monthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2200 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • ICU delirium
  • post-operative delirium, POD
  • subsyndromal delirium
  • sepsis-associated delirium, SAD
  • delirium monitoring
  • risk factors
  • delirium biomarkers
  • outcome
  • pharmacological interventions in delirium
  • non-pharmacological interventions in delirium
  • ABCDEF care bundle
  • post-intensive care syndrome
  • post-operative cognitive dysfunction, POCD

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Published Papers (8 papers)

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Research

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18 pages, 1340 KiB  
Article
Influence of Sedation Level and Ventilation Status on the Diagnostic Validity of Delirium Screening Tools in the ICU—An International, Prospective, Bi-Center Observational Study (IDeAS)
by Flavio E. Nacul, Nicolas Paul, Claudia D. Spies, Henriette Sechting, Thomas Hecht, Jörn S. Dullinger, Sophie K. Piper, Alawi Luetz, Felix S. Balzer, Klaus-Dieter Wernecke, Anna Karinina Sa, Carolina Barros Ferreira da Costa, Lisa Eymold, Chokri Chenitir and Björn Weiss
Medicina 2020, 56(8), 411; https://doi.org/10.3390/medicina56080411 - 13 Aug 2020
Cited by 6 | Viewed by 3730
Abstract
Background and objectives: The use of delirium screening instruments (DSIs) is recommended in critical care practice for a timely detection of delirium. We hypothesize that the patient-related factors “level of sedation” and “mechanical ventilation” impact test validity of DSIs. Materials and Methods: This [...] Read more.
Background and objectives: The use of delirium screening instruments (DSIs) is recommended in critical care practice for a timely detection of delirium. We hypothesize that the patient-related factors “level of sedation” and “mechanical ventilation” impact test validity of DSIs. Materials and Methods: This is a prospective, bi-center observational study (clinicaltrials.gov: NCT01720914). Critically ill patients were screened for delirium daily for up to seven days after enrollment using the Nursing Delirium Screening Scale (Nu-DESC), Intensive Care Delirium Screening Checklist (ICDSC), and Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Reference standard for delirium diagnosis was the neuropsychiatric examination using the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Immediately before delirium assessment, ventilation status and sedation levels were documented. Results: 160 patients were enrolled and 151 patients went into final analysis. Delirium incidence was 23.2%. Nu-DESC showed a sensitivity and specificity of 88.5%, a positive predictive value (PPV) of 71.9%, and a negative predictive value (NPV) of 95.8%. ICDSC had a sensitivity of 62.5%, a specificity of 92.4%, a PPV of 71.4%, and a NPV of 89.0%. CAM-ICU showed a sensitivity of 75.0%, a specificity of 94.7%, a PPV of 85.7%, and a NPV of 90.0%. For Nu-DESC and ICDSC, test validity was significantly better for non-sedated patients (Richmond Agitation Sedation Scale (RASS) 0/−1), whereas test validity for CAM-ICU in a severity scale version showed no significant differences for different sedation levels. No DSI showed a significant difference in test validity between noninvasively and invasively ventilated patients. Conclusions: Test validities of DSIs were comparable to previous studies. The observational scores ICDSC and Nu-DESC showed a significantly better performance in awake and drowsy patients (RASS 0/−1) when compared with other sedation levels. Physicians should refrain from sedation whenever possible to avoid suboptimal performance of DSIs. Full article
(This article belongs to the Special Issue Delirium in Critically Ill Patients)
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11 pages, 1178 KiB  
Article
Postoperative Delirium in Patients with Chronic Obstructive Pulmonary Disease after Coronary Artery Bypass Grafting
by Aleksandra Szylińska, Iwona Rotter, Mariusz Listewnik, Kacper Lechowicz, Mirosław Brykczyński, Sylwia Dzidek, Maciej Żukowski and Katarzyna Kotfis
Medicina 2020, 56(7), 342; https://doi.org/10.3390/medicina56070342 - 9 Jul 2020
Cited by 10 | Viewed by 2663
Abstract
Background and Objectives: The incidence of postoperative delirium (POD) in patients with chronic obstructive pulmonary disease (COPD) is unclear. It seems that postoperative respiratory problems that may occur in COPD patients, including prolonged mechanical ventilation or respiratory-tract infections, may contribute to the development [...] Read more.
Background and Objectives: The incidence of postoperative delirium (POD) in patients with chronic obstructive pulmonary disease (COPD) is unclear. It seems that postoperative respiratory problems that may occur in COPD patients, including prolonged mechanical ventilation or respiratory-tract infections, may contribute to the development of delirium. The aim of the study was to identify a relationship between COPD and the occurrence of delirium after cardiac surgery and the impact of these combined disorders on postoperative mortality. Materials and Methods: We performed an analysis of data collected from 4151 patients undergoing isolated coronary artery bypass grafting (CABG) in a tertiary cardiac-surgery center between 2012 and 2018. We included patients with a clinical diagnosis of COPD according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria. The primary endpoint was postoperative delirium; Confusion Assessment Method in the Intensive Care Unit (CAM-ICU) was used for delirium assessment. Results: Final analysis included 283 patients with COPD, out of which 65 (22.97%) were diagnosed with POD. Delirious COPD patients had longer intubation time (p = 0.007), more often required reintubation (p = 0.019), had significantly higher levels of C-reactive protein (CRP) three days after surgery (p = 0.009) and were more often diagnosed with pneumonia (p < 0.001). The CRP rise on day three correlated positively with the occurrence of postoperative pneumonia (r = 0.335, p = 0.005). The probability of survival after CABG was significantly lower in COPD patients with delirium (p < 0.001). Conclusions: The results of this study confirmed the relationship between chronic obstructive pulmonary disease and the incidence of delirium after cardiac surgery. The probability of survival in COPD patients undergoing CABG who developed postoperative delirium was significantly decreased. Full article
(This article belongs to the Special Issue Delirium in Critically Ill Patients)
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9 pages, 286 KiB  
Article
Natriuretic Peptides as a Prognostic Marker for Delirium in Cardiac Surgery—A Pilot Study
by Thomas Saller, Sven Peterss, Patrick Scheiermann, Daniela Eser-Valeri, Johannes Ehler, Dirk Bruegger, Daniel Chappell, Othmar Kofler, Christian Hagl and Klaus Hofmann-Kiefer
Medicina 2020, 56(6), 258; https://doi.org/10.3390/medicina56060258 - 27 May 2020
Cited by 1 | Viewed by 2646
Abstract
Background and Objectives: Delirium is a common and major complication subsequent to cardiac surgery. Despite scientific efforts, there are no parameters which reliably predict postoperative delirium. In delirium pathology, natriuretic peptides (NPs) interfere with the blood–brain barrier and thus promote delirium. Therefore, we [...] Read more.
Background and Objectives: Delirium is a common and major complication subsequent to cardiac surgery. Despite scientific efforts, there are no parameters which reliably predict postoperative delirium. In delirium pathology, natriuretic peptides (NPs) interfere with the blood–brain barrier and thus promote delirium. Therefore, we aimed to assess whether NPs may predict postoperative delirium and long-term outcomes. Materials and Methods: To evaluate the predictive value of NPs for delirium we retrospectively analyzed data from a prospective, randomized study for serum levels of atrial natriuretic peptide (ANP) and the precursor of C-type natriuretic peptide (NT-proCNP) in patients undergoing coronary artery bypass grafting (CABG) with or without cardiopulmonary bypass (off-pump coronary bypass grafting; OPCAB). Delirium was assessed by a validated chart-based method. Long-term outcomes were assessed 10 years after surgery by a telephone interview. Results: The overall incidence of delirium in the total cohort was 48% regardless of the surgical approach (CABG vs. OPCAB). Serum ANP levels > 64.6 pg/mL predicted delirium with a sensitivity (95% confidence interval) of 100% (75.3–100) and specificity of 42.9% (17.7–71.1). Serum NT-proCNP levels >1.7 pg/mL predicted delirium with a sensitivity (95% confidence interval) of 92.3% (64.0–99.8) and specificity of 42.9% (17.7–71.1). Both NPs could not predict postoperative survival or long-term cognitive decline. Conclusions: We found a positive correlation between delirium and preoperative plasma levels of ANP and NT-proCNP. A well-powered and prospective study might identify NPs as biomarkers indicating the risk of delirium and postoperative cognitive decline in patients at risk for postoperative delirium. Full article
(This article belongs to the Special Issue Delirium in Critically Ill Patients)
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9 pages, 266 KiB  
Article
Hallucinations after Cardiac Surgery: A Prospective Observational Study
by Thomas H. Ottens, Iris E.C. Sommer, Marieke J. Begemann, Maya Schutte, Maarten Jan Cramer, Willem J. Suyker, Diederik Van Dijk and Arjen J.C. Slooter
Medicina 2020, 56(3), 104; https://doi.org/10.3390/medicina56030104 - 2 Mar 2020
Cited by 6 | Viewed by 4048
Abstract
Background and Objective: Hallucinations after cardiac surgery can be a burden, but their prevalence and phenomenology have not been studied well. Risk factors for postoperative hallucinations, as well as their relation to delirium are unclear. We aimed to study the prevalence and phenomenology [...] Read more.
Background and Objective: Hallucinations after cardiac surgery can be a burden, but their prevalence and phenomenology have not been studied well. Risk factors for postoperative hallucinations, as well as their relation to delirium are unclear. We aimed to study the prevalence and phenomenology of hallucinations after cardiac surgery, and to study the association between hallucinations and delirium in this population. Materials and Methods: We used the Questionnaire for Psychotic Experiences to detect hallucinations in cardiac surgery patients and a control group of cardiology outpatients. We assessed postoperative delirium with validated instruments. Risk factors for postoperative hallucinations and the association between hallucinations and delirium were analysed using logistic regression. Results: We included 201 cardiac surgery patients and 99 cardiology outpatient controls. Forty-four cardiac surgery patients (21.9%) experienced postoperative hallucinations in the first four postoperative days. This was significantly higher compared to cardiology outpatient controls (n = 4, 4.1%, p < 0.001). Visual hallucinations were the most common type of hallucinations in cardiac surgery patients, and less common in outpatient controls. Cardiac surgery patients who experienced hallucinations were more likely to also have delirium (10/44, 22.7%) compared to patients without postoperative hallucinations (16/157, 10.2% p = 0.03). However, the majority of patients with postoperative hallucinations (34/44, 77.3%) did not develop delirium. Conclusion: After cardiac surgery, hallucinations occurred more frequently than in outpatient controls. Hallucinations after cardiac surgery were most often visual in character. Although postoperative hallucinations were associated with delirium, most patients with hallucinations did not develop delirium. Full article
(This article belongs to the Special Issue Delirium in Critically Ill Patients)

Review

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18 pages, 970 KiB  
Review
Current Evidence Regarding Biomarkers Used to Aid Postoperative Delirium Diagnosis in the Field of Cardiac Surgery—Review
by Paweł Majewski, Małgorzata Zegan-Barańska, Igor Karolak, Karolina Kaim, Maciej Żukowski and Katarzyna Kotfis
Medicina 2020, 56(10), 493; https://doi.org/10.3390/medicina56100493 - 24 Sep 2020
Cited by 15 | Viewed by 3866
Abstract
Postoperative cognitive disorders after cardiac surgery may manifest as postoperative delirium (POD) or later as postoperative cognitive dysfunction (POCD). The incidence of POD after cardiac surgery ranges from 16% to 73%. In contrast to POD, POCD is usually diagnosed after the discharge from [...] Read more.
Postoperative cognitive disorders after cardiac surgery may manifest as postoperative delirium (POD) or later as postoperative cognitive dysfunction (POCD). The incidence of POD after cardiac surgery ranges from 16% to 73%. In contrast to POD, POCD is usually diagnosed after the discharge from hospital, with an incidence of 30 to 70% of cases, very often noticed only by close relative or friends, decreasing after six (20–30%) and twelve (15–25%) months after surgery. Perioperative cognitive disorders are associated with adverse short- and long-term effects, including increased morbidity and mortality. Due to the complexity of delirium pathomechanisms and the difficulties in the diagnosis, researchers have not yet found a clear answer to the question of which patient will be at a higher risk of developing delirium. The risk for POD and POCD in older patients with numerous comorbidities like hypertension, diabetes, and previous ischemic stroke is relatively high, and the predisposing cognitive profile for both conditions is important. The aim of this narrative review was to identify and describe biomarkers used in the diagnosis of delirium after cardiac surgery by presenting a search through studies regarding this subject, which have been published during the last ten years. The authors discussed brain-derived biomarkers, inflammation-related biomarkers, neurotransmitter-based biomarkers, and others. Work based on inflammation-related biomarkers, which are characterized by the low cost of implementation and the effectiveness of delirium diagnosis, seems to be the closest to the goal of discovering an inexpensive and effective marker. Currently, the use of a panel of tests, and not a single biomarker, brings us closer to the discovery of a test, or rather a set of tests ideal for the diagnosis of delirium after cardiac surgery. Full article
(This article belongs to the Special Issue Delirium in Critically Ill Patients)
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17 pages, 803 KiB  
Review
Pathomechanisms of Non-Traumatic Acute Brain Injury in Critically Ill Patients
by Wojciech Dabrowski, Dorota Siwicka-Gieroba, Malgorzata Gasinska-Blotniak, Sami Zaid, Maja Jezierska, Cezary Pakulski, Shawniqua Williams Roberson, Eugene Wesley Ely and Katarzyna Kotfis
Medicina 2020, 56(9), 469; https://doi.org/10.3390/medicina56090469 - 13 Sep 2020
Cited by 9 | Viewed by 3851
Abstract
Delirium, an acute alteration in mental status characterized by confusion, inattention and a fluctuating level of arousal, is a common problem in critically ill patients. Delirium prolongs hospital stay and is associated with higher mortality. The pathophysiology of delirium has not been fully [...] Read more.
Delirium, an acute alteration in mental status characterized by confusion, inattention and a fluctuating level of arousal, is a common problem in critically ill patients. Delirium prolongs hospital stay and is associated with higher mortality. The pathophysiology of delirium has not been fully elucidated. Neuroinflammation and neurotransmitter imbalance seem to be the most important factors for delirium development. In this review, we present the most important pathomechanisms of delirium in critically ill patients, such as neuroinflammation, neurotransmitter imbalance, hypoxia and hyperoxia, tryptophan pathway disorders, and gut microbiota imbalance. A thorough understanding of delirium pathomechanisms is essential for effective prevention and treatment of this underestimated pathology in critically ill patients. Full article
(This article belongs to the Special Issue Delirium in Critically Ill Patients)
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10 pages, 814 KiB  
Review
Sepsis Associated Delirium
by Ben Atterton, Maria Carolina Paulino, Pedro Povoa and Ignacio Martin-Loeches
Medicina 2020, 56(5), 240; https://doi.org/10.3390/medicina56050240 - 18 May 2020
Cited by 40 | Viewed by 8802
Abstract
Sepsis is a potentially life-threatening condition caused by a systemic dysregulated host response to infection. The brain is particularly susceptible to the effects of sepsis with clinical manifestations ranging from mild confusion to a deep comatose state. Sepsis-associated delirium (SAD) is a cerebral [...] Read more.
Sepsis is a potentially life-threatening condition caused by a systemic dysregulated host response to infection. The brain is particularly susceptible to the effects of sepsis with clinical manifestations ranging from mild confusion to a deep comatose state. Sepsis-associated delirium (SAD) is a cerebral manifestation commonly occurring in patients with sepsis and is thought to occur due to a combination of neuroinflammation and disturbances in cerebral perfusion, the blood brain barrier (BBB) and neurotransmission. The neurological impairment associated with SAD can persist for months or even longer, after the initial septic episode has subsided which may impair the rehabilitation potential of sepsis survivors. Early identification and treatment of the underlying sepsis is key in the management of SAD as once present it can be difficult to control. Through the regular use of validated screening tools for delirium, cases of SAD can be identified early; this allows potentially aggravating factors to be addressed promptly. The usefulness of biomarkers, neuroimaging and electroencephalopathy (EEG) in the diagnosis of SAD remains controversial. The Society of Critical Care Medicine (SCCM) guidelines advise against the use of medications to treat delirium unless distressing symptoms are present or it is hindering the patient’s ability to wean from organ support. Full article
(This article belongs to the Special Issue Delirium in Critically Ill Patients)
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Other

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7 pages, 1384 KiB  
Case Report
Acute Disseminated Encephalomyelitis with Seizures and Myocarditis: A Fatal Triad
by Hanne Lademann, Astrid Bertsche, Axel Petzold, Fred Zack, Andreas Büttner, Jan Däbritz, Christina Hauenstein, Erik Bahn, Christian Spang, Daniel Reuter, Philipp Warnke and Johannes Ehler
Medicina 2020, 56(6), 277; https://doi.org/10.3390/medicina56060277 - 4 Jun 2020
Cited by 6 | Viewed by 2791
Abstract
Autoimmune pathology of acute disseminated encephalomyelitis (ADEM) is generally restricted to the brain. Our objective is to expand the phenotype of ADEM. A four-year-old girl was admitted to the pediatric emergency room of a university medical center five days after a common upper [...] Read more.
Autoimmune pathology of acute disseminated encephalomyelitis (ADEM) is generally restricted to the brain. Our objective is to expand the phenotype of ADEM. A four-year-old girl was admitted to the pediatric emergency room of a university medical center five days after a common upper respiratory tract infection. Acute symptoms were fever, leg pain, and headaches. She developed meningeal signs, and her level of consciousness dropped rapidly. Epileptic seizure activity started, and she became comatose, requiring intubation and mechanical ventilation. Serial brain magnetic resonance imaging (MRI) illustrated the fulminant development of ADEM. Treatment escalation with high-dose corticosteroids, immunoglobulins, and plasma exchange did not lead to clinical improvement. On day ten, the patient developed treatment-refractory cardiogenic shock and passed away. The postmortem assessment confirmed ADEM and revealed acute lymphocytic myocarditis, likely explaining the acute cardiac failure. Human metapneumovirus and picornavirus were detected in the tracheal secrete by PCR. Data sources–medical chart of the patient. This case is consistent with evidence from experimental findings of an association of ADEM with myocarditis as a postinfectious systemic autoimmune response, with life-threatening involvement of the brain and heart. Full article
(This article belongs to the Special Issue Delirium in Critically Ill Patients)
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