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Delirium Monitoring in Neurocritically Ill Patients: A Systematic Review.

ABSTRACT: OBJECTIVES:The Society of Critical Care Medicine recommends routine delirium monitoring, based on data in critically ill patients without primary neurologic injury. We sought to answer whether there are valid and reliable tools to monitor delirium in neurocritically ill patients and whether delirium is associated with relevant clinical outcomes (e.g., survival, length of stay, functional independence, cognition) in this population. DATA SOURCES:We systematically reviewed Cumulative Index to Nursing and Allied Health Literature, Web of Science, and PubMed. STUDY SELECTION AND DATA EXTRACTION:Inclusion criteria allowed any study design investigating delirium monitoring in neurocritically ill patients (e.g., neurotrauma, ischemic, and/or hemorrhagic stroke) of any age. We extracted data relevant to delirium tool sensitivity, specificity, negative predictive value, positive predictive value, interrater reliability, and associated clinical outcomes. DATA SYNTHESIS:Among seven prospective cohort studies and a total of 1,173 patients, delirium was assessed in neurocritically patients using validated delirium tools after considering primary neurologic diagnoses and associated complications, finding a pooled prevalence rate of 12-43%. When able to compare against a common reference standard, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, the test characteristics showed a sensitivity of 62-76%, specificity of 74-98%, positive predictive value of 63-91%, negative predictive value of 70-94%, and reliability kappa of 0.64-0.94. Among four studies reporting multivariable analyses, delirium in neurocritically patients was associated with increased hospital length of stay (n = 3) and ICU length of stay (n = 1), as well as worse functional independence (n = 1) and cognition (n = 2), but not survival. CONCLUSIONS:These data from studies of neurocritically ill patients demonstrate that patients with primary neurologic diagnoses can meet diagnostic criteria for delirium and that delirious features may predict relevant untoward clinical outcomes. There is a need for ongoing investigations regarding delirium in these complicated neurocritically ill patients.

SUBMITTER: Patel MB

PROVIDER: S-EPMC6185789 | biostudies-literature | 2018 Nov

REPOSITORIES: biostudies-literature

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Delirium Monitoring in Neurocritically Ill Patients: A Systematic Review.

Patel Mayur B MB Bednarik Josef J Lee Patricia P Shehabi Yahya Y Salluh Jorge I JI Slooter Arjen J AJ Klein Kate E KE Skrobik Yoanna Y Morandi Alessandro A Spronk Peter E PE Naidech Andrew M AM Pun Brenda T BT Bozza Fernando A FA Marra Annachiara A John Sayona S Pandharipande Pratik P PP Ely E Wesley EW

Critical care medicine 20181101 11

<h4>Objectives</h4>The Society of Critical Care Medicine recommends routine delirium monitoring, based on data in critically ill patients without primary neurologic injury. We sought to answer whether there are valid and reliable tools to monitor delirium in neurocritically ill patients and whether delirium is associated with relevant clinical outcomes (e.g., survival, length of stay, functional independence, cognition) in this population.<h4>Data sources</h4>We systematically reviewed Cumulativ ...[more]

PMID: 30142098

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Project description:IntroductionAccumulating evidence suggests that, in critically ill patients, a lower hemoglobin transfusion threshold is safe. However, the optimal hemoglobin level and associated transfusion threshold remain unknown in neurocritically ill patients.MethodsWe conducted a systematic review of comparative studies (randomized and nonrandomized) to evaluate the effect of hemoglobin levels on mortality, neurologic function, intensive care unit (ICU) and hospital length of stay, duration of mechanical ventilation, and multiple organ failure in adult and pediatric neurocritically ill patients. We searched MEDLINE, The Cochrane Central Register of Controlled Trials, Embase, Web of Knowledge, and Google Scholar. Studies focusing on any neurocritical care conditions were included. Data are presented by using odds ratios for dichotomous outcomes and mean differences for continuous outcomes.ResultsAmong 4,310 retrieved records, six studies met inclusion criteria (n = 537). Four studies were conducted in traumatic brain injury (TBI), one in subarachnoid hemorrhage (SAH), and one in a mixed population of neurocritically ill patients. The minimal hemoglobin levels or transfusion thresholds ranged from 7 to 10 g/dl in the lower-Hb groups and from 9.3 to 11.5 g/dl in the higher-Hb groups. Three studies had a low risk of bias, and three had a high risk of bias. No effect was observed on mortality, duration of mechanical ventilation, or multiple organ failure. In studies reporting on length of stay (n = 4), one reported a significant shorter ICU stay (mean, -11.4 days (95% confidence interval, -16.1 to -6.7)), and one, a shorter hospital stay (mean, -5.7 days (-10.3 to -1.1)) in the lower-Hb groups, whereas the other two found no significant association.ConclusionsWe found insufficient evidence to confirm or refute a difference in effect between lower- and higher-Hb groups in neurocritically ill patients. Considering the lack of evidence regarding long-term neurologic functional outcomes and the high risk of bias of half the studies, no recommendation can be made regarding which hemoglobin level to target and which associated transfusion strategy (restrictive or liberal) to favor in neurocritically ill patients.

Project description:ObjectivesTo determine the relation between delirium in critically ill patients and their outcomes in the short term (in the intensive care unit and in hospital) and after discharge from hospital.DesignSystematic review and meta-analysis of published studies.Data sourcesPubMed, Embase, CINAHL, Cochrane Library, and PsychINFO, with no language restrictions, up to 1 January 2015.Eligibility criteria for selection studiesReports were eligible for inclusion if they were prospective observational cohorts or clinical trials of adults in intensive care units who were assessed with a validated delirium screening or rating system, and if the association was measured between delirium and at least one of four clinical endpoints (death during admission, length of stay, duration of mechanical ventilation, and any outcome after hospital discharge). Studies were excluded if they primarily enrolled patients with a neurological disorder or patients admitted to intensive care after cardiac surgery or organ/tissue transplantation, or centered on sedation management or alcohol or substance withdrawal. Data were extracted on characteristics of studies, populations sampled, identification of delirium, and outcomes. Random effects models and meta-regression analyses were used to pool data from individual studies.ResultsDelirium was identified in 5280 of 16,595 (31.8%) critically ill patients reported in 42 studies. When compared with control patients without delirium, patients with delirium had significantly higher mortality during admission (risk ratio 2.19, 94% confidence interval 1.78 to 2.70; P<0.001) as well as longer durations of mechanical ventilation and lengths of stay in the intensive care unit and in hospital (standard mean differences 1.79 (95% confidence interval 0.31 to 3.27; P<0.001), 1.38 (0.99 to 1.77; P<0.001), and 0.97 (0.61 to 1.33; P<0.001), respectively). Available studies indicated an association between delirium and cognitive impairment after discharge.ConclusionsNearly a third of patients admitted to an intensive care unit develop delirium, and these patients are at increased risk of dying during admission, longer stays in hospital, and cognitive impairment after discharge.

Project description:BackgroundIron, an essential mineral for human body, has the potential to cause toxicity at high levels. Previous studies have shown inconsistent predictive value of iron parameters in critically ill patients. Thus, we aimed to evaluate the performance of iron parameters in outcome prediction of neurocritically ill patients.MethodsRetrospective data were collected from patients admitted to the neurocritical care unit (NCU) of a tertiary teaching hospital between August 2016 and January 2017. The iron parameters were obtained at NCU admission. Primary endpoints were short-term (30-day) mortality and long-term (6-month) poor outcome, with the latter defined as modified Rankin Scale of 4-6. The predictive value of variables was determined with univariate and multivariate logistic analysis. A further subanalysis was conducted in patients stratified by the level of estimated glomerular filtration rate (eGFR).ResultsOf 103 eligible patients, the etiology included stroke (58.2%, N = 60), central nervous system infection (13.6%, N = 14), and other neurologic disorders (28.2%, N = 29). The correlation analysis showed that the increase in ferritin, as well as the reduction in transferrin and total iron-binding capacity, had strong correlation with C-reactive protein, procalcitonin, duration of NCU stay, Acute Physiology and Chronic Health Evaluation II score, and Sequential Organ Failure Assessment score. In a further subanalysis of 75 patients with eGFR ≥ 60 ml/min/1.73 m2 , twelve (16.0%) patients died within 30 days and 39 (52.0%) patients achieved good follow-up outcome data. In the multivariate logistic regression analysis, we identified baseline ferritin level as an independent predictor of short-term mortality (OR: 1.002; 95% CI: 1.000-1.003; p = 0.008) and long-term functional outcome (OR: 1.002; 95% CI: 1.000-1.004; p = 0.031).ConclusionsSerum ferritin level at admission could be used as an independent predictor of short-term mortality and long-term functional outcome in neurocritically ill patients with eGFR ≥ 60 ml/min/1.73 m2 .

Project description:ObjectiveHypernatremia is a common complication encountered during the treatment of neurocritically ill patients. However, it is unclear whether clinical outcomes correlate with the severity of hypernatremia in such patients. Therefore, we investigated the impact of hypernatremia on mortality of these patients, depending on the degree of hypernatremia.MethodsAmong neurosurgical patients admitted to the intensive care unit (ICU) in a tertiary hospital from January 2013 to December 2019, patients who were hospitalized in the ICU for more than 5 days and whose serum sodium levels were obtained during ICU admission were included. Hypernatremia was defined as the highest serum sodium level exceeding 150 mEq/L observed. We classified the patients into four subgroups according to the severity of hypernatremia and performed propensity score matching analysis.ResultsAmong 1146 patients, 353 patients (30.8%) showed hypernatremia. Based on propensity score matching, 290 pairs were included in the analysis. The hypernatremia group had higher rates of in-hospital mortality and 28-day mortality in both overall and matched population (both p<0.001 and p=0.001, respectively). In multivariable analysis of propensity score-matched population, moderate and severe hypernatremia were significantly associated with in-hospital mortality (adjusted odds ratio [OR], 4.58; 95% confidence interval [CI], 2.15-9.75 and adjusted OR, 6.93; 95% CI, 3.46-13.90, respectively) and 28-day mortality (adjusted OR, 3.51; 95% CI, 1.54-7.98 and adjusted OR, 10.60; 95% CI, 5.10-21.90, respectively) compared with the absence of hypernatremia. However, clinical outcomes, including in-hospital mortality and 28-day mortality, were not significantly different between the group without hypernatremia and the group with mild hypernatremia (p=0.720 and p=0.690, respectively). The mortality rates of patients with moderate and severe hypernatremia were significantly higher in both overall and matched population. Interestingly, the mild hypernatremia group of matched population showed the best survival rate.ConclusionModerate and severe hypernatremia were associated with poor clinical outcomes in neurocritically ill patients. However, the prognosis of patients with mild hypernatremia was similar with that of patients without hypernatremia. Therefore, mild hypernatremia may be allowed during treatment of intracranial hypertension using hyperosmolar therapy.

Project description:OBJECTIVES:Impaired cerebral autoregulation following neurologic injury is a predictor of poor clinical outcome. We aimed to assess the relationship between body temperature and cerebral autoregulation in comatose patients. DESIGN:Retrospective analysis of prospectively collected data. SETTING:Neurocritical care unit of the Johns Hopkins Hospital. PATIENTS:Eighty-five acutely comatose patients (Glasgow Coma Scale score of ? 8) admitted between 2013 and 2017. INTERVENTIONS:None. MEASUREMENT AND MAIN RESULTS:Cerebral autoregulation was monitored using multimodal monitoring with near-infrared spectroscopy-derived cerebral oximetry index. Cerebral oximetry index was calculated as a Pearson correlation coefficient between low-frequency changes in regional cerebral oxygenation saturation and mean arterial pressure. Patients were initially analyzed together, then stratified by temperature pattern over the monitoring period: no change (< 1°C difference between highest and lowest temperatures; n = 11), increasing (? 1°C; n = 9), decreasing (? 1°C; n = 9), and fluctuating (? 1°C difference but no sustained direction of change; n = 56). Mixed random effects models with random intercept and multivariable logistic regression analysis were used to assess the association between hourly temperature and cerebral oximetry index, as well as between temperature and clinical outcomes. Cerebral oximetry index showed a positive linear relationship with temperature (? = 0.04?±?0.10; p = 0.29). In patients where a continual increase or decrease in temperature was seen during the monitoring period, every 1°C change in temperature resulted in a cerebral oximetry index change in the same direction by 0.04?±?0.01 (p < 0.001) and 0.02?±?0.01 (p = 0.12), respectively, after adjusting for PaCO2, hemoglobin, mean arterial pressure, vasopressor and sedation use, and temperature probe location. There was no significant difference in mortality or poor outcome (modified Rankin Scale score of 4-6) between temperature pattern groups at discharge, 3, or 6 months. CONCLUSIONS:In acute coma patients, increasing body temperature is associated with worsening cerebral autoregulation as measured by cerebral oximetry index. More studies are needed to clarify the impact of increasing temperature on cerebral autoregulation in patients with acute brain injury.

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Delirium Monitoring in Neurocritically Ill Patients: A Systematic Review.

Publications

Delirium Monitoring in Neurocritically Ill Patients: A Systematic Review.

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