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Review
. 2021 Oct;47(10):1089-1103.
doi: 10.1007/s00134-021-06503-1. Epub 2021 Aug 16.

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

Joanna L Stollings  1   2 , Katarzyna Kotfis  3 , Gerald Chanques  4 , Brenda T Pun  5   6 , Pratik P Pandharipande  5   6   7 , E Wesley Ely  5   6   8   9
Affiliations
Review

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

Joanna L Stollings et al. Intensive Care Med. 2021 Oct.

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.

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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
See this image and copyright information in PMC

References

    1. Morandi A, Piva S, Ely EW, Myatra SN, Salluh JIF, Amare D, Azoulay E, Bellelli G, Csomos A, Fan E, et al. Worldwide survey of the "assessing pain, both spontaneous awakening and breathing trials, choice of drugs, delirium monitoring/management, early exercise/mobility, and family empowerment" (ABCDEF) bundle. Crit Care Med. 2017;45(11):e1111–e1122. doi: 10.1097/CCM.0000000000002640. - DOI - PMC - PubMed
    1. Girard TD, Thompson JL, Pandharipande PP, Brummel NE, Jackson JC, Patel MB, Hughes CG, Chandrasekhar R, Pun BT, Boehm LM, et al. Clinical phenotypes of delirium during critical illness and severity of subsequent long-term cognitive impairment: a prospective cohort study. Lancet Respir Med. 2018;6(3):213–222. doi: 10.1016/S2213-2600(18)30062-6. - DOI - PMC - PubMed
    1. Chanques G, Ely EW, Garnier O, Perrigault F, Eloi A, Carr J, Rowan CM, Prades A, de Jong A, Moritz-Gasser S, et al. The 2014 updated version of the confusion assessment method for the intensive care unit compared to the 5th version of the diagnostic and statistical manual of mental disorders and other current methods used by intensivists. Ann Intensive Care. 2018;8(1):33. doi: 10.1186/s13613-018-0377-7. - DOI - PMC - PubMed
    1. American Psychiatric Association . Diagnostic and statistical manual of mental disorders: DSM-5. American Psychiatric Association; 2013.
    1. Slooter AJC, Otte WM, Devlin JW, Arora RC, Bleck TP, Claassen J, Duprey MS, Ely EW, Kaplan PW, Latronico N, et al. Updated nomenclature of delirium and acute encephalopathy: statement of ten Societies. Intensive Care Med. 2020;46(5):1020–1022. doi: 10.1007/s00134-019-05907-4. - DOI - PMC - PubMed

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