Modifiable Risk Factors for Delirium in Critically Ill Trauma Patients: A Multicenter Prospective Study

Duceppe, Marc‐Alexandre; Elliott, Audrée; Para, Mélissa; Poirier, Marie-Christine; Delisle, Marie-Soleil; Deckelbaum, Dan; Razek, Tarek; Desjardins, Marie‐Pier; Bertrand, Jean-Claude; Bernard, Francis; Rico, Philippe; Burry, Lisa; Frenette, Anne Julie; Perreault, Marc M.

doi:10.1177/0885066617698646

Cited by 26 publications

(32 citation statements)

References 38 publications

(56 reference statements)

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“…This is likely because midazolam was used less frequently than other sedative agents. Opioids are a known risk factor for delirium in the medical population; however, in trauma patients, where inadequate pain control can lead to delirium, opioids were associated with both increased and decreased risk of delirium . In our analysis, cumulative opioid dose was not associated with delirium.…”

Section: Discussioncontrasting

confidence: 58%

Effect of Neuromuscular Blocking Agents on Sedation Requirements in Trauma Patients with an Open Abdomen

2019

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The appropriate level of sedation in patients with an open abdomen following damage control laparotomy (DCL) is debated. Chemical paralysis with neuromuscular blocking agents (NMBAs) has been used to decrease time to abdominal closure. We sought to evaluate the effect of NMBA use on sedation requirements in patients with an open abdomen and to determine the effect of sedation on patient outcomes. A retrospective cohort study was conducted at an American College of Surgeons’ verified level 1 trauma center. Adult trauma patients who underwent DCL between 2009 and 2015 were included. Patients with an intensive care unit length of stay of less than 48 hours and those who died before abdominal closure were excluded. The NMBA+ group received continuous NMBA within 24 hours of DCL; the NMBA− group did not. The primary outcome was cumulative sedation dose during the 7 days following DCL. Secondary outcomes included Richmond Agitation‐Sedation Scale (RASS) score, mechanical ventilation‐free days, and delirium‐coma‐free days. Delirium‐coma‐free days were analyzed with linear regression. A total of 222 patients were included (NMBA+ 125; NMBA− 97). Demographics were similar between groups including age, Injury Severity Score, and mechanism of injury. The median time to closure in the overall cohort was 2 days (interquartile range [IQR] 1–2 days). Propofol and fentanyl were the primary sedatives used. The NMBA+ group received higher cumulative doses of propofol (NMBA+ 5405 mg, IQR 3103–10,573 mg; NMBA− 3601 mg, IQR 1605–6887 mg; p=0.007), but not of fentanyl. Time to abdominal closure, but not NMBA use, was associated with a higher cumulative propofol dose on multivariate analysis. The NMBA+ group had significantly lower RASS scores on the first 3 days following DCL. Mechanical ventilation‐free days (NMBA+ 20 days vs NMBA− 18 days, p=0.960) and delirium‐coma‐free days (NMBA+ 18 days vs NMBA− 18 days, p=0.610) were similar between the groups. On linear regression, cumulative propofol dose was associated with fewer delirium‐coma‐free days (β‐coefficient −0.007, 95% confidence interval −0.015 to −0.003). In trauma patients managed with DCL, higher cumulative sedative doses were administered in patients who received adjunctive NMBA, although NMBA therapy was not associated with a higher cumulative propofol dose on multivariate analysis. Consideration must be given to the potential effect of sedation on delirium and awakening following DCL.

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Section: Discussioncontrasting

confidence: 58%

Effect of Neuromuscular Blocking Agents on Sedation Requirements in Trauma Patients with an Open Abdomen

2019

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“…Mortality is increased by 11% for every additional 48 h of active delirium, highlighting the requirement for timely detection and treatment. In our study, the incidence of early postoperative delirium was 35%, which is consistent with the findings of previous studies [41, 42] and lower than the incidence of delirium among patients with cancer (49.8%) or trauma ICU patients (38.7%) [15, 43]. We described the incidence of delirium using an algorithm based on the CAM.…”

Section: Discussionsupporting

confidence: 91%

Regional cerebral oxygen saturation and postoperative delirium in endovascular surgery: a prospective cohort study

Wang

Feng

Liu

et al. 2019

Trials

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Background Delirium is an acute mental disorder and common postoperative complication. Monitoring regional cerebral oxygen saturation (rSO 2 ) in endovascular therapeutic surgery may allow real-time monitoring of cerebral desaturation, avoiding profound cerebral dysfunction, and reducing the incidence of delirium. We sought to examine the incidence of delirium in patients undergoing endovascular surgery. Methods This was a clinical cohort trial (registered with http://www.clinicaltrials.gov [NCT02356133]). We monitored the rSO 2 of 43 patients undergoing general anesthesia and cerebral endovascular surgery. The occurrence of delirium after surgery was recorded with the Confusion Assessment Method (CAM). Multivariate logistic regression was performed to identify the main predictor of delirium. Results rSO 2 was significantly different between the delirium and no-delirium groups. The occurrence of delirium was 35% in our cohort, and higher rSO 2 desaturation scores were significantly associated with profound delirium (higher CAM score; odds ratio = 1.002; P = 0.021). The maximum declines of systolic blood pressure were 24.86 (21.78–27.93) and 32.98 (28.78–37.19) in the no-delirium and delirium groups, respectively, which were significantly different ( P = 0.002) but not closely associated with delirium in multivariate analysis ( P = 0.512). Anesthesia, mechanical ventilation duration, and having two vascular risk factors differed significantly between groups but were poorly associated with delirium outcome. Conclusions Elevated rSO 2 desaturation score was predictive of the occurrence of postoperative delirium following endovascular surgery. Monitoring rSO 2 is invaluable for managing controlled hypotension during endovascular surgery and reducing postoperative delirium. Trial registration ClinicalTrials.gov, NCT02356133 . Registered 1 February 2015. All statistical analysis results submitted August 4, 2018. Electronic supplementary material The online version of this article (10.1186/s13063-019-3586-y) contains supplementary material, which is available to authorized users.

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“…During data extraction, two articles were further excluded as they failed to provide outcome data relevant to delirium test characteristics or complications of delirium (38, 39). Of the remaining were eleven articles (40–50) without overlapping data, four final articles were excluded due to the ICU cohorts not exclusively composed of neurocritically ill patients (40–42, 50), thus leaving 7 articles for qualitative synthesis.…”

Section: Resultsmentioning

confidence: 99%

“…There have been broader and well-done reviews relevant to delirium in stroke (59, 61), and our work is uniquely limited by our focus on the critically ill patient affected by primary neurologic conditions. Additionally, we acknowledge our review excluded four studies of impure neurocritically populations (40–42, 50). We note that there is no study validating any delirium tool in the neurocritically ill against the current psychiatric gold-standard for delirium, the DSM-5 (62), which formally excludes coma from inattention (i.e.…”

Section: Discussionmentioning

confidence: 99%

Delirium Monitoring in Neurocritically Ill Patients: A Systematic Review*

Patel

Bednařík

Lee

et al. 2018

Critical Care Medicine

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Modifiable Risk Factors for Delirium in Critically Ill Trauma Patients: A Multicenter Prospective Study

Abstract: We have identified modifiable risk factors for delirium. Future studies should aim at implementing strategies to modify these risk factors and evaluate their impact on the risk of delirium.

Cited by 26 publications

References 38 publications

Effect of Neuromuscular Blocking Agents on Sedation Requirements in Trauma Patients with an Open Abdomen

Effect of Neuromuscular Blocking Agents on Sedation Requirements in Trauma Patients with an Open Abdomen

Regional cerebral oxygen saturation and postoperative delirium in endovascular surgery: a prospective cohort study

Delirium Monitoring in Neurocritically Ill Patients: A Systematic Review*

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