Delirium in the cardiac surgical ICU

Charles H Brown, Charles H Brown

Abstract

Purpose of review: Evidence is emerging that delirium is associated with both short-term and long-term morbidity and mortality. This review highlights the epidemiology, outcomes, prevention and treatment strategies associated with delirium after cardiac surgery.

Recent findings: The incidence of delirium after cardiac surgery is estimated to be 26-52%, with a significant percentage being hypoactive delirium. It is clear that without an appropriate structured test for delirium, the incidence of delirium will be underrecognized clinically. Delirium after cardiac surgery is associated with poor outcomes, including increased long-term mortality, increased risk of stroke, poor functional status, increased hospital readmissions and substantial cognitive dysfunction for 1 year following surgery. The effectiveness of prophylactic antipsychotics to reduce the risk of delirium is controversial, with data from recent small studies in noncardiac surgery potentially showing a benefit. Although antipsychotic medications are often used to treat delirium, the evidence that antipsychotics in cardiac surgery patients reduce duration of delirium or improve long-term outcomes following delirium is poor.

Summary: Clinicians in the ICU must recognize the impact of delirium in predicting long-term outcomes for patients. Further research is needed in determining interventions that will be effective in preventing and treating delirium in cardiac surgical setting.

References

    1. Rudolph J, Inouye S, Jones R, et al. Delirium: An independent predictor of functional decline after cardiac surgery. J Am Geriatr Soc. 2010;58:643–649.
    1. Rudolph JL, Jones RN, Levkoff SE, et al. Derivation and validation of a preoperative prediction rule for delirium after cardiac surgery. Circulation. 2009;119(2):229–36.
    1. Schoen J, Meyerrose J, Paarmann H, et al. Preoperative regional cerebral oxygen saturation is a predictor of postoperative delirium in on-pump cardiac surgery patients: a prospective observational trial. Crit Care. 2011;15(5):R218.
    1. Plaschke K, Fichtenkamm P, Schramm C, et al. Early postoperative delirium after open-heart cardiac surgery is associated with decreased bispectral EEG and increased cortisol and interleukin-6. Intensive Care Med. 2010;36(12):2081–9.

    1. Martin B-J, Buth KJ, Arora RC, Baskett RJ. Delirium: a cause for concern beyond the immediate postoperative period. Ann Thorac Surg. 2012 Mar.93(4):1114–20. In a large Canadian cohort, delirium was associated with long-term mortality and increased long-term risk for stroke after cardiac surgery, supporting the hypothesis that the effects of delirium are not short-lived.

    1. Saczynski JS, Marcantonio ER, Quach L, et al. Cognitive trajectories after postoperative delirium. N Engl J Med. 2012;367(1):30–9. Delirium after cardiac surgery was shown to be associated with cognitive decline during the first year after surgery, with a period of steep initial decline followed by prolonged impairment.

    1. Gottesman R, Grega M, Bailey M, et al. Delirium after coronary artery bypass graft surgery and late mortality. Ann Neurol. 2010;67:338–344.

    1. Inouye SK, Westendorp R, Saczynski J. Delirium in elderly people. Lancet. 2013 Aug.25:1–12. A thorough review from a pre-eminent researcher in delirium.

    1. Association AP. Diagnostic and Statistical Manual of Mental Disorders. 5th Edition: DSM-5. American Psychiatric Publishing; 2013. 5th ed.
    1. Liptzin B, Levkoff SE. An empirical study of delirium subtypes. The British Journal of Psychiatry. 1992;161(6):843–5.

    1. McPherson JA, Wagner CE, Boehm LM, et al. Delirium in the cardiovascular ICU. Crit Care Med. 2013;41(2):405–13. In a mixed cardiology and cardiac surgical ICU, 92% of delirium was demonstrated to be hypoactive delirium, supporting the notion that clinicians will likely miss delirium if a structured test is not used.

    1. Cole MM, McCusker JJ, Dendukuri NN, Han LL. The prognostic significance of subsyndromal delirium in elderly medical inpatients. J Am Geriatr Soc. 2003;51(6):754–60.
    1. van Eijk MMJ, van Marum RJ, Klijn IAM, et al. Comparison of delirium assessment tools in a mixed intensive care unit. Crit Care Med. 2009;37(6):1881–5.
    1. Inouye SK, van Dyck CHC, Alessi CA, et al. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med. 1990;113(12):941–8.
    1. Ely EW, Margolin R, Francis J, et al. Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) Crit Care Med. 2001;29(7):1370–9.
    1. Neufeld KJ, Hayat MJ, Coughlin JM, et al. Evaluation of two intensive care delirium screening tools for non-critically ill hospitalized patients. Psychosomatics. 2011;52(2):133–40.

    1. Neufeld KJ, Leoutsakos JS, Sieber FE, et al. Evaluation of two delirium screening tools for detecting post-operative delirium in the elderly. Br J Anaesth. 2013;111(4):612–8. CAM-ICU was specific but not sensitive to the diagnosis of delirium in general ward patients, indicating that CAM-ICU should be used cautiously in delirium assessments outside of the ICU.

    1. Inouye SK, Leo-Summers L, Zhang Y, et al. A chart-based method for identification of delirium: validation compared with interviewer ratings using the confusion assessment method. J Am Geriatr Soc. 2005;53(2):312–8.
    1. Inouye SK, Foreman MD, Mion LC, et al. Nurses’ recognition of delirium and its symptoms: comparison of nurse and researcher ratings. Arch Int Med. 2001;161(20):2467–73.
    1. Inouye SK, Charpentier PA. Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability. JAMA. 1996;275(11):852–7.
    1. Vinkers DJ, Stek ML, van der Mast RC, et al. Generalized atherosclerosis, cognitive decline, and depressive symptoms in old age. Neurology. 2005;65(1):107–12.
    1. Debette S, Markus HS. The clinical importance of white matter hyperintensities on brain magnetic resonance imaging: systematic review and meta-analysis. BMJ. 2010;341:c3666.

    1. Hatano Y, Narumoto J, Shibata K, et al. White-matter hyperintensities predict delirium after cardiac surgery. Am J Geriatr Psychiatry. 2013;21(10):938–45. White matter intensities on MRI (a marker of cerebral ischemia) were associated with increased risk for delirium after cardiac surgery, emphasizing the importance of unrecognized patient vulnerability in the development of delirium.

    1. Pandharipande P, Pun B, Herr D, et al. Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial. JAMA. 2007;298(22):2644–53.
    1. Pandharipande PP, Sanders RD, Girard TD, et al. Effect of dexmedetomidine versus lorazepam on outcome in patients with sepsis: an a priori-designed analysis of the MENDS randomized controlled trial. Crit Care. 2010;14(2):R38.
    1. Sieber F, Zakriya K, Gottschalk A, et al. Sedation depth during spinal anesthesia and the development of postoperative delirium in elderly patients undergoing hip fracture repair. Mayo Clinic Proc. 2010;85:18–26.
    1. Siepe M, Pfeiffer T, Gieringer A, et al. Increased systemic perfusion pressure during cardiopulmonary bypass is associated with less early postoperative cognitive dysfunction and delirium. Eur J Cardiothorac Surg. 2011;40(1):200–7.
    1. Pfister D, Siegemund M, Dell-Kuster S, et al. Cerebral perfusion in sepsis-associated delirium. Crit Care. 2008;12(3):R63.
    1. Cerejeira J, Firmino H, Vaz-Serra A, Mukaetova-Ladinska EB. The neuroinflammatory hypothesis of delirium. Acta Neuropathol. 2010 Mar.119(6):737–54.
    1. Hshieh TT, Fong TG, Marcantonio ER, Inouye SK. Cholinergic deficiency hypothesis in delirium: a synthesis of current evidence. J Gerontol A Biol Sci Med Sci. 2008 Jul.63(7):764–72.
    1. Caplan JP, Chang G. Refeeding syndrome as an iatrogenic cause of delirium: a retrospective pilot study. Psychosomatics. 2010;51(5):419–24.
    1. Adamis D, van Munster BC, Macdonald AJ. The genetics of deliria. Int Rev Psychiatry. 2009;21(1):20–9.

    1. Kazmierski J, Banys A, Latek J, et al. Cortisol levels and neuropsychiatric diagnosis as markers of postoperative delirium: a prospective cohort study. Crit Care. 2013;17(2):R38. Baseline cortisol and major depression were higher among patients with delirium after cardiac surgery, and the authors hypothesize that elevated cortisol may mediate the enhanced delirium risk in patients with major depression.

    1. Perry VH, Cunningham C, Holmes C. Systemic infections and inflammation affect chronic neurodegeneration. Nat Rev Immunol. 2007;7(2):161–7.
    1. Cunningham C. Systemic inflammation and delirium: important co-factors in the progression of dementia. Biochem Soc Trans. 2011;39(4):945–53.

    1. Cunningham CC, Maclullich A. At the extreme end of the psychoneuroimmunological spectrum: Delirium as a maladaptive sickness behaviour response. Brain Behav Immun. 2013;28:1–13. A comparison of delirium with sickness behavior responses, with a focus on how susceptibility interacts with stimuli to promote delirium.

    1. Marcantonio E. Postoperative delirium: acute change with long-term implications. Anesth Analg. 2011;112:1202–1211.
    1. Fong TG, Jones RN, Shi P, et al. Delirium accelerates cognitive decline in Alzheimer disease. Neurology. 2009;72(18):1570–5.
    1. Girard TD, Jackson JC, Pandharipande PP, et al. Delirium as a predictor of long-term cognitive impairment in survivors of critical illness. Crit Care Med. 2010;38(7):1513–20.
    1. Ehlenbach WJ, Hough CL, Crane PK, et al. Association between acute care and critical illness hospitalization and cognitive function in older adults. JAMA. 2010;303(8):7, 63–70.

    1. Wilson RS, Hebert LE, Scherr PA, Dong X, Leurgens SE, Evans DA. Cognitive decline after hospitalization in a community population of older persons. Neurology. 2012;78(13):950–6. This paper adds to growing evidence that hospitalization in older adults can lead to long-term cognitive decline.

    1. Pandharipande PP, Girard TD, Jackson JC, et al. Long-Term Cognitive Impairment after Critical Illness. N Engl J Med. 2013;369(14):1306–16. Cognitive outcomes at one year after septic or cardiogenic shock in the ICU were similar to cognitive scores of patients with moderate traumatic brain injury or mild Alzheimer’s disease in 25-30% of patients. This study illustrates the profound long-term cognitive effect of ICU events, including delirium.

    1. Koster S, Hensens AG, Schuurmans MJ, van der Palen J. Consequences of delirium after cardiac operations. Ann Thor Surg. 2012;93(3):705–11. Delirium is associated with functional decline, reduced quality of life, and more hospital readmissions— important patient-centered outcomes.

    1. Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet. 2009;373(9678):1874–82.
    1. Needham DM, Korupolu R, Zanni JM, et al. Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project. Arch Phys Med Rehabil. 2010;91(4):7–7.

    1. Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41(1):278–80. These guidelines from the American College of Critical Care Medicine represent updated expert opinion in the issues of pain, agitation, and delirium in the ICU.

    1. Arenson BG, et al. Effect of intensive care unit environment on in-hospital delirium after cardiac surgery. J Thorac Cardiovasc Surg. 2013 Jun.146(1):172–8. Private rooms with significant natural lighting in the ICU were not associated with reduced delirium after cardiac surgery.

    1. Ettema RG, Van Koeven H, Peelen LM, et al. Preadmission interventions to prevent postoperative complications in older cardiac surgery patients: A systematic review of the literature. Int J Nurs Stud. 2013;20:1–10.
    1. Inouye S, Bogardus S, Charpentier P, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Eng J Med. 1999;340:669–676.
    1. Marcantonio E, Flacker J. Reducing delirium after hip fracture: a randomized trial. J Am Geriatr Soc. 2001;49:516–521.

    1. Wang W, Li H-L, Wang D-X, et al. Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery. Critical Care Med. 2012;40(3):731–9. In a randomized trial of haldol bolus and infusion, the administration of haldol reduced the incidence of delirium and increased the number of delirium-free days.

    1. van den Boogaard M, Schoonhoven L, van Achterberg T, et al. Haloperidol prophylaxis in critically ill patients with a high risk for delirium. Crit Care. 2013;17(1):R9. Results are based on comparison to historical controls or patient that did not receive haldol due to protocol non-compliance, so results must be interpreted cautiously.

    1. Prakanrattana UU, Prapaitrakool SS. Efficacy of risperidone for prevention of postoperative delirium in cardiac surgery. Anaesth Intensive Care. 2007;35(5):714–9.
    1. Kalisvaart K, De Jonghe J, Bogaards M, et al. Haloperidol prophylaxis for elderly hip-surgery patients at risk for delirium: a randomized placebo-controlled study. J Am Geriatr Soc. 2005;53:1658–1666.
    1. Larsen KA, Kelly SE, Stern TA, et al. Administration of olanzapine to prevent postoperative delirium in elderly joint-replacement patients: a randomized, controlled trial. Psychosomatics. 2010;51(5):409–18.

    1. Gilmore ML, Wolfe DJ. Antipsychotic prophylaxis in surgical patients modestly decreases delirium incidence — but not duration — in high-incidence samples: A meta-analysis. Gen Hosp Psych. 2013;35(4):370–5. This meta-analysis of 5 randomized trials (primarily with haloperidol) concluded that prophylaxis with antipsychotic medication reduced the odds of post-operative delirium by greater than 50%.

    1. Teslyar P, Stock VM, Wilk CM, et al. Prophylaxis with antipsychotic medication reduces the risk of post-operative delirium in elderly patients: a meta-analysis. Psychosomatics. 2013;54(2):124–31. This meta-analysis of randomized trials used the same trials as in the prior reference and reached the same conclusion.

    1. Mariscalco G, Cottini M, Zanobini M, et al. Preoperative statin therapy is not associated with a decrease in the incidence of delirium after cardiac operations. Ann Thorac Surg. 2012;93(5):1439–47. Preoperative statin use was not associated with delirium in an observational trial using propensity score analysis; however, the overall incidence of delirium was only 3%, so the delirium assessments may not have been sensitive.

    1. Katznelson R, Djaiani GN, Borger MA, et al. Preoperative use of statins is associated with reduced early delirium rates after cardiac surgery. Anesthesiology. 2009;110(1):67–73.

    1. Dieleman JM, Nierich AP, Rosseel PM, et al. Intraoperative high dose dexamethasone for cardiac surgery: a randomized controlled trial. JAMA. 2012;308:1761–1767. Dexamethasone (1 mg/kg) vs placebo did not reduce the incidence of major adverse events after cardiac surgery, but did slightly reduce the incidence of delirium, albeit with sub-optimal delirium assessments.

    1. Gamberini M, Bolliger D, Lurati Buse GA, et al. Rivastigmine for the prevention of postoperative delirium in elderly patients undergoing elective cardiac surgery—A randomized controlled trial. Crit Care Med. 2009;37(5):1762–8.
    1. van Eijk MD, Roes K, Honing M, et al. Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients: a multicentre, double-blind, placebo-controlled randomized trial. Lancet. 2010;376(9755):1829–37.
    1. Hudetz JA, Patterson KM, Iqbal Z, et al. Ketamine attenuates delirium after cardiac surgery with cardiopulmonary bypass. J Card Vasc Anes. 2009;23(5):651–7.
    1. Riker R, Shehabi Y, Bokesch P, et al. Dexmedetomidine vs midazolam for sedation of critically ill patients. JAMA. 2009;301:489–499.
    1. Maldonado JR, Wysong A, van der Starre PJA, et al. Dexmedetomidine and the reduction of postoperative delirium after cardiac surgery. Psychosomatics. 2009;50(3):206–17.
    1. Shehabi Y, Grant P, Wolfenden H, et al. Prevalence of delirium with dexmedetomidine compared with morphine based therapy after cardiac surgery: a randomized controlled trial (DEXmedetomidine COmpared to Morphine-DEXCOM Study) Anesthesiology. 2009;111(5):1075–84.
    1. Tan J, Ho K. Use of dexmedetomidine as a sedative and analgesic agent in critically ill adult patients: a meta-analysis. Intensive Care Med. 2010;36:926–939.
    1. Flaherty JH, Gonzales JP, Dong B. Antipsychotics in the treatment of delirium in older hospitalized adults: a systematic review. J Am Geriatr Soc. 2011;59:S269–76.
    1. Lacasse H, Perreault MM, Williamson DR. Systematic review of antipsychotics for the treatment of hospital-associated delirium in medically or surgically ill patients. Ann Pharmacother. 2006;40(11):1966–73.
    1. Seitz DP, Gill SS, van Zyl LT. Antipsychotics in the treatment of delirium: a systematic review. J Clin Psychiatry. 2007;68(1):11–21.
    1. Jacobi J, Fraser GL, Coursin DB, et al. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med. 2002;30:119–41.

    1. Chaput AJ, Bryson GL. Postoperative delirium: risk factors and management: Continuing Professional Development. Can J Anesth. 2012;59(3):304–20. Continuing professional development module on postoperative delirium

    1. Tagarakis GI, Voucharas C, Tsolaki F, et al. Ondasetron versus haloperidol for the treatment of postcardiotomy delirium: a prospective, randomized, double-blinded study. J Cardiothorac Surg. 2012;7(1):25. Small study which noted similar improvement in a delirium rating scale for delirious patients receiving haloperidol or ondansetron.

    1. Hakim S, et al. Early treatment with risperidone for subsyndromal delirium after on-pump cardiac surgery in the elderly. Anesthesiology. 2012;116:987–997. This interesting study demonstrates that progression of subsyndromal delirium to full delirium might be reduced with risperidone. It is unclear if long-term outcomes are also improved.

Source: PubMed

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