Background & Aims
BACKGROUND
Delirium, is a common manifestation of acute brain dysfunction in critically ill patients, is reported to be associated with poor short-term outcomes and may result in adverse sequelae even years after ICU discharge. Inadequate pain management and disregard towards the normal cicardian patterns of sleep is a common cause. This study was designed to find out the incidence and prevalence of delirium in the ICU and explore relationship with inadequate pain management.
AIMS & OBJECTIVES
To determine incidence and prevalence of ICU delirium and its correlation with pain and other risk factors.
Primary Objective
1.Incidence and prevalence of ICU Delirium as measured by RASS and CAM-ICU
Secondary Objective
1.Subtyping of delirium using RASS
2.BPS, SOFA measured at entry to the ICU and every 24 hours till discharge from ICU/mortality.
3.APACHE IV, Barthel’s ADL measured at entry to the ICU.
4.Impact of delirium on Length of Stay
Methods
250 consecutive patients admitted in the Intensive Care Unit were assessed, of which 110 patients were enrolled. Patients <18 years of age, with primary diagnosis of delirium tremens, bilateral hearing loss, severe aphasias and neurotrauma/neurosurgery and cardiac surgery patients were excluded.
Study design
This was a prospective longitudinal, observational study.
On admission: APACHE IV, SOFA, BPS and RASS followed by CAM ICU were noted. Estimated mortality and estimated length of stay (LOS) were derived from APACHE IV. If CAM ICU was positive on admission it was counted as incidence, any CAM ICU positive during the stay was characterised as prevalence.
Every 24 hours: SOFA, BPS, RASS followed by CAM ICU were noted. Patients with RASS of +1 to +4 were subgrouped as hyperactive delirium while RASS of 0 to -4 were subgrouped as hypoactive delirium.
SAMPLE SIZE
n0=(z)**2*(p)(q)/(d)**2 = 96. 10% for attrition= 105
CI=95%;?=0.05.
Results
The present study showed the prevalence rate of delirium to be 66.3% and the incidence rate to be 61.45% in patients admitted to the ICU. Out of the motor subtypes, hypoactive delirium constituted more than half of the cases of delirium (n = 45, 61.6% of the cases prevalence 40%) while the mixed and hyperactive subtypes were 21.9% (prevalence 15%) and 16.4% (prevalence 11%) respectively. Statistically significant higher prevalence of delirium was seen in sicker patients as denoted by a higher average SOFA score (8.28+3.33 vs. 2.28+0.96) and higher APACHE IV and APS scores (71.83+31.3; 65.13+28.42 Vs 31.2+10.92; 27.0+9.36). Statistically significant higher prevalence of pain was seen in patients suffering from delirium (6.87+0.74 vs 3.88+0.45; p< 0.00001). LOS was 2.39 days longer in delrious patients while non-delirious patients had LOS 1 day shorter than the predicted SOFA adjusted LOS.
Conclusions
The present study concludes that ICU delirium is a highly prevalent condition in the ICU. The major risk factor for it include pre-admission frailty and sepsis. Hypoactive delirium is the most common subtype and requires special attention as the signs and symptoms might not be overt. Unacceptable levels of pain and inadequate pain management amongst ICU patients is an independent risk factor for ICU delirium. ICU delirium results in longer ICU stays and can have significant financial implications. Simple interventions such as institutional adherence to Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption (PADIS) guidelines can come a long way in managing and preventing delirium in patients.
References
1. Jones RN, Fong TG, Metzger E, Tulebaev S, Yang FM, Alsop DC, et al. Aging, brain disease, and reserve: implications for delirium. Am J Geriatr Psychiatry. 2010 Feb;18(2):117–27.
2. Gaudreau J-D, Gagnon P. Psychotogenic drugs and delirium pathogenesis: the central role of the thalamus. Med Hypotheses. 2005;64(3):471–5.
3. Vasilevskis EE, Han JH, Hughes CG, Ely EW. Epidemiology and risk factors for delirium across hospital settings. Best Pract Res Clin Anaesthesiol. 2012 Sep;26(3):277–87.
4. Needham DM, Colantuoni E, Dinglas VD, Hough CL, Wozniak AW, Jackson JC, et al. Rosuvastatin versus placebo for delirium in intensive care and subsequent cognitive impairment in patients with sepsis-associated acute respiratory distress syndrome: an ancillary study to a randomised controlled trial. Lancet Respir Med. 2016 Mar;4(3):203–12.
5. Cavallazzi R, Saad M, Marik PE. Delirium in the ICU: an overview. Ann Intensive Care. 2012 Dec 27;2:49.
6. Grover S, Sarkar S, Yaddanapudi LN, Ghosh A, Desouza A, Basu D. Intensive Care Unit delirium: A wide gap between actual prevalence and psychiatric referral. J Anaesthesiol Clin Pharmacol. 2017;33(4):480–6.
7. Salluh JI, Soares M, Teles JM, Ceraso D, Raimondi N, Nava VS, et al. Delirium epidemiology in critical care (DECCA): an international study. Crit Care. 2010;14(6):R210.
8. van Eijk MMJ, van Marum RJ, Klijn IAM, de Wit N, Kesecioglu J, Slooter AJC. Comparison of delirium assessment tools in a mixed intensive care unit. Crit Care Med. 2009 Jun;37(6):1881–5.
9. Fong TG, Tulebaev SR, Inouye SK. Delirium in elderly adults: diagnosis, prevention and treatment. Nat Rev Neurol. 2009 Apr;5(4):210–20.
10. Inouye SK. Delirium in hospitalized older patients. Clin Geriatr Med. 1998 Nov;14(4):745–64.
11. Inouye SK. Delirium in older persons. N Engl J Med. 2006 Mar 16;354(11):1157–65.
12. Pisani MA, McNicoll L, Inouye SK. Cognitive impairment in the intensive care unit. Clin Chest Med. 2003 Dec;24(4):727–37.
13. Jones RN, Fong TG, Metzger E, Tulebaev S, Yang FM, Alsop DC, et al. Aging, brain disease, and reserve: implications for delirium. Am J Geriatr Psychiatry. 2010 Feb;18(2):117–27.
14. Gaudreau J-D, Gagnon P. Psychotogenic drugs and delirium pathogenesis: the central role of the thalamus. Med Hypotheses. 2005;64(3):471–5.
Presenting Author
Pradeep Atter
Poster Authors
Topics
- Pain in Special Populations: Non-verbal