Finn M. Radtke

Different assessment tools for intensive care unit delirium: which score to use?

Objective: To compare validity and reliability of three instruments for detection and assessment of delirium in intensive care unit (ICU) patients. Delirium in critically ill patients is associated with higher mortality, prolonged duration of ICU stay, and greater healthcare costs. Currently, there are several assessment tools available for detection of delirium, but only a few of these assessment systems are developed specifically to screen for delirium in ICU patients. Design: Prospective cohort study. Setting: ICU at a university hospital. Patients: A total of 156 surgical patients aged ≥60 yrs consecutively admitted to the ICU, with a length of stay of at least 24 hrs. Measurements and Main Results: This study was approved by the institutional ethics committee. Trained staff members performed daily and independently the Confusion Assessment Method for the ICU (CAM-ICU), the Nursing Delirium Screening Scale (Nu-DESC), and the Delirium Detection Score (DDS). These evaluations were compared against the reference standard conducted by a delirium expert (blinded to the study), who used delirium criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Of 156 patients, 63 (40%) were identified as delirious by the reference standard during the study. Using the CAM-ICU and the Nu-DESC, we measured comparable sensitivities (CAM-ICU, 81%; Nu-DESC, 83%). The specificity of the CAM-ICU was significantly higher than that of the Nu-DESC (96% vs. 81%, p < .01). In contrast, the DDS showed poor sensitivity (30%), whereas the specificity was significantly higher compared with the Nu-DESC (DDS, 91%; Nu-DESC, 81%, p < .05). The interrater reliability was “almost perfect” for the CAM-ICU (&kgr; = 0.89) and “substantial” for DDS and Nu-DESC (&kgr; = 0.79, 0.68). Conclusion: The CAM-ICU showed the best validity of the evaluated scales to identify delirium in ICU patients. The Nu-DESC might be an alternative tool for detection of ICU delirium. The DDS should not be used as a screening tool.

Monitoring depth of anaesthesia in a randomized trial decreases the rate of postoperative delirium but not postoperative cognitive dysfunction

BACKGROUND Postoperative delirium in elderly patients is a frequent complication and associated with poor outcome. The aim of this parallel group study was to determine whether monitoring depth of anaesthesia influences the incidence of postoperative delirium. METHODS Patients who were planned for surgery in general anaesthesia expected to last at least 60 min and who were older than 60 yr were included between March 2009 and May 2010. A total of 1277 patients of a consecutive sample were randomized (n=638 open, n=639 blinded) and the data of 1155 patients were analysed (n=575 open, n=580 blinded). In one group, the anaesthesiologists were allowed to use the bispectral index (BIS) data to guide anaesthesia, while in the other group, BIS monitoring was blinded. Cognitive function was evaluated at baseline, 1 week, and 3 months after operation. RESULTS Delirium incidence was lower in patients guided with BIS. Postoperative delirium was detected in 95 patients (16.7%) in the intervention group compared with 124 patients (21.4%) in the control group (P=0.036). In a multivariate analysis, the percentage of episodes of deep anaesthesia (BIS values <20) were independently predictive for postoperative delirium (P=0.006; odds ratio 1.027). BIS monitoring did not alter the incidence of postoperative cognitive dysfunction (7th day P=0.062; 90th day P=0.372). CONCLUSIONS Intraoperative neuromonitoring is associated with a lower incidence of delirium, possibly by reducing extreme low BIS values. Therefore, in high-risk surgical patients, this may give the anaesthesiologist a possibility to influence one precipitating factor in the complex genesis of delirium. Clinical trial registration ISRCTN Register: 36437985. http://www.controlled-trials.com/ISRCTN36437985/.

Delayed Treatment of Delirium Increases Mortality Rate in Intensive Care Unit Patients

Delirium in the intensive care unit (ICU) is a serious complication associated with a poor outcome in critically ill patients. In this prospective observational study of the effect of a delay in delirium therapy on mortality rate, 418 ICU patients were regularly assessed using the Delirium Detection Score (DDS). The departmental standard required that if delirium was diagnosed (DDS > 7), therapy should be started within 24 h. In total, 204 patients (48.8%) were delirious during their ICU stay. In 184 of the delirious patients (90.2%), therapy was started within 24 h; in 20 patients (9.8%), therapy was delayed. During their ICU stay, patients whose delirium treatment was delayed were more frequently mechanically ventilated, had more nosocomial infections (including pneumonia) and had a higher mortality rate than patients whose treatment was not delayed. Thus, it would appear that a delay in initiating delirium therapy in ICU patients was associated with increased mortality.

Duration of fluid fasting and choice of analgesic are modifiable factors for early postoperative delirium.

Background and objective Most therapeutic options for postoperative delirium are only symptom oriented; therefore, the best approach remains prevention. The aim of this study was to identify predisposing and precipitating factors for early postoperative delirium. Methods A total of 1002 patients were screened for delirium in an observational, cohort study. Nine hundred and ten patients were observed in the recovery room and 862 patients on the first postoperative day in the ward at the Charité – Universitaetsmedizin, Berlin. Delirium was measured with the nursing delirium screening scale. Risk factors were analysed in a multivariate analysis. Results Delirium was seen in 11.0% of the patients in the recovery room and in 4.2% of the patients on the ward. Delirium in the recovery room was associated with delirium on the ward (McNemars test P = <0.001). Apart from age and site of surgery, we found the duration of preoperative fluid fasting to be a modifiable precipitating factor for delirium in the recovery room (odds ratio 2.69, 95% confidence interval 1.4–5.2) and on the ward (odds ratio 10.57, 95% confidence interval 1.4–78.6) and the choice of intraoperative opioid for delirium on the ward (odds ratio 2.27, 95% confidence interval 1.0–5.1). Conclusion Duration of preoperative fluid fasting and the choice of intraoperative analgesic are risk factors for postoperative delirium, and their modification provides a promising approach to reduce the incidence of postoperative delirium.

European Society of Anaesthesiology evidence-based and consensus-based guideline on postoperative delirium.

The purpose of this guideline is to present evidence-based and consensus-based recommendations for the prevention and treatment of postoperative delirium. The cornerstones of the guideline are the preoperative identification and handling of patients at risk, adequate intraoperative care, postoperative detection of delirium and management of delirious patients. The scope of this guideline is not to cover ICU delirium. Considering that many medical disciplines are involved in the treatment of surgical patients, a team-based approach should be implemented into daily practice. This guideline is aimed to promote knowledge and education in the preoperative, intraoperative and postoperative setting not only among anaesthesiologists but also among all other healthcare professionals involved in the care of surgical patients.

Independent risk factors for postoperative pain in need of intervention early after awakening from general anaesthesia

Despite advances in postoperative pain management, the proportion of patients with moderate to severe postoperative pain is still ranging 20–80%. In this retrospective study, we investigated 1736 patients to determine the incidence of postoperative pain in need of intervention (PPINI)defined as numeric rating scale >4 at rest in the post anaesthesia care unit early after awakening from general anaesthesia, and to identify possible risk factors. The proportion of patients with PPINI was 28.5%. On multivariate analysis, younger age (OR = 1.300 [1.007–1.678], p = 0.044), female gender (OR = 1.494 [1.138–1.962], p = 0.004), obesity (OR = 1.683 [1.226–2.310], p = 0.001), use of nitrous oxide (OR = 1.621 [1.110–2.366], p = 0.012), longer duration of surgery (OR = 1.165 [1.050–1.292], p = 0.004), location of surgery (musculoskeletal OR = 2.026 [1.326–3.095], p = 0.001; intraabdominal OR = 1.869 [1.148–3.043], p = 0.012), and ASA‐PS I–II (OR = 1.519 [1.131–2.039], P = 0.005) were identified as independent risk factors for PPINI. Patients with PPINI experienced significantly more PONV (10.3% vs. 6.2%, p = 0.003), more psychomotor agitation (5.5% vs. 2.7%, p = 0.004), needed more application of opioid in PACU (62.8% vs. 24.2%, p < 0.001), stayed significantly longer in PACU (89.6 min [70–120] vs. 80 min [60–100], p < 0.001), had a longer median length of hospital stay (6.6 days [4.0–8.8] vs. 6.0 days [3.2–7.8]], p < 0.001), and longer postoperative stay (5.0 days [3.0–6.5] vs. 4.1 days [2.5–5.8], p < 0.001]). Patients with PPINI required more piritramid (8.0 mg [5.0–12.0] vs. 5.0 mg [3.0–7.8], p < 0.001) in PACU than patients without. The identification of patients at high risk for immediate postoperative pain in need of intervention would enable the formation of effective postoperative pain management programs.

A Comparison of Three Scores to Screen for Delirium on the Surgical Ward

BackgroundPostoperative delirium is associated with adverse outcome. The aim of this study was to find a valid and easy-to-use tool to screen for postoperative delirium on the surgical ward.MethodsData were collected from 88 patients who underwent elective surgery. Delirium screening was performed daily until the sixth postoperative day using the Confusion Assessment Method (CAM), the Nursing Delirium Screening Scale (Nu-DESC), and the Delirium Detection Score (DDS), and the DSM-IV criteria as the gold standard.ResultsSeventeen of 88 patients (19%) developed delirium on at least one of the postoperative days according to the gold standard. The DDS scored positive for 40 (45%) patients, the CAM for 15 (17%), and the Nu-DESC for 28 (32%) patients. Sensitivity and specificity were 0.71 and 0.87 for the DDS, 0.75 and 1.00 for the CAM, and 0.98 and 0.92 for the Nu-DESC. The interrater reliability was 0.83 for the Nu-DESC, 0.77 for the DDS, and 1.00 for the CAM.ConclusionsAll scores showed high specificity but differed in their sensitivity. The Nu-DESC proved to be the most sensitive test for screening for a postoperative delirium on the surgical ward followed by the CAM and DDS when compared to the gold standard.

[The Intensive Care Delirium Screening Checklist (ICDSC)--translation and validation of intensive care delirium checklist in accordance with guidelines].

BACKGROUND Although Delirium is the most common psychiatric disease in ICU settings, it is recognized late or not at all in up to 84 % of all cases. METHODS Translation of the ICDSC, in accordance with ISPOR guidelines and validation by conducting a screening of 68 ICU patients. RESULTS The translation process was authorized by the original author. The final German translation of the ICDSC showed a sensitivity and specificity of 89 % and 57 % respectively. CONCLUSION The ICDSC is suitable for delirium screening by nurses even on ventilated patients. Besides a high sensitivity another advantage is the possibility to screen for a subsyndromal delirium.

Die Nursing Delirium Screening Scale (Nu–DESC) – Richtlinienkonforme Übersetzung für den deutschsprachigen Raum

BACKGROUND Both in the recovery room as well as in the intensive care unit post-operative delirium is the most common psychiatric disease. The post-operative delirium is stated in literature to occur in 15 % to 50 % of patients, whereby up to 80 % of patients requiring intensive care with artificial respiration develop a delirium. The delirium correlates with the length of hospital stay and leads to a tripple rate of the six-month-mortality. Nu-DESC, developed by Gaudreau et al. is a measuring instrument for the clinical diagnostics of deliriums which is quickly operable, care-based and which can thus be easily integrated in everyday routine. The aim of this study was the translation of Nu-DESC from English as basis for the use in clinical research and routine. MATERIALS AND METHODS The translation process was conducted in accordance with the internationally acknowledged guidelines of Translation and Cultural Adaptation of Patient Reported Outcomes Measures - Principles of Good Practice (PGP). An interim German version was developed from 3 independently devised translations, a back-translation of which was then conducted by a registered state-approved translator. The back-translation was then presented to the author of the original for evaluation. RESULTS The back-translation of the German translation was authorised by the author of the original. On the basis of the cognitive debriefing results which were consistently very good to good, the translation process could be finalised and the final German version of Nu-DESC could be passed by the expert team. An evaluation of the German Nu-DESC regarding its practicability showed significant differences between doctors and nursing staff. CONCLUSION The German version of Nu-DESC provides an instrument for evaluating the delirium in the area of clinical routine and research.

Documentation of Post-operative Nausea and Vomiting in Routine Clinical Practice:

This study investigated the quality of documentation of post-operative nausea and vomiting (PONV) by comparing incidences collected by a research team with those reported routinely by nursing personnel. A total of 560 patients passing through an interdisciplinary recovery room were included in the study. The overall recorded incidence of PONV over 24 h was 30.7%, which was in agreement with the predicted value of 32% calculated using incidences from published randomized controlled trials. Out of the total number of 86 cases of PONV in the recovery room only 36 (42%) were detected by nursing staff. Similarly, out of the total number of 129 cases of PONV on the ward over 24 h, only 37 (29%) were recognized by nursing staff during routine care. In conclusion, PONV in routine clinical care is likely to be under-reported. To use PONV as a valid quality measure, patients need to be actively asked about nausea and vomiting at frequent intervals in a standardized fashion. A considerable proportion of patients experience PONV after discharge from the recovery room, so the assessment of PONV should cover at least 24 h post-operatively