Delirium in critical illness: clinical manifestations, outcomes, and management

Joanna L Stollings, Katarzyna Kotfis, Gerald Chanques, Brenda T Pun, Pratik P Pandharipande, E Wesley Ely, Joanna L Stollings, Katarzyna Kotfis, Gerald Chanques, Brenda T Pun, Pratik P Pandharipande, E Wesley Ely

Abstract

Delirium is the most common manifestation of brain dysfunction in critically ill patients. In the intensive care unit (ICU), duration of delirium is independently predictive of excess death, length of stay, cost of care, and acquired dementia. There are numerous neurotransmitter/functional and/or injury-causing hypotheses rather than a unifying mechanism for delirium. Without using a validated delirium instrument, delirium can be misdiagnosed (under, but also overdiagnosed and trivialized), supporting the recommendation to use a monitoring instrument routinely. The best-validated ICU bedside instruments are CAM-ICU and ICDSC, both of which also detect subsyndromal delirium. Both tools have some inherent limitations in the neurologically injured patients, yet still provide valuable information about delirium once the sequelae of the primary injury settle into a new post-injury baseline. Now it is known that antipsychotics and other psychoactive medications do not reliably improve brain function in critically ill delirious patients. ICU teams should systematically screen for predisposing and precipitating factors. These include exacerbations of cardiac/respiratory failure or sepsis, metabolic disturbances (hypoglycemia, dysnatremia, uremia and ammonemia) receipt of psychoactive medications, and sensory deprivation through prolonged immobilization, uncorrected vision and hearing deficits, poor sleep hygiene, and isolation from loved ones so common during COVID-19 pandemic. The ABCDEF (A2F) bundle is a means to facilitate implementation of the 2018 Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (PADIS) Guidelines. In over 25,000 patients across nearly 100 institutions, the A2F bundle has been shown in a dose-response fashion (i.e., greater bundle compliance) to yield improved survival, length of stay, coma and delirium duration, cost, and less ICU bounce-backs and discharge to nursing homes.

Keywords: Antipsychotics; Cognitive impairment; Critical care; Delirium; ICU Liberation.

© 2021. Springer-Verlag GmbH Germany, part of Springer Nature.

Figures

Fig. 1
Fig. 1
Prevalence of delirium phenotypes. Each plot area (on the y-axis) shows the percentage of the study participatnets in the hospital who had any delirium, a single delirium phenotype, or a combination of multiple delirum phenotypes according to the study day (shown on the x-axis). The grey shading indicates the overall percentage of participants with delirium on each study day. The red lines and shaded area represent the numbe of phenotypes of delirum present, with darker reds respresenting the presence of more phenotypes of delirum. The lighetest red regions show the percentage of participants with a given single phenotype (H hypoxic, M metabolic, Sed sedative, Sep septic)
Fig. 2
Fig. 2
Global cognition scores in survivors of critical illness
Fig. 3
Fig. 3
Diagnosis and treatment algorithm for critically ill patients. Exhibiting a sudden change in their mental status including inappropriate speech

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Source: PubMed

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