Dalila Veiga

Postoperative Delirium in Intensive Care Patients: Risk Factors and Outcome

BACKGROUND AND OBJECTIVES Postoperative delirium (POD) in Surgical Intensive Care patients is an important independent outcome determinant. The purpose of our study was to evaluate the incidence and determinants of POD. METHODS Prospective cohort study conducted during a period of 10 months in a Post-Anesthesia Care Unit (PACU) with five intensive care beds. All consecutive adult patients submitted to major surgery were enrolled. Demographic data, perioperative variables, length of stay (LOS) and the mortality at PACU, hospital and at 6-months follow-up were recorded. Postoperative delirium was evaluated using the Intensive Care Delirium Screening Checklist (ICDSC). Descriptive analyses were conducted and the Mann-Whitney test, Chi-square test or Fishers exact test were used for comparisons. Logistic regression analysis evaluated the determinants of POD with calculation of odds ratio (OR) and its confidence interval 95% (95% CI). RESULTS There were 775 adult PACU admissions and 95 patients had exclusion criteria. Of the remaining 680 patients, 128 (18.8%) developed POD. Independent determinants of POD identified were age, ASA-PS, emergency surgery and total amount of fresh frozen plasma administered during surgery. Patients with delirium had higher mortality rates, were more severely ill and stayed longer at the PACU and in the hospital. POD was an independent risk factor for hospital mortality DISCUSSION There was a high incidence of delirium had a high incidence in intensive care surgical patients. POD was associated with worse severity of disease scores, longer LOS in hospital, and in PACU and higher mortality rates. The independent risk factors for POD were age, ASAPS, emergency surgery and the amount of plasma administered during surgery.

Delirium assessment in postoperative patients: validation of the portuguese version of the Nursing Delirium Screening Scale in critical care

BACKGROUND AND OBJECTIVES The aim of this study was to validate the Portuguese version of the Nursing Delirium Screening Scale (Nu-DESC) for use in critical care settings. METHODS We simultaneously and independently evaluated all postoperative patients admitted to a surgical Intensive Care Unit (SICU) over a 1-month period for delirium, using the Portuguese versions of both the Nu-DESC and the Intensive Care Delirium Screening Checklist (ICDSC) within 24 hours of admission by both the research staff physician and one bedside nurse. We determined the diagnostic accuracy of the Nu-DESC using sensitivity, specificity and ROC curve analyses. We assessed reliability between nurses and the research staff physician for Nu-DESC by intraclass correlation coefficient (ICC). We assessed agreement and reliability between Nu-DESC and ICDSC by overall and specific proportions of agreement and by kappa statistics. RESULTS Based on the ICDSC, we diagnosed delirium in 12 of the 78 patients. Reliability between nurses and the staff physician for total Nu-DESC score was high. Agreement between nurses and staff physician in the delirium diagnosis was perfect. The proportion of overall agreement between Nu-DESC and ICDSC in the delirium diagnosis was 0.88 and the kappa ranged from 0.79 to 0.93. Nu-DESC Sensitivity was 100 and specificity was 86%. CONCLUSIONS The Portuguese version of the Nu-DESC appears to be an accurate and reliable assessment and monitoring instrument for delirium in critical care settings.

Anaesthetic, procedure and complications management of serial whole-lung lavage in an obese patient with pulmonary alveolar proteinosis: case report.

BACKGROUND AND OBJECTIVES The first case of Pulmonary Alveolar Proteinosis (PAP) was described by Rose in 1958, but it is still a rare disorder. PAP is characterized by deposition of lipoproteinaceous material secondary to abnormal processing of surfactant by macrophages. Patients may suffer from progressive dyspnea and cough that at times is accompanied by worsening hypoxia and its course can vary from progressive deterioration to spontaneous improvement. Many therapies have been used to treat PAP including antibiotics, postural drainage, and intermittent positive pressure breathing with aerosolized Acetylcysteine, heparin and saline. At present, the mainstay of treatment is whole lung lavage (WLL). Although generally well tolerated, WLL can be associated with some complications. CASE REPORT We report a case of severe PAP through the anaesthetic, procedure and complications management of pulmonary alveolar proteinosis in one patient who has undergone multiple, alternating, single-lung lavages over the past seven years, the last three in our hospital, with improvements in her symptoms following each therapy.

Outcome after hepatectomy-delirium as an independent predictor for mortality

BackgroundMost studies that follow up hepatectomy cases are limited in scope to an investigation of mortality and morbidity rates or the costs and length of hospital stay. In this study the authors aimed to characterize the quality of life and to evaluate mortality and its determinants after hepatectomy.MethodsThis prospective study was carried in a Post-Anaesthesia Care Unit (PACU) over 15 months, and 70 patients submitted to hepatectomy were enrolled. Demographic and peri-operative characteristics were evaluated for associations with mortality. At admission and 6 months after discharge, patients completed a Short Form-36 questionnaire (SF-36) and have their independence in Activities of Daily Living (ADL) was evaluated. Binary and multiple logistic regression analyses were used to evaluate of associations with mortality, and the Wilcoxon signed rank test was used to compare SF-36 scores before and after 6 months after hepatectomy.ResultsThe mortality rate was 19% at 6 months. Multivariate analysis identified postoperative delirium as an independent determinant for mortality. Six months after discharge, 46% patients stated that their health in general was better or much better than that 1 year previously. Six months after hepatectomy, patients had worse scores in the physical function domain of SF-36; however, scores for all the other domains did not differ. At this time point, patients were more dependent in instrumental ADL than before surgery (32% versus 7%, p = 0.027).ConclusionThis study identified postoperative delirium as an independent risk factor for mortality 6 months after hepatectomy. After 6 months, survivors were more dependent in instrumental ADL tasks and had worse scores in the physical function domain of SF-36.

Delirium pós-operatório em pacientes críticos: fatores de risco e resultados

BACKGROUND AND OBJECTIVES: Postoperative delirium (POD) in Surgical Intensive Care patients is an important independent outcome determinant. The purpose of our study was to evaluate the incidence and determinants of POD. METHODS: Prospective cohort study conducted during a period of 10 months in a Post-Anesthesia Care Unit (PACU) with five intensive care beds. All consecutive adult patients submitted to major surgery were enrolled. Demographic data, perioperative variables, length of stay (LOS) and the mortality at PACU, hospital and at 6-months follow-up were recorded. Postoperative delirium was evaluated using the Intensive Care Delirium Screening Checklist (ICDSC). Descriptive analyses were conducted and the Mann-Whitney test, Chi-square test or Fishers exact test were used for comparisons. Logistic regression analysis evaluated the determinants of POD with calculation of odds ratio (OR) and its confidence interval 95% (95% CI). RESULTS: There were 775 adult PACU admissions and 95 patients had exclusion criteria. Of the remaining 680 patients, 128 (18.8%) developed POD. Independent determinants of POD identified were age, ASA-PS, emergency surgery and total amount of fresh frozen plasma administered during surgery. Patients with delirium had higher mortality rates, were more severely ill and stayed longer at the PACU and in the hospital. POD was an independent risk factor for hospital mortality DISCUSSION: There was a high incidence of delirium had a high incidence in intensive care surgical patients. POD was associated with worse severity of disease scores, longer LOS in hospital, and in PACU and higher mortality rates. The independent risk factors for POD were age, ASA-PS, emergency surgery and the amount of plasma administered during surgery.JUSTIFICATIVA Y OBJETIVOS: El delirio postoperatorio (DPO) en pacientes quirurgicos en cuidados intensivos es un resultado independiente y un importante determinante. El objetivo de nuestro estudio fue evaluar la incidencia y los determinantes del DPO. METODOS: Estudio prospectivo de cohorte realizado durante un periodo de 10 meses en una unidad de recuperacion de postanestesia (URPA) con cinco camas especializadas en cuidados intensivos. Todos los pacientes adultos consecutivos que fueron sometidos a cirugia mayor fueron incluidos. Los datos demograficos, las variables perioperatorias, el tiempo de ingreso (TI) y la mortalidad en la URPA en el hospital y en los 6 meses de seguimiento quedaron registrados. El delirio postoperatorio se evaluo utilizando el Checklist para la seleccion de delirio en cuidados intensivos (Intensive Care Delirium Screening Checklist - ICDSC). Los analisis descriptivos fueron realizados y el test de Mann-Whitney, Xi-Cuadrado (Xi2) y el test exacto de Fisher fueron usados para las comparaciones. El analisis de regresion logistica evaluo los factores determinantes del DPO con el calculo de la razon de chances (RC) y su intervalo de confianza de 95% (IC 95%). RESULTADOS: La admision fue de 775 pacientes adultos en la URPA y 95 pacientes no respetaron los criterios de inclusion. De los 680 pacientes restantes, 128 (18,8%) desarrollaron DPO. Los determinantes independientes de DPO identificados fueron la edad, ASA-PS, cirugia de emergencia y la cantidad total de plasma fresco congelado (PFC) administrado durante la cirugia. Los pacientes con delirio tuvieron tasas mas elevadas de mortalidad, estaban mas gravemente enfermos y permanecieron mas tiempo en la URPA y en el hospital. El DPO fue un factor de riesgo independiente para la mortalidad hospitalaria. DISCUSION: La incidencia de delirio fue elevada en los pacientes quirurgicos en cuidados intensivos. El DPO estuvo asociado con una peor puntuacion de gravedad de la enfermedad, tiempo de permanencia mas largo en el hospital y en la URPA y tasas mas elevadas de mortalidad. Los factores de riesgo independientes para DPO fueron la edad, ASA-PS, cirugia de emergencia y cantidad de plasma administrado durante la cirugia.

Procedimento e complicações anestésicas no manejo de lavagem pulmonar total em paciente obeso com proteinose alveolar pulmonar: relato de caso

JUSTIFICATIVA Y OBJETIVOS: El primer caso de proteinosis alveolar pulmonar (PAP) fue descrito por Rose en 1958, pero todavia continua siendo un trastorno raro. La PAP se caracteriza por la deposicion de material lipoproteico secundario al procesamiento anormal de surfactantes por los macrofagos. Los pacientes pueden tener disnea progresiva y tos, a veces seguidas de un agravamiento de la hipoxia, y su curso puede variar de deterioracion progresiva a una mejoria espontanea. A lo largo de los anos, muchas terapias han sido usadas para tratar la PAP, incluyendo antibioticos, drenaje postural y ventilacion con presion positiva intermitente con acetilcisteina, heparina y suero fisiologico en aerosol. Hoy por hoy, la base del tratamiento es el lavado pulmonar total (LPT), descrito por primera vez por Ramirez-Rivera y col. Existen tres variantes de la enfermedad: congenita, secundaria y adquirida. Las recientes investigaciones sugieren que en la forma mas comun (PAP adquirida [idiopatica]), la autoinmunidad contra el factor estimulador de las colonias de granulocitos y macrofagos (FEC-GM) pulmonares desempena un importante papel. El factor recombinante que estimula las colonias de granulocitos y macrofagos parece beneficiarse con un subconjunto de pacientes adultos con PAP y puede representar una alternativa en el tratamiento de la enfermedad, pero la tasa de exito todavia no es suficiente para substituir la LPT. La LPT, aunque sea generalmente bien tolerada, puede estar asociada con algunas complicaciones. RELATO DE CASO: Relatamos un caso de PAP grave durante el procedimiento anestesico y las complicaciones en el manejo de la proteinosis alveolar pulmonar en un paciente que habia sido sometido a multiples y alternados lavados de uno de los pulmones a lo largo de siete anos (los ultimos tres en nuestro hospital), con una mejoria de los sintomas despues de cada tratamiento.

Postoperative delirium in intensive care patients: factores de riesgo y resultados

BACKGROUND AND OBJECTIVES: Postoperative delirium (POD) in Surgical Intensive Care patients is an important independent outcome determinant. The purpose of our study was to evaluate the incidence and determinants of POD. METHODS: Prospective cohort study conducted during a period of 10 months in a Post-Anesthesia Care Unit (PACU) with five intensive care beds. All consecutive adult patients submitted to major surgery were enrolled. Demographic data, perioperative variables, length of stay (LOS) and the mortality at PACU, hospital and at 6-months follow-up were recorded. Postoperative delirium was evaluated using the Intensive Care Delirium Screening Checklist (ICDSC). Descriptive analyses were conducted and the Mann-Whitney test, Chi-square test or Fishers exact test were used for comparisons. Logistic regression analysis evaluated the determinants of POD with calculation of odds ratio (OR) and its confidence interval 95% (95% CI). RESULTS: There were 775 adult PACU admissions and 95 patients had exclusion criteria. Of the remaining 680 patients, 128 (18.8%) developed POD. Independent determinants of POD identified were age, ASA-PS, emergency surgery and total amount of fresh frozen plasma administered during surgery. Patients with delirium had higher mortality rates, were more severely ill and stayed longer at the PACU and in the hospital. POD was an independent risk factor for hospital mortality DISCUSSION: There was a high incidence of delirium had a high incidence in intensive care surgical patients. POD was associated with worse severity of disease scores, longer LOS in hospital, and in PACU and higher mortality rates. The independent risk factors for POD were age, ASA-PS, emergency surgery and the amount of plasma administered during surgery.JUSTIFICATIVA Y OBJETIVOS: El delirio postoperatorio (DPO) en pacientes quirurgicos en cuidados intensivos es un resultado independiente y un importante determinante. El objetivo de nuestro estudio fue evaluar la incidencia y los determinantes del DPO. METODOS: Estudio prospectivo de cohorte realizado durante un periodo de 10 meses en una unidad de recuperacion de postanestesia (URPA) con cinco camas especializadas en cuidados intensivos. Todos los pacientes adultos consecutivos que fueron sometidos a cirugia mayor fueron incluidos. Los datos demograficos, las variables perioperatorias, el tiempo de ingreso (TI) y la mortalidad en la URPA en el hospital y en los 6 meses de seguimiento quedaron registrados. El delirio postoperatorio se evaluo utilizando el Checklist para la seleccion de delirio en cuidados intensivos (Intensive Care Delirium Screening Checklist - ICDSC). Los analisis descriptivos fueron realizados y el test de Mann-Whitney, Xi-Cuadrado (Xi2) y el test exacto de Fisher fueron usados para las comparaciones. El analisis de regresion logistica evaluo los factores determinantes del DPO con el calculo de la razon de chances (RC) y su intervalo de confianza de 95% (IC 95%). RESULTADOS: La admision fue de 775 pacientes adultos en la URPA y 95 pacientes no respetaron los criterios de inclusion. De los 680 pacientes restantes, 128 (18,8%) desarrollaron DPO. Los determinantes independientes de DPO identificados fueron la edad, ASA-PS, cirugia de emergencia y la cantidad total de plasma fresco congelado (PFC) administrado durante la cirugia. Los pacientes con delirio tuvieron tasas mas elevadas de mortalidad, estaban mas gravemente enfermos y permanecieron mas tiempo en la URPA y en el hospital. El DPO fue un factor de riesgo independiente para la mortalidad hospitalaria. DISCUSION: La incidencia de delirio fue elevada en los pacientes quirurgicos en cuidados intensivos. El DPO estuvo asociado con una peor puntuacion de gravedad de la enfermedad, tiempo de permanencia mas largo en el hospital y en la URPA y tasas mas elevadas de mortalidad. Los factores de riesgo independientes para DPO fueron la edad, ASA-PS, cirugia de emergencia y cantidad de plasma administrado durante la cirugia.

Delirio postoperatorio en pacientes en cuidados intensivos

BACKGROUND AND OBJECTIVES: Postoperative delirium (POD) in Surgical Intensive Care patients is an important independent outcome determinant. The purpose of our study was to evaluate the incidence and determinants of POD. METHODS: Prospective cohort study conducted during a period of 10 months in a Post-Anesthesia Care Unit (PACU) with five intensive care beds. All consecutive adult patients submitted to major surgery were enrolled. Demographic data, perioperative variables, length of stay (LOS) and the mortality at PACU, hospital and at 6-months follow-up were recorded. Postoperative delirium was evaluated using the Intensive Care Delirium Screening Checklist (ICDSC). Descriptive analyses were conducted and the Mann-Whitney test, Chi-square test or Fishers exact test were used for comparisons. Logistic regression analysis evaluated the determinants of POD with calculation of odds ratio (OR) and its confidence interval 95% (95% CI). RESULTS: There were 775 adult PACU admissions and 95 patients had exclusion criteria. Of the remaining 680 patients, 128 (18.8%) developed POD. Independent determinants of POD identified were age, ASA-PS, emergency surgery and total amount of fresh frozen plasma administered during surgery. Patients with delirium had higher mortality rates, were more severely ill and stayed longer at the PACU and in the hospital. POD was an independent risk factor for hospital mortality DISCUSSION: There was a high incidence of delirium had a high incidence in intensive care surgical patients. POD was associated with worse severity of disease scores, longer LOS in hospital, and in PACU and higher mortality rates. The independent risk factors for POD were age, ASA-PS, emergency surgery and the amount of plasma administered during surgery.JUSTIFICATIVA Y OBJETIVOS: El delirio postoperatorio (DPO) en pacientes quirurgicos en cuidados intensivos es un resultado independiente y un importante determinante. El objetivo de nuestro estudio fue evaluar la incidencia y los determinantes del DPO. METODOS: Estudio prospectivo de cohorte realizado durante un periodo de 10 meses en una unidad de recuperacion de postanestesia (URPA) con cinco camas especializadas en cuidados intensivos. Todos los pacientes adultos consecutivos que fueron sometidos a cirugia mayor fueron incluidos. Los datos demograficos, las variables perioperatorias, el tiempo de ingreso (TI) y la mortalidad en la URPA en el hospital y en los 6 meses de seguimiento quedaron registrados. El delirio postoperatorio se evaluo utilizando el Checklist para la seleccion de delirio en cuidados intensivos (Intensive Care Delirium Screening Checklist - ICDSC). Los analisis descriptivos fueron realizados y el test de Mann-Whitney, Xi-Cuadrado (Xi2) y el test exacto de Fisher fueron usados para las comparaciones. El analisis de regresion logistica evaluo los factores determinantes del DPO con el calculo de la razon de chances (RC) y su intervalo de confianza de 95% (IC 95%). RESULTADOS: La admision fue de 775 pacientes adultos en la URPA y 95 pacientes no respetaron los criterios de inclusion. De los 680 pacientes restantes, 128 (18,8%) desarrollaron DPO. Los determinantes independientes de DPO identificados fueron la edad, ASA-PS, cirugia de emergencia y la cantidad total de plasma fresco congelado (PFC) administrado durante la cirugia. Los pacientes con delirio tuvieron tasas mas elevadas de mortalidad, estaban mas gravemente enfermos y permanecieron mas tiempo en la URPA y en el hospital. El DPO fue un factor de riesgo independiente para la mortalidad hospitalaria. DISCUSION: La incidencia de delirio fue elevada en los pacientes quirurgicos en cuidados intensivos. El DPO estuvo asociado con una peor puntuacion de gravedad de la enfermedad, tiempo de permanencia mas largo en el hospital y en la URPA y tasas mas elevadas de mortalidad. Los factores de riesgo independientes para DPO fueron la edad, ASA-PS, cirugia de emergencia y cantidad de plasma administrado durante la cirugia.