Update of the European Society of Anaesthesiology and Intensive Care Medicine evidence-based and consensus-based guideline on postoperative delirium in adult patients.

Postoperative delirium (POD) remains a common, dangerous and resource-consuming adverse event but is often preventable. The whole peri-operative team can play a key role in its management. This update to the 2017 ESAIC Guideline on the prevention of POD is evidence-based and consensus-based and considers the literature between 01 April 2015, and 28 February 2022. The search terms of the broad literature search were identical to those used in the first version of the guideline published in 2017. POD was defined in accordance with the DSM-5 criteria. POD had to be measured with a validated POD screening tool, at least once per day for at least 3 days starting in the recovery room or postanaesthesia care unit on the day of surgery or, at latest, on postoperative day 1. Recent literature confirmed the pathogenic role of surgery-induced inflammation, and this concept reinforces the positive role of multicomponent strategies aimed to reduce the surgical stress response. Although some putative precipitating risk factors are not modifiable (length of surgery, surgical site), others (such as depth of anaesthesia, appropriate analgesia and haemodynamic stability) are under the control of the anaesthesiologists. Multicomponent preoperative, intra-operative and postoperative preventive measures showed potential to reduce the incidence and duration of POD, confirming the pivotal role of a comprehensive and team-based approach to improve patients' clinical and functional status.

Telemedicine in Intensive Care Units: Protocol for a Scoping Review.

BACKGROUND: Telemedicine has been deployed to address issues in intensive care delivery, as well as to improve outcome and quality of care. Implementation of this technology has been characterized by high variability. Tele-intensive care unit (ICU) interventions involve the combination of multiple technological and organizational components, as well as interconnections of key stakeholders inside the hospital organization. The extensive literature on the benefits of tele-ICUs has been characterized as heterogeneous. On one hand, positive clinical and economical outcomes have been shown in multiple studies. On the other hand, no tangible benefits could be detected in several cases. This could be due to the diverse forms of organizations and the fact that tele-ICU interventions are complex to evaluate. The implementation context of tele-ICUs has been shown to play an important role in the success of the technology. The benefits derived from tele-ICUs depend on the organization where it is deployed and how the telemedicine systems are applied. There is therefore value in analyzing the benefits of tele-ICUs in relation to the characteristics of the organization where it is deployed. To date, research on the topic has not provided a comprehensive overview of literature taking both the technology setup and implementation context into account. OBJECTIVE: We present a protocol for a scoping review of the literature on telemedicine in the ICU and its benefits in intensive care. The purpose of this review is to map out evidence about telemedicine in critical care in light of the implementation context. This review could represent a valuable contribution to support the development of tele-ICU technologies and offer perspectives on possible configurations, based on the implementation context and use case. METHODS: We have followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist and the recommendations of the Joanna Briggs Institute methodology for scoping reviews. The scoping review and subsequent systematic review will be completed by spring 2021. RESULTS: The preliminary search has been conducted. After removing all duplicates, we found 2530 results. The review can now be advanced to the next steps of the methodology, including literature database queries with appropriate keywords, retrieval of the results in a reference management tool, and screening of titles and abstracts. CONCLUSIONS: The results of the search indicate that there is sufficient literature to complete the scoping review. Upon completion, the scoping review will provide a map of existing evidence on tele-ICU systems given the implementation context. Findings of this research could be used by researchers, clinicians, and implementation teams as they determine the appropriate setup of new or existing tele-ICU systems. The need for future research contributions and systematic reviews will be identified. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/19695.

Effects of pain, sedation and delirium monitoring on clinical and economic outcome: A retrospective study.

BACKGROUND: Significant improvements in clinical outcome can be achieved by implementing effective strategies to optimise pain management, reduce sedative exposure, and prevent and treat delirium in ICU patients. One important strategy is the monitoring of pain, agitation and delirium (PAD bundle). We hypothesised that there is no sufficient financial benefit to implement a monitoring strategy in a Diagnosis Related Group (DRG)-based reimbursement system, therefore we expected better clinical and decreased economic outcome for monitored patients. METHODS: This is a retrospective observational study using routinely collected data. We used univariate and multiple linear analysis, machine-learning analysis and a novel correlation statistic (maximal information coefficient) to explore the association between monitoring adherence and resulting clinical and economic outcome. For univariate analysis we split patients in an adherence achieved and an adherence non-achieved group. RESULTS: In total 1,323 adult patients from two campuses of a German tertiary medical centre, who spent at least one day in the ICU between admission and discharge between 1. January 2016 and 31. December 2016. Adherence to PAD monitoring was associated with shorter hospital LoS (e.g. pain monitoring 13 vs. 10 days; p<0.001), ICU LoS, duration of mechanical ventilation shown by univariate analysis. Despite the improved clinical outcome, adherence to PAD elements was associated with a decreased case mix per day and profit per day shown by univariate analysis. Multiple linear analysis did not confirm these results. PAD monitoring is important for clinical as well as economic outcome and predicted case mix better than severity of illness shown by machine learning analysis. CONCLUSION: Adherence to PAD bundles is also important for clinical as well as economic outcome. It is associated with improved clinical and worse economic outcome in comparison to non-adherence in univariate analysis but not confirmed by multiple linear analysis. TRIAL REGISTRATION: clinicaltrials.gov NCT02265263, Registered 15 October 2014.

Enhanced Recovery after Intensive Care (ERIC): study protocol for a German stepped wedge cluster randomised controlled trial to evaluate the effectiveness of a critical care telehealth program on process quality and functional outcomes.

INTRODUCTION: Survival after critical illness has noticeably improved over the last decades due to advances in critical care medicine. Besides, there is an increasing number of elderly patients with chronic diseases being treated in the intensive care unit (ICU). More than half of the survivors of critical illness suffer from medium-term or long-term cognitive, psychological and/or physical impairments after ICU discharge, which is recognised as post-intensive care syndrome (PICS). There are evidence-based and consensus-based quality indicators (QIs) in intensive care medicine, which have a positive influence on patients' long-term outcomes if adhered to. METHODS AND ANALYSIS: The protocol of a multicentre, pragmatic, stepped wedge cluster randomised controlled, quality improvement trial is presented. During 3 predefined steps, 12 academic hospitals in Berlin and Brandenburg, Germany, are randomly selected to move in a one-way crossover from the control to the intervention condition. After a multifactorial training programme on QIs and clinical outcomes for site personnel, ICUs will receive an adapted, interprofessional protocol for a complex telehealth intervention comprising of daily telemedical rounds at ICU. The targeted sample size is 1431 patients. The primary objective of this trial is to evaluate the effectiveness of the intervention on the adherence to eight QIs daily measured during the patient's ICU stay, compared with standard of care. Furthermore, the impact on long-term recovery such as PICS-related, patient-centred outcomes including health-related quality of life, mental health, clinical assessments of cognition and physical function, all-cause mortality and cost-effectiveness 3 and 6 months after ICU discharge will be evaluated. ETHICS AND DISSEMINATION: This protocol was approved by the ethics committee of the Charité-Universitätsmedizin, Berlin, Germany (EA1/006/18). The results will be published in a peer-reviewed scientific journal and presented at international conferences. Study findings will also be disseminated via the website (www.eric-projekt.net). TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Registry (NCT03671447).

Clinical practice in the management of postoperative delirium by Chinese anesthesiologists: a cross-sectional survey designed by the European Society of Anaesthesiology.

OBJECTIVE: In this survey, we assessed the current clinical management of postoperative delirium (POD) among Chinese anesthesiologists, after publishing the European POD guideline. METHODS: We administered an electronic survey, designed according to the European POD guideline. The survey was completed using mobile devices. RESULTS: In total, 1,514 respondents from China participated in the survey. Overall, 74.4% of participants reported that delirium is very important. More than 95% of participants stated that they routinely assessed POD. In total, 61.4% screened for POD using clinical observation and 37.6% used a delirium screening tool. Although the depth of anesthesia (a POD risk factor) was monitored, electroencephalogram monitoring was unavailable to 30.6% of respondents. Regarding treatment, only 24.1% of respondents used a standard algorithm; 58.5% used individualized treatment. CONCLUSION: Our survey showed that there are high awareness levels among Chinese anesthesiologists regarding the importance of POD. However, routine assessment and monitoring of all patients, including perioperative anesthesia depth monitoring, and a treatment algorithm need to be implemented on a larger scale. According to the results, efforts should be made to improve the knowledge of POD among Chinese anesthesiologists.

Routine management of postoperative delirium outside the ICU: Results of an international survey among anaesthesiologists.

BACKGROUND: Postoperative delirium (POD) is a severe brain dysfunction. Although data indicate a high relevance, no survey has investigated the routine practice to monitor delirium outside the ICU setting after surgery. Prior to publishing of the new European Society of Anaesthesiology (ESA) guidelines on POD, an international survey was conducted to assess current practice. METHODS: European Society of Anaesthesiology-endorsed online survey; Trial Registration: NCT-identifier: 02513537. RESULTS: In total, 566 respondents from 62 countries accessed, and 564 (99.6%) completed the survey (completion rate). Overall, 385 (68%) of the respondents reported that delirium is either "very relevant" or "relevant" for their daily clinical practice. In all, 38 (7%) of the respondents routinely monitor for delirium in >50% of all patients. Asked on the monitoring time point, more than half (n = 308, 55%) indicated to screen before or at recovery room discharge, 235 (42%) up to the first postoperative day, 143 (25%) up to 3 days, and 77 (14%) up to 5 postoperative days. Although there is a lack of long-term monitoring, nearly all respondents (n = 530, 94%) reported to treat delirium. Availability of EEG/EMG-based monitoring to assess the depth of anaesthesia was high in the study group (n = 547, 97%) and was used by more than one-third of the respondents to reduce risk of burst suppression (n = 189, 34%). CONCLUSION: Although delirium is perceived as a relevant condition among anaesthesiologists, there is a high demand for implementing monitoring strategies after publishing of the POD Guideline. The survey shows that tools necessary for POD Guideline implementation are available in the centres represented by the respondents.

Anticholinergic burden of long-term medication is an independent risk factor for the development of postoperative delirium: A clinical trial.

BACKGROUND: Postoperative delirium (POD) is a common complication after surgery. OBJECTIVE: We sought to determine the association between preoperative anticholinergic load calculated using the anticholinergic drug scale (ADS) and POD in cancer patients over 65 years of age. DESIGN: A retrospective sub-investigation of a randomised controlled interventional trial. SETTING: Two tertiary university hospitals. PATIENTS: Overall, patients aged 65 years and older scheduled for surgical treatment of gastrointestinary, genitourinary or gynaecological cancers. MAIN OUTCOME MEASURES: The primary outcome was the interaction between anticholinergic drug scale and occurrence of postoperative delirium. Patient clinical parameters and ADS scores were assessed preoperatively. POD screening was conducted for a total of 7 days following surgery using validated measures. Independent associations between ADS and POD were assessed using multivariate logistical regression analyses. RESULTS: A total of 651 patients (mean age, 71.8 years; 68.5% males) were included. Of those, 66 patients (10.1%) developed POD. The ADS score was independently associated with the occurrence of POD (higher ADS per point OR 1.496; 95% CI 1.09-2.05; p = 0.01). Additionally, age (per year OR 1.06; CI 95% CI 1.01-1.11; p = 0.03) and ASA state (OR 2.16; 95% CI 1.22-3.83; p = 0.01), as well as stay on ICU (yes vs. no OR 2.8; 95% CI 1.57-4.998; p < 0.01), were independently associated with POD. CONCLUSIONS: ADS assessment according to chronic medication use is a cost-effective, non-invasive method of identifying elderly cancer patients at risk for POD. TRIAL REGISTRY: www.clinicaltrials.gov. Identifier NCT01278537. Ethics: IRB of Charité University-Medicine Berlin, Germany; EA2/241/08.

Innovative ICU Solutions to Prevent and Reduce Delirium and Post-Intensive Care Unit Syndrome.

Delirium, the most common form of acute brain dysfunction affecting up to 80% of intensive care unit (ICU) patients, has been shown to predict long-term cognitive impairment, one of the domains in "Post-ICU Syndrome" (PICS). The ICU environment affects several potentially modifiable risk factors for delirium, such as disorientation and disruption, of the sleep-wake cycle. Innovative solutions aim to transform standard concepts of ICU room design to limit potential stressors, and utilizing the patient care space as a treatment tool, exerting positive, therapeutic effects. The main areas affected by most architectural and interior design modifications are sound environment, light control, floor planning, and room arrangement. Implementation of corresponding solutions is challenging considering the significant medical and technical demands of ICUs. This article discusses innovative concepts and promising approaches in ICU design that may be used to prevent stress and to support the healing process of patients, potentially limiting the impact of delirium and PICS.

Statement paper on diversity for the European Society of Intensive Care Medicine (ESICM).

INTRODUCTION: Diversity has become a key-strategic element of success in various political and economic fields. The European Society of Intensive Care Medicine (ESICM) decided to make diversity a key strategic priority for the future and appointed a Task-Force on this topic. METHODS: In a consensus process, three Working-Groups, nominated by Task-Force members, developed statements on strategic future topics. In addition, diversity-related data available from the membership database have been analyzed and reported in aggregated form. RESULTS: The Task-Force decided to nominate working groups on (1) "sex, gender identity and sexual orientation", (2) "ethnicity, culture and socio-economic status", and (3) "multiprofessionalism". These are the first prioritized topics for the near future. The first diversity-report shows targetable items in all three domains. CONCLUSION: The diversity Task-Force defined actionable items for a one- and three-year plan that are especially aiming at the identification of potential gaps and an implementation of concrete projects for members of the ESICM.

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.

Routine delirium monitoring is independently associated with a reduction of hospital mortality in critically ill surgical patients: A prospective, observational cohort study.

PURPOSE: Although delirium monitoring is recommended in international guidelines, there is lacking evidence for improved outcome due to it. We hypothesized that adherence to routine delirium monitoring would improve clinical outcome in adult critically ill patients. MATERIAL AND METHODS: We present the results of a prospective, noninterventional, observational cohort study that was conducted on 2 intensive care units (ICUs) of a tertiary care medical center between July and October 2007 (International Standard Registered Clinical Trial Record identifier: 76100795). We assessed delirium-monitoring and outcome parameters on a daily basis. Besides multivariate logistic and robust linear regression to analyze the relationship between delirium monitoring and outcome, we used the doubly robust augmented inverse probability weighting method for observational data to estimate effect sizes. RESULTS: Of 355 screened patients, we included 185 surgical ICU patients into our final analysis, of which 87 were mechanically ventilated. We found an independent association between delirium-monitoring adherence and in-hospital mortality for ventilated patients (odds ratio, 0.973; P= .041). Estimating the effect size, delirium monitoring indicated a reduction of 22% of in-hospital mortality if conducted 50% or more of ICU days per patient. The average ICU length of stay of 46 days was estimated to be reduced by 19 days (P= .031) if patients were sufficiently monitored. CONCLUSION: Our data suggest an improved outcome for mechanically ventilated patients being screened for delirium in clinical routine.

Validity of Different Delirium Assessment Tools for Critically Ill Children: Covariates Matter.

OBJECTIVES: To evaluate test validity of the Pediatric Confusion Assessment Method for the ICU, the Pediatric Anesthesia Emergence Delirium scale, and the newly developed severity scale for the Pediatric Confusion Assessment Method for the ICU; to prospectively assess covariates and their influence on test validity of the scores. DESIGN: Prospective observational cohort study. SETTING: PICU of a tertiary care medical center. PATIENTS: Critically ill patients 5 years old or older ventilated or nonventilated with an ICU length of stay of at least 24 hours. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were scored with the Pediatric Confusion Assessment Method for the ICU and the Pediatric Anesthesia Emergence Delirium scale once daily for a maximum of 21 days. Validity was determined by comparing scoring results with the evaluations of the delirium experts who used the criteria of the Diagnostic and Statistical Manual, 4th Edition, Text Revision, for delirium diagnosis. Sixty-four patients were enrolled and 214 assessments were conducted and included in data analysis. The first assessments within each patient revealed sensitivities of 69.2% for the Pediatric Anesthesia Emergence Delirium scale, 76.9% for the Pediatric Confusion Assessment Method for the ICU, and 84.9% for the severity scale for the Pediatric Confusion Assessment Method for the ICU. Specificities were 98% for all scores. Considering repeated measurements, sensitivities decreased to 35.9% for the Pediatric Anesthesia Emergence Delirium scale and to 52.3% for the Pediatric Confusion Assessment Method for the ICU. The sensitivity of the severity scale for the Pediatric Confusion Assessment Method for the ICU dropped to 71.8%, which was significantly higher compared to the Pediatric Anesthesia Emergence Delirium scale (p = 0.0008). Receiver operator characteristic regression unveiled that sedation and mechanical ventilation had a significant negative effect on the validity of the Pediatric Anesthesia Emergence Delirium scale and the severity scale for the Pediatric Confusion Assessment Method for the ICU. Age and gender had a significant impact on the receiver operator characteristic curve of the severity scale for the Pediatric Confusion Assessment Method for the ICU. CONCLUSIONS: The severity scale for the Pediatric Confusion Assessment Method for the ICU showed the best test validity when used in critically ill children of 5 years old or older. Nevertheless, validity of delirium screening itself depends on patient specific factors. These factors should be taken into consideration when choosing a delirium screening instrument.

Evidence and consensus based guideline for the management of delirium, analgesia, and sedation in intensive care medicine. Revision 2015 (DAS-Guideline 2015) - short version.

In 2010, under the guidance of the DGAI (German Society of Anaesthesiology and Intensive Care Medicine) and DIVI (German Interdisciplinary Association for Intensive Care and Emergency Medicine), twelve German medical societies published the "Evidence- and Consensus-based Guidelines on the Management of Analgesia, Sedation and Delirium in Intensive Care". Since then, several new studies and publications have considerably increased the body of evidence, including the new recommendations from the American College of Critical Care Medicine (ACCM) in conjunction with Society of Critical Care Medicine (SCCM) and American Society of Health-System Pharmacists (ASHP) from 2013. For this update, a major restructuring and extension of the guidelines were needed in order to cover new aspects of treatment, such as sleep and anxiety management. The literature was systematically searched and evaluated using the criteria of the Oxford Center of Evidence Based Medicine. The body of evidence used to formulate these recommendations was reviewed and approved by representatives of 17 national societies. Three grades of recommendation were used as follows: Grade "A" (strong recommendation), Grade "B" (recommendation) and Grade "0" (open recommendation). The result is a comprehensive, interdisciplinary, evidence and consensus-based set of level 3 guidelines. This publication was designed for all ICU professionals, and takes into account all critically ill patient populations. It represents a guide to symptom-oriented prevention, diagnosis, and treatment of delirium, anxiety, stress, and protocol-based analgesia, sedation, and sleep-management in intensive care medicine.

Delirium, sedation and analgesia in the intensive care unit: a multinational, two-part survey among intensivists.

Analgesia, sedation and delirium management are important parts of intensive care treatment as they are relevant for patients' clinical and functional long-term outcome. Previous surveys showed that despite this fact implementation rates are still low. The primary aim of the prospective, observational multicenter study was to investigate the implementation rate of delirium monitoring among intensivists. Secondly, current practice concerning analgesia and sedation monitoring as well as treatment strategies for patients with delirium were assesed. In addition, this study compares perceived and actual practice regarding delirium, sedation and analgesia management. Data were obtained with a two-part, anonymous survey, containing general data from intensive care units in a first part and data referring to individual patients in a second part. Questionnaires from 101 hospitals (part 1) and 868 patients (part 2) were included in data analysis. Fifty-six percent of the intensive care units reported to monitor for delirium in clinical routine. Fourty-four percent reported the use of a validated delirium score. In this respect, the survey suggests an increasing use of delirium assessment tools compared to previous surveys. Nevertheless, part two of the survey revealed that in actual practice 73% of included patients were not monitored with a validated score. Furthermore, we observed a trend towards moderate or deep sedation which is contradicting to guideline-recommendations. Every fifth patient was suffering from pain. The implementation rate of adequate pain-assessment tools for mechanically ventilated and sedated patients was low (30%). In conclusion, further efforts are necessary to implement guideline recommendations into clinical practice. The study was registered (ClinicalTrials.gov identifier: NCT01278524) and approved by the ethical committee.

Intravenous Lormetazepam during Sedation Weaning in a 26-Year-Old Critically Ill Woman.

Recent evidence revealed that sedation is related to adverse outcomes including a higher mortality. Despite this fact, patients sometimes require deep sedation for a limited period of time to control, for example, intracranial hypertension. In particular in these cases, weaning from sedation is often challenging due to emerging agitation, stress, and delirium. The submitted research letter reports a rare case of severe and persisting agitation that was unresponsive to all available treatments. Ultimately, lormetazepam which has recently become available for intravenous use in Germany resolved the problem by stress-reduction and anxiolysis without leading to measurable sedation.