Postoperative delirium (POD) is a common neuropsychiatric disorder characterized by inattention, fluctuating levels of consciousness, and disorganized thinking. POD can have serious consequences, including institutionalization and death. Risk stratification may target prevention to individuals at greater risk of POD. The objective of this study was to identify all published POD risk prediction models (RPMs) and to compare them with regard to their clinical practicability and predictive and discriminative performance. PubMed and EMBASE were searched from inception to January 1, 2013, for articles describing POD RPMs. Studies were included if they presented data from a cohort study, examined one or more RPMs, examined POD as an outcome, and assessed the performance of the RPM(s). Thirty of 2,246 articles were included, and 37 RPMs were found. Sixteen and six studies described individuals who had undergone cardiovascular and orthopedic surgery, respectively. The Confusion Assessment Method (CAM) for the intensive care unit checklist was the most often used diagnostic method (65%), followed by the Diagnostic and Statistical Manual of Mental Disorders (DSM), Fourth Edition criteria (16%). Predictors most often used in RPMs were age (20), preoperative Mini-Mental State Examination score (10), and preoperative increased alcohol use (7). Thirty RPMs were not validated, three were validated internally, and four were validated externally. Size of the models was not associated with their discriminatory performance. Instead of creating steadily new RPMs, existing RPMs should be further tested, improved, and meta-analytically integrated. It may be too early to implement a particular PODRPM in clinical practice with confidence.

IMPORTANCE It remains uncertain whether nebulization of mucolytics with bronchodilators should be applied for clinical indication or preventively in intensive care unit (ICU) patients receiving invasive ventilation. OBJECTIVETo determine if a strategy that uses nebulization for clinical indication (on-demand) is noninferior to one that uses preventive (routine) nebulization. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial enrolling adult patients expected to need invasive ventilation for more than 24 hours at 7 ICUs in the Netherlands. INTERVENTIONSOn-demand nebulization of acetylcysteine or salbutamol (based on strict clinical indications, n = 471) or routine nebulization of acetylcysteine with salbutamol (every 6 hours until end of invasive ventilation, n = 473). MAIN OUTCOMES AND MEASURESThe primary outcome was the number of ventilator-free days at day 28, with a noninferiority margin for a difference between groups of −0.5 days. Secondary outcomes included length of stay, mortality rates, occurrence of pulmonary complications, and adverse events. RESULTS Nine hundred twenty-two patients (34% women; median age, 66 (interquartile range [IQR], 54-75 years) were enrolled and completed follow-up. At 28 days, patients in the on-demand group had a median 21 (IQR, 0-26) ventilator-free days, and patients in the routine group had a median 20 (IQR, 0-26) ventilator-free days (1-sided 95% CI, −0.00003 to ϱ). There was no significant difference in length of stay or mortality, or in the proportion of patients developing pulmonary complications, between the 2 groups. Adverse events (13.8% vs 29.3%; difference, −15.5% [95% CI, −20.7% to −10.3%]; P < .001) were more frequent with routine nebulization and mainly related to tachyarrhythmia (12.5% vs 25.9%; difference, −13.4% [95% CI, −18.4% to −8.4%]; P < .001) and agitation (0.2% vs 4.3%; difference, −4.1% [95% CI, −5.9% to −2.2%]; P < .001). CONCLUSIONS AND RELEVANCEAmong ICU patients receiving invasive ventilation who were expected to not be extubated within 24 hours, on-demand compared with routine nebulization of acetylcysteine with salbutamol did not result in an inferior number of ventilator-free days. On-demand nebulization may be a reasonable alternative to routine nebulization.

We describe the incidence and practice of prone positioning and determined the association of use of prone positioning with outcomes in invasively ventilated patients with acute respiratory distress syndrome (ARDS) due to coronavirus disease 2019 (COVID-19) in a national, multicenter observational study, performed at 22 intensive care units in the Netherlands. Patients were categorized into 4 groups, based on indication for and actual use of prone positioning. The primary outcome was 28-day mortality. Secondary endpoints were 90-day mortality, and ICU and hospital length of stay. In 734 patients, prone positioning was indicated in 60%—the incidence of prone positioning was higher in patients with an indication than in patients without an indication for prone positioning (77 vs. 48%, p = 0.001). Patients were left in the prone position for median 15.0 (10.5–21.0) hours per full calendar day—the duration was longer in patients with an indication than in patients without an indication for prone positioning (16.0 (11.0–23.0) vs. 14.0 (10.0–19.0) hours, p < 0.001). Ventilator settings and ventilation parameters were not different between the four groups, except for FiO2 which was higher in patients having an indication for and actually receiving prone positioning. Our data showed no difference in mortality at day 28 between the 4 groups (HR no indication, no prone vs. no indication, prone vs. indication, no prone vs. indication, prone: 1.05 (0.76–1.45) vs. 0.88 (0.62–1.26) vs. 1.15 (0.80–1.54) vs. 0.96 (0.73–1.26) (p = 0.08)). Factors associated with the use of prone positioning were ARDS severity and FiO2. The findings of this study are that prone positioning is often used in COVID-19 patients, even in patients that have no indication for this intervention. Sessions of prone positioning lasted long. Use of prone positioning may affect outcomes.

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