Traumatic Brain Injury Patients Admitted on High-Census Days Receive Less Critical Care and Have an Increased Risk for Delirium.

INTRODUCTION: The utilization of healthcare services in a growing population has raised concerns about its impact on clinical outcomes. Studies have shown that increased hospital census is associated with higher admission rates and unnecessary consults, tests, and procedures in various areas of healthcare. Traumatic brain injuries (TBIs), a significant concern due to their potential for long-term disabilities, are commonly encountered in intensive care units (ICUs) and are a leading cause of patient mortality. Despite extensive research on various aspects of TBI, the effect of the patient census on TBI outcomes remains unexplored. This study aims to investigate the relationship between healthcare provider patient census and clinical outcomes in TBI patients at a level I trauma center. METHODS: A retrospective review was conducted from 2017 to 2022. The mean number of patients per day in the trauma service was determined, with patients below this average considered to be present on low-census days and those above it on high-census days. Patient demographics, mechanisms of injury, vital signs, TBI severity, and associated injuries were analyzed. Adjusted regression analyses were conducted. RESULTS: Over the study period, 1,527 TBI patients were identified. Demographics were similar between patients admitted on high- and low-census days. Patients with moderate TBI were 30% less likely to be admitted to the ICU on high-census days, whereas there was no difference in ICU admission for patients with mild or severe TBI. Delirium was significantly higher in patients admitted on high-census days compared to those on low-census days. This was further identified to be predominantly driven by patients with mild TBI admitted on high-census days. CONCLUSION: While most outcomes remained consistent, significant rates of delirium were found in our mild TBI patients admitted on high-census days suggesting the need for additional factors in the evaluation of these patients on admission. This study also reveals potential under-triage in moderate TBI patients on high-census days as they had significantly lower rates of ICU admission. These findings emphasize the need for further investigations to optimize patient care strategies within the context of fluctuating healthcare system demands.

Patient Outcomes and Management Strategies for Intensive Care Unit (ICU)-Associated Delirium: A Literature Review.

Delirium is a significant public health concern, with tremendous implications for patient outcomes. Intensive care unit (ICU)-related delirium is gaining attention due to the higher prevalence of delirium in ICU-admitted patients. The most common negative outcomes of ICU delirium include cognitive impairments, functional dependence, high incidence of mortality, extended stay in the ICU, and high costs. So far, no single etiological factor has been identified as the sole cause of delirium. Several functional, neurotransmitter, or injury-causing hypotheses have been proposed for ICU delirium. Several risk factors contribute to the development of delirium in patients admitted to the ICU. These are age, gender, types of sedation, physical restraints, medical and surgical interventions, pain, and extended stay in the ICU. The most commonly used assessment modules for ICU delirium are the PREdiction of DELIRium in ICu patients (PRE-DELIRIC), Early PREdiction model for DELIRium in ICu patients (E-PRE-DELERIC), and Lanzhou Model, Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), Intensive Care Delirium Screening Checklist (ICDSC), and Delirium Rating Scale (DRS). There is no proper treatment for ICU delirium; however, it can be managed through various pharmacological and non-pharmacological interventions. Healthcare providers should receive constant education and training on delirium recognition, prevention, and management to enhance patient care and outcomes in the ICU. Further research is needed on the effective prevention and management of ICU delirium.

Controlled Mechanical Ventilation in Critically Ill Patients and the Potential Role of Venous Bagging in Acute Kidney Injury.

A very low incidence of acute kidney injury (AKI) has been observed in COVID-19 patients purposefully treated with early pressure support ventilation (PSV) compared to those receiving mainly controlled ventilation. The prevention of subdiaphragmatic venous congestion through limited fluid intake and the lowering of intrathoracic pressure is a possible and attractive explanation for this observed phenomenon. Both venous congestion, or "venous bagging", and a positive fluid balance correlate with the occurrence of AKI. The impact of PSV on venous return, in addition to the effects of limiting intravenous fluids, may, at least in part, explain this even more clearly when there is no primary kidney disease or the presence of nephrotoxins. Optimizing the patient-ventilator interaction in PSV is challenging, in part because of the need for the ongoing titration of sedatives and opioids. The known benefits include improved ventilation/perfusion matching and reduced ventilator time. Furthermore, conservative fluid management positively influences cognitive and psychiatric morbidities in ICU patients and survivors. Here, it is hypothesized that cranial lymphatic congestion in relation to a more positive intrathoracic pressure, i.e., in patients predominantly treated with controlled mechanical ventilation (CMV), is a contributing risk factor for ICU delirium. No studies have addressed the question of how PSV can limit AKI, nor are there studies providing high-level evidence relating controlled mechanical ventilation to AKI. For this perspective article, we discuss studies in the literature demonstrating the effects of venous congestion leading to AKI. We aim to shed light on early PSV as a preventive measure, especially for the development of AKI and ICU delirium and emphasize the need for further research in this domain.

Former smoking, but not active smoking, is associated with delirium in postoperative ICU patients: a matched case-control study.

Objective: To examine the relationship between current and former smoking and the occurrence of delirium in surgical Intensive Care Unit (ICU) patients. Methods: We conducted a single center, case-control study involving 244 delirious and 251 non-delirious patients that were admitted to our ICU between 2018 and 2022. Using propensity score analysis, we obtained 115 pairs of delirious and non-delirious patients matched for age and Simplified Acute Physiology Score II (SAPS II). Both groups of patients were further stratified into non-smokers, active smokers and former smokers, and logistic regression was performed to further investigate potential confounders. Results: Our study revealed a significant association between former smoking and the incidence of delirium in ICU patients, both in unmatched (adjusted odds ratio (OR): 1.82, 95% confidence interval (CI): 1.17-2.83) and matched cohorts (OR: 3.0, CI: 1.53-5.89). Active smoking did not demonstrate a significant difference in delirium incidence compared to non-smokers (unmatched OR = 0.98, CI: 0.62-1.53, matched OR = 1.05, CI: 0.55-2.0). Logistic regression analysis of the matched group confirmed former smoking as an independent risk factor for delirium, irrespective of other variables like surgical history (p = 0.010). Notably, also respiratory and vascular surgeries were associated with increased odds of delirium (respiratory: OR: 4.13, CI: 1.73-9.83; vascular: OR: 2.18, CI: 1.03-4.59). Medication analysis showed that while Ketamine and Midazolam usage did not significantly correlate with delirium, Morphine use was linked to a decreased likelihood (OR: 0.27, 95% CI: 0.13-0.55). Discussion: Nicotine's complex neuropharmacological impact on the brain is still not fully understood, especially its short-term and long-term implications for critically ill patients. Although our retrospective study cannot establish causality, our findings suggest that smoking may induce structural changes in the brain, potentially heightening the risk of postoperative delirium. Intriguingly, this effect seems to be obscured in active smokers, potentially due to the recognized neuroprotective properties of nicotine. Our results motivate future prospective studies, the results of which hold the potential to substantially impact risk assessment procedures for surgeries.

ICU Delirium in Cardiac Patients.

Delirium is a prevalent complication in critically ill medical and surgical cardiac patients. It is associated with increased morbidity and mortality, prolonged hospitalizations, cognitive impairments, functional decline, and hospital costs. The incidence of delirium in cardiac patients varies based on the criteria used for the diagnosis, the population studied, and the type of surgery (cardiac or not cardiac). Delirium experienced when cardiac patients are in the intensive care unit (ICU) is likely preventable in most cases. While there are many protocols for recognizing and managing ICU delirium in medical and surgical cardiac patients, there is no homogeneity, nor are there established clinical guidelines. This review provides a comprehensive overview of delirium in cardiac patients and highlights its presentation, course, risk factors, pathophysiology, and management. We define cardiac ICU patients as both medical and postoperative surgical patients with cardiac disease in the ICU. We also highlight current controversies and future considerations of innovative therapies and nonpharmacological and pharmacological management interventions. Clinicians caring for critically ill patients with cardiac disease must understand the complex syndrome of ICU delirium and recognize the impact of delirium in predicting long-term outcomes for ICU patients.

Delirium education for family caregivers of patients in the intensive care unit: A pilot study.

Objectives: Delirium, an acute change in mental state, seen in hospitalized older adults is a growing public health concern with implications for both patients and caregivers; however, there is minimal research on educating caregivers about delirium. Utilizing family caregivers to assist with delirium management in acute care settings demonstrates improved health outcomes supporting the need for patient and family centered care. The primary aims of the study were to determine feasibility of implementing a delirium education video for caregivers of patients in an adult oncology intensive care unit and compare delirium knowledge to caregivers in a control group. Methods: A quasi-experimental design comprised of 31 family caregivers of adult patients in an oncology intensive care unit to determine feasibility of implementing a delirium education video. Results: The results demonstrate feasibility of implementing a caregiver education video in-person and virtually. While total delirium knowledge scores were not statistically significant, knowledge gained within the delirium presentation subgroup was significant (p = .05). Conclusion: This study demonstrates feasibility of implementing a caregiver education video and findings support further research in this area. Innovation: Collaborating with caregivers to develop virtual video education for delirium allows for a versatile approach to connect with caregivers to support their caregiving role.

Exploring perceptions regarding family-based delirium management in the intensive care unit.

Background: Delirium is a common complication in patients treated in the intensive care unit (ICU). Family members can help alleviate patient anxiety and may be able to aid in the management of delirium. This study aimed to explore the perceptions of former ICU patients and their families together, regarding the involvement of family in delirium management. Method: Nine audio-recorded, semi-structured interviews took place with former ICU patients together with a family member. Participants were interviewed after their intensive care follow-up clinic appointment in an East Midlands hospital in England. Interviews were transcribed, coded and analysed using thematic analysis. Results: Three themes were identified: 'understanding about delirium'; 'influencers of delirium management: family and healthcare professionals' and 'family-based delirium care'. Participants expressed that family have a valuable role to play in the management of delirium in the ICU. However, education and guidance is needed to support the family in how delirium can be managed and the current treatment options available. It is important for ICU staff to gain an understanding of the patient's life and personality to personalise delirium management to the needs of the patient and their family. Conclusion: This study found that family presence and knowledge about the patient may be beneficial to delirium management in the ICU. Further research should investigate the effectiveness of the strategies and interventions to understand their influence on delirium management in ICU patients.

Frequency of Follow-Up Assessment for Post-Intensive Care Syndrome Among Alert and Non-Delirious Critically Ill Patients.

INTRODUCTION: Many patients surviving critical illness develop post-intensive care syndrome, a constellation of psychological, physical, and cognitive symptoms which can have long-term consequences. Physicians and nurses at our large rural teaching hospital treat many of the critically ill patients in the state. Our focus has been the subset of these critically ill patients who were alert and not delirious for multiple consecutive days. The goal of our retrospective cohort study was to estimate the percentage of the patients with multiple intensive care unit days alert and not delirious who had follow-up assessments for post-intensive care syndrome within 15 months. METHODS: The inclusion criteria for the case series of randomly selected patients were: adults defined as patients aged >17 years on the date of hospital admission between October 2014 and December 2020, present in a critical care unit at noon one day and continually so for another 48 hours, and for that interval, ≥≥48 hours had every Riker sedation-agitation scale "4, calm and cooperative," as well as either all Confusion Assessment Method for the Intensive Care Unit scores negative (i.e., no delirium) or Delirium Observation Screening Scale <3 (i.e., no delirium). Each patient was then categorized as having a full one-year follow-up if there was an encounter at our hospital between 12 and 15 months after the last date meeting study inclusion criteria. All follow-up appointments completed within 15 months of the index intensive care unit stay were screened for systematic assessment for psychological and cognitive sequelae of critical illness. RESULTS: From a manual chart review of 366 records, 73 patients were found with follow-up ≥≥12 months. There were 21% (15/73) of the patients assessed for post-intensive care syndrome sequelae (99% confidence interval 10%-35%). CONCLUSIONS: The fact that far fewer than half the patients had documented assessments suggests that retrospective studies should not be used to judge the incidence of post-intensive care syndrome at our hospital. Prospective observational studies would be needed to judge outcomes among critically ill patients with multiple consecutive days of alert and without delirium.

Prospective Randomized Controlled Pilot Study of High-Intensity Lightbox Phototherapy to Prevent ICU-Acquired Delirium Incidence.

Background This study aimed to evaluate the role of disturbed circadian rhythm in potentiating intensive care unit (ICU)-acquired delirium.Previous studies have demonstrated bright light therapy (BLT) as an effective modality to improve sleeping patterns and cognitive function in non-critically ill patients. However, its benefit in the ICU has not been clearly established. In this study, we aimed to evaluate the application of daily high-intensity phototherapy at the bedside to deter ICU delirium incidence and duration. Methodology This was a single center, prospective study conducted in ICUs at the Carilion Roanoke Memorial Hospital in Roanoke, VA. Adults patients admitted to the ICU from July 9, 2018 to March 20, 2020 were included in the study. The patients were subjected to 30-minute BLT session (10,000 lux) at the bedside starting at 0700 while in the ICU. Patients were randomized into either the control group (standard hospital lighting) or phototherapy group. Data were analyzed using Wilcoxon rank sum test for continuous variables, Pearson chi-square test for categorical variables, and logistic regression for multivariable analysis that examined significant risk factors for ICU delirium. Results Delirium incidence between BLT (18%) and control (17.5%) groups was non-significant. Total number of delirium-free, coma-free days, as determined by Confusion Assessment Method for the ICU, demonstrated no differences between groups with a median of 28 days (p = 0.516). In multivariable analysis, patients with a Sequential Organ Failure Assessment Score >3 also showed no significant change in ICU delirium incidence when provided bedside BLT compared to those with standard hospital lighting (odds ratio: 0.08; 95% confidence interval: 0.002-1.40; p = 0.867). Conclusions In this randomized control pilot study, daily morning 10,000 lux BLT of 30-minute duration alone was not associated with a significant decrease in ICU-acquired delirium incidence or duration compared to standard hospital lighting. Future studies should consider a nuanced approach to better elucidate the role of disturbed circadian rhythm in influencing ICU-acquired delirium by not only undertaking BLT during the day but also minimizing nighttime light exposure.

Descriptive analysis of the unwarranted continuation of antipsychotics for the management of ICU delirium during transitions of care: A multicenter evaluation across New Jersey.

PURPOSE: Nearly half of intensive care unit (ICU) patients will develop delirium. Antipsychotics are used routinely for the management of ICU delirium despite limited reliable data supporting this approach. The unwarranted continuation of antipsychotics initiated for ICU delirium is an emerging transitions of care concern, especially considering the adverse event profile of these agents. We sought to evaluate the magnitude of this issue across 6 centers in New Jersey and describe risk factors for continuation. METHODS: This multicenter, retrospective study examined adult ICU patients who developed ICU delirium from June 2016 to June 2018. Patients were included in the study if they received at least 3 doses of antipsychotics while in the ICU with presence of either a clinical diagnosis of delirium or a positive Confusion Assessment Method score. Patients were excluded if they were on an antipsychotic before ICU admission. RESULTS: Of the 300 patients included and initiated on antipsychotics for ICU delirium, 157 (52.3%) were continued on therapy upon transfer from the ICU to another level of inpatient care. The number of patients continued on newly initiated antipsychotics further increased to 183 (61%) upon discharge from the hospital. CONCLUSION: The continuation of antipsychotics for the management of delirium during transitions of care was a common practice across ICUs in New Jersey. Several risk factors for continuation of antipsychotics were identified. Efforts to reduce unnecessary continuation of antipsychotics at transitions of care are warranted.

Association Between Early Tracheostomy and Delirium in Older Adults in the United States.

OBJECTIVES: Early tracheostomy (fewer than eight days after intubation) is associated with shorter length of stay in the intensive care unit and shorter duration of mechanical ventilation. Studies assessing the association between early tracheostomy and incidence of delirium, however, are lacking. This investigation sought to fill this gap. DESIGN: Retrospective cross-sectional study. SETTING: Multi-institutional acute care facilities in the United States. PARTICIPANTS: Data were derived from the National Inpatient Sample data from 2010 to 2014. Included patients were 65 or older and underwent both intubation and tracheostomy during the hospitalization. The authors excluded patients who underwent multiple intubations or tracheostomy procedures. INTERVENTIONS: Early tracheostomy versus non-early tracheostomy. RESULTS: In total, 23,310 patients were included, of whom 24.8% underwent early tracheostomy. From multivariate logistic regression, early tracheostomy was associated with lower odds of having a delirium diagnosis (odds ratio [OR] 0.77, p < 0.00001) across all admission classifications. Upon subgroup analysis, early tracheostomy was associated significantly with lower odds of having delirium for patients admitted with medical (OR 0.74, p < 0.00001) and nonsurgical injury admissions (OR 0.74, p = 0.00116). CONCLUSIONS: Early tracheostomy was associated significantly with lower odds of delirium among all patients studied. This association held true across medical and nonsurgical subgroups.

Prolonged Refractory ICU Delirium Successfully Treated With Valproic Acid: Case Report and Literature Review.

Intensive care unit (ICU) delirium is characterized by acute onset of cerebral dysfunction with a change or fluctuation in baseline mental status. Delirium management includes non-pharmacologic and pharmacologic treatment. However at times, alternative pharmacologic treatment is warranted. Valproic acid (VPA) is a potential pharmacologic agent that can be utilized to treat ICU delirium, though there is a paucity of evidence for its use, especially in patients with a history of substance abuse. We review the literature on VPA use in ICU delirium, and describe a challenging case of a 27-year-old female with a history of substance abuse experiencing hyperactive ICU delirium for greater than a month, refractory to multiple treatment modalities, and successfully treated with VPA therapy.

Melatonin for delirium prevention in hospitalized patients: A systematic review and meta-analysis.

BACKGROUND AND AIMS: Melatonin, a pineal gland hormone is reported to have a protective effect against delirium. This systematic review and meta-analysis explores the effect of melatonin and melatonin receptor agonist, ramelteon on delirium prevention in adult hospitalized patients. METHODS: Randomized Controlled trials of melatonin/ramelteon published up to May 7, 2020 were identified from MEDLINE, PREMEDLINE, Embase, PsycINFO, the Cochrane Central Register of Controlled trials, PubMed, and Google Scholar. The primary outcome was delirium incidence. The secondary outcomes were sleep quality, sedation score, sedatives requirement, delirium duration, length of hospital stay, length of Intensive Care Unit (ICU) stay, mortality and adverse events. A meta-analysis with a random-effects models was performed. Estimates were presented as Risk Ratio (RR) or Mean Differences (MD) with 95% Confidence Interval (CI). FINDINGS: Fourteen studies with 1712 participants were included. Melatonin/ramelteon significantly reduced delirium incidence (RR 0·61, 95% CI 0·42-0·89, p 0·009) with risk reduction of 49% in surgical patients and 34% in ICU patients. Non-significant reduction was found in medical patients. Melatonin/ramelteon were associated with improvement in sleep quality, increased sedation score and lower sedatives consumption. However, they did not reduce delirium duration, length of hospital stay, length of ICU stay and mortality. Hallucinations, nightmares and gastrointestinal disorders were prevalent in melatonin group. INTERPRETATION: Melatonin/ramelteon are associated with reduction in delirium incidence in hospitalized patients. However, this effect seems confined to surgical and ICU patients. The optimum dosage and formulation of melatonin, and treatment duration remain uncleared and open to further studies with larger sample sizes.

Providing Culturally Competent Care for COVID-19 Intensive Care Unit Delirium: A Case Report and Review.

Coronavirus disease 2019 (COVID-19) was declared a pandemic by the World Health Organization in March 2020. Caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus, its high transmissibility required infected individuals to be placed in negative pressure isolation rooms when admitted to intensive care units (ICU). Studies have shown that limited social support can increase the risk of developing delirium during ICU stays. Minimal research exists on COVID-19-associated ICU delirium as hospitals and government organizations focus on combating equipment shortages and case surges. Here, we present the case of a 64-year-old Filipino male with COVID-19 ICU delirium status post-intubation and ventilation. His hospital course was complicated by the medical staff's assumption that the patient spoke Spanish and improved after being assigned a Tagalog-speaking nurse who facilitated family communication. This case highlights the importance of cultural competency and communication in the management of COVID-19 associated ICU delirium. In particular, Filipino cultural practices and their intersection with healthcare in the larger context of providing culturally competent care are highlighted. The use of culturally competent care serves to assure the use of appropriate services and reduces the occurrence of medical errors due to misunderstandings caused by differences in language or culture. Familial involvement is critical for ICU delirium; however, the COVID-19 pandemic has required healthcare providers to think beyond conventional means. The use of technology to virtually communicate with family also serves as a helpful tool to treat signs of delirium. As seen in this case, a lack of understanding of the Filipino culture resulted in assumptions on the part of the healthcare provider which led to the prolongation of delirium in a COVID-19 ICU patient, but the correct utilization of cultural competence helped the patient recover successfully.

Impact of Therapeutic Music Listening on Intensive Care Unit Patients: A Pilot Study.

This pilot study investigated the association between patient-specific, therapeutic music listening as a nursing intervention for mechanically ventilated patients, and the proportion of time those patients were considered to have intensive care unit delirium. The pilot study used the person-centered nursing framework as its theoretic foundation. Findings from an intimate prospective cohort design encourage an expanded look at potential benefits of therapeutic music listening in large, multisite, randomized clinical trials. Research and practice implications are discussed.

Effect of early cognitive interventions on delirium in critically ill patients: a systematic review.

PURPOSE: A systematic review of the literature was conducted to determine the effects of early cognitive interventions on delirium outcomes in critically ill patients. SOURCE: Search strategies were developed for MEDLINE, EMBASE, Joanna Briggs Institute, Cochrane, Scopus, and CINAHL databases. Eligible studies described the application of early cognitive interventions for delirium prevention or treatment within any intensive care setting. Study designs included randomized-controlled trials, quasi-experimental trials, and pre/post interventional trials. Two reviewers independently extracted data and assessed risk of bias using Cochrane methodology. PRINCIPAL FINDINGS: Four hundred and four citations were found. Seven full-text articles were included in the final review. Six of the included studies had an overall serious, high, or critical risk of bias. After application of cognitive intervention protocols, a significant reduction in delirium incidence, duration, occurrence, and development was found in four studies. Feasibility of cognitive interventions was measured in three studies. Cognitive stimulation techniques were described in the majority of studies. CONCLUSION: The study of early cognitive interventions in critically ill patients was identified in a small number of studies with limited sample sizes. An overall high risk of bias and variability within protocols limit the utility of the findings for widespread practice implications. This review may help to promote future large, multi-centre trials studying the addition of cognitive interventions to current delirium prevention practices. The need for robust data is essential to support the implementation of early cognitive interventions protocols.

RéSUMé: OBJECTIF : Une revue systématique de la littérature a été réalisée afin de déterminer les effets des interventions cognitives précoces sur l'évolution du delirium chez les patients en état critique. SOURCE: Des stratégies de recherche ont été mises au point pour explorer les bases de données MEDLINE, EMBASE, Joanna Briggs Institute, Cochrane, Scopus et CINAHL. Les études éligibles devaient décrire l'application d'interventions cognitives précoces pour la prévention ou le traitement du delirium dans un contexte de soins intensifs. Les types d'études retenues incluaient des études randomisées contrôlées, des études quasi expérimentales et des études pré-/post-interventionnelles. En se fondant sur la méthodologie Cochrane, deux réviseurs ont extrait les données et évalué le risque de biais de manière indépendante. CONSTATATIONS PRINCIPALES: Quatre cent quatre citations ont été extraites. Sept articles ont été retenus pour le compte rendu final. Six des études incluses présentaient un risque global de biais majeur, élevé ou critique. Après l'application des protocoles d'interventions cognitives, quatre études ont noté une réduction significative de l'incidence, de la durée, de la survenue et de l'apparition de delirium. Trois études ont mesuré la faisabilité des interventions cognitives. La majorité des études décrivaient les techniques de stimulation cognitive. CONCLUSION: Nous sommes parvenus à identifier quelques études ayant des tailles d'échantillon limitées décrivant des interventions cognitives précoces chez les patients en état critique. Un risque global élevé de biais et de variabilité au sein des protocoles limite toutefois l'utilité de ces observations pour leurs applications dans la pratique. Ce compte rendu pourrait susciter l'intérêt de chercheurs pour réaliser des études d'envergure et multicentriques examinant l'ajout d'interventions cognitives aux pratiques actuelles de prévention du delirium. Le besoin de données robustes est crucial pour soutenir la mise en œuvre de protocoles précoces d'interventions cognitives.

Pharmacologic Management of Delirium in the ICU: A Review of the Literature.

PURPOSE: Conflicting data exists on the pharmacologic management of intensive care unit (ICU) delirium. This review appraises the current evidence of pharmacologic management of ICU delirium. MATERIALS AND METHODS: A systematic literature search of MEDLINE and Embase was conducted to answer the population, intervention, comparison, and outcome (PICO) question of: "Does the use of a pharmacologic agent compared to standard of care or placebo improve ICU delirium in a critically ill patient population?" RESULTS: After application of the PICO question and the inclusion and exclusion criteria, 13 articles were included. Of these articles, 7 were prospective randomized controlled trials, 1 was a prospective nonrandomized controlled trial, and 5 were retrospective investigations. The included articles differed in the agents evaluated, primary outcome, and method of identifying delirium. CONCLUSION: The variability of outcomes illustrates the need for a large-scale investigation to further evaluate the role of pharmacologic management of ICU delirium.

Delirium Management in the ICU.

PURPOSE OF REVIEW: Delirium occurs frequently in critically ill patients and is associated with adverse outcomes in both the short and long term. In this review, we aim to highlight recent study findings on the prevention and treatment of delirium, provide additional recommendations based on expert guidelines, and indicate knowledge gaps deserving of future study. RECENT FINDINGS: Multicomponent non-pharmacologic interventions have been shown to be efficacious in non-ICU populations, and multicomponent strategies such as the ABCDEF bundle have been adopted in the ICU with several studies showing a potential benefit in delirium outcomes. Meanwhile, two negative randomized clinical trials of antipsychotics in ICU patients (REDUCE and MIND-USA) have provided strong evidence that such medications neither prevent nor shorten the duration of delirium. Other potential pharmacologic treatments with promising results include dexmedetomidine and, to a lesser extent, ramelteon, but more data is needed before they may be more definitively recommended. Effective and proven delirium management strategies are still largely lacking, though there is evidence to support the use of some non-pharmacologic interventions. Future studies of novel non-pharmacologic interventions and pharmacologic agents other than antipsychotics are warranted.

Management Strategies in the Intensive Care Unit to Improve Psychosocial Outcomes.

Critical care nurses work in challenging environments that are often sterile, impersonal, noisy, and frightening to patients and their families. Nurses act as liaisons between medical professionals and patients and their families in multiple specialty intensive care units. Critical care nursing practice, guided by the American Nurses Association Code of Ethics, respects patients' religious, spiritual, and cultural beliefs, contributing to holistic care delivery. Therapeutic psychosocial outcomes of holistic care delivery and patient advocacy are explored. Personalized psychosocial care through treating patients holistically will support and maintain positive psychosocial outcomes in intensive care units across the country.

Long-term cognitive impairment after acute respiratory distress syndrome: a review of clinical impact and pathophysiological mechanisms.

Acute respiratory distress syndrome (ARDS) survivors experience a high prevalence of cognitive impairment with concomitantly impaired functional status and quality of life, often persisting months after hospital discharge. In this review, we explore the pathophysiological mechanisms underlying cognitive impairment following ARDS, the interrelations between mechanisms and risk factors, and interventions that may mitigate the risk of cognitive impairment. Risk factors for cognitive decline following ARDS include pre-existing cognitive impairment, neurological injury, delirium, mechanical ventilation, prolonged exposure to sedating medications, sepsis, systemic inflammation, and environmental factors in the intensive care unit, which can co-occur synergistically in various combinations. Detection and characterization of pre-existing cognitive impairment imparts challenges in clinical management and longitudinal outcome study enrollment. Patients with brain injury who experience ARDS constitute a distinct population with a particular combination of risk factors and pathophysiological mechanisms: considerations raised by brain injury include neurogenic pulmonary edema, differences in sympathetic activation and cholinergic transmission, effects of positive end-expiratory pressure on cerebral microcirculation and intracranial pressure, and sensitivity to vasopressor use and volume status. The blood-brain barrier represents a physiological interface at which multiple mechanisms of cognitive impairment interact, as acute blood-brain barrier weakening from mechanical ventilation and systemic inflammation can compound existing chronic blood-brain barrier dysfunction from Alzheimer's-type pathophysiology, rendering the brain vulnerable to both amyloid-beta accumulation and cytokine-mediated hippocampal damage. Although some contributory elements, such as the presenting brain injury or pre-existing cognitive impairment, may be irreversible, interventions such as minimizing mechanical ventilation tidal volume, minimizing duration of exposure to sedating medications, maintaining hemodynamic stability, optimizing fluid balance, and implementing bundles to enhance patient care help dramatically to reduce duration of delirium and may help prevent acquisition of long-term cognitive impairment.