Current Perspectives on the Assessment and Management of Pain in the Intensive Care Unit.

Critical illness is often painful, both from the underlying source of illness, as well as necessary procedures performed for the monitoring and care of these patients. Pain is often under-recognized in the critically ill, especially among those who cannot self-report, so accurate assessment and management continue to be major consideration in their care. Pain management in the intensive care unit (ICU) is an evolving practice, with a focus on accurate and frequent pain assessment, and targeted pharmacologic and non-pharmacologic treatment methods to maximize analgesia and minimize sedation. In this review, we will evaluate several validated methods of pain assessment in the ICU and present management options. We will review the evidence-based recommendations put forth by the largest critical care societies and several high-quality studies related to both the in-hospital approach to pain, as well as the short- and long-term consequences of untreated pain in ICU patients. We conclude with future directions.

Prospective Validation of the Preschool Confusion Assessment Method for the ICU to Screen for Delirium in Infants Less Than 6 Months Old.

OBJECTIVES: ICU delirium is a predictor of greater morbidity and higher mortality in the pediatric population. The diagnostic obstacles and validity of delirium monitoring among neonates and young infants have yet to be fully delineated. We sought to validate the Preschool Confusion Assessment Method for the ICU in neonates and young infants and determine delirium prevalence in this young population. DESIGN: Prospective cohort study to validate the Preschool Confusion Assessment Method for the ICU for the assessment of ICU delirium in neonates and young infants compared with the reference standard, Child and Adolescent Psychiatry. SETTING: Tertiary medical center PICU, including medical, surgical, and cardiac patients. PARTICIPANTS: Infants less than 6 months old admitted to the PICU regardless of admission diagnosis. MEASUREMENTS AND MAIN RESULTS: We enrolled 49 patients with a median age of 1.8 months (interquartile range, 0.7-4.1 mo), 82% requiring mechanical ventilation. Enrolled patients were assessed for delirium in blinded-fashion by the research team using the Preschool Confusion Assessment Method for the ICU and independently assessed by the psychiatry reference rater using Diagnostic and Statistical Manual of Mental Disorders-5 criteria. A total of 189 paired assessments were completed, and the Preschool Confusion Assessment Method for the ICU performed with a sensitivity of 95% (95% CI, 89-100%), specificity of 81% (68-90%), "negative and positive predictive values" of 97% (94-100%) and 69% (55-79%), respectively, compared with the reference rater. Delirium prevalence was 47%, with higher rates of 61% observed among neonates (< 1 mo old) and 39% among infants 1-6 months old. CONCLUSIONS: The Preschool Confusion Assessment Method for the ICU is a valid screening tool for delirium monitoring in infants less than 6 months old. Delirium screening was feasible in this population despite evolving neurocognition and arousal architecture. ICU delirium was prevalent among infants. The consequence of acute brain dysfunction during crucial neurocognitive development remains unclear. Future studies are necessary to determine the long-term impact of ICU delirium and strategies to reduce associated harm in critically ill infants.

A Survey of Charge Sensitivity and Charge Awareness Among Intensive Care Unit Providers in a Large Academic Medical Center.

Little is known about charge sensitivity or charge awareness among intensive care unit (ICU) providers in the United States. In a survey of 295 ICU providers at a large, academic medical center, 92.5% of respondents agreed that controlling health care expenses is partly their responsibility. However, 87.4% of respondents reported that they did not know the charges for most of the tests and medications they prescribe. Among surveyed participants, the correct charge for a medical procedure or test was selected only 35% of the time. While ICU providers overwhelmingly agree that controlling expenses is their responsibility, charge awareness is low and likely limits their ability to make value-based decisions.

The Cost of ICU Delirium and Coma in the Intensive Care Unit Patient.

RATIONALE: Intensive care unit (ICU) delirium is highly prevalent and a potentially avoidable hospital complication. The current cost of ICU delirium is unknown. OBJECTIVES: To specify the association between the daily occurrence of delirium in the ICU with costs of ICU care accounting for time-varying illness severity and death. RESEARCH DESIGN: We performed a prospective cohort study within medical and surgical ICUs in a large academic medical center. SUBJECTS: We analyzed critically ill patients (N=479) with respiratory failure and/or shock. MEASURES: Covariates included baseline factors (age, insurance, cognitive impairment, comorbidities, Acute Physiology and Chronic Health Evaluation II Score) and time-varying factors (sequential organ failure assessment score, mechanical ventilation, and severe sepsis). The primary analysis used a novel 3-stage regression method: first, estimation of the cumulative cost of delirium over 30 ICU days and then costs separated into those attributable to increased resource utilization among survivors and those that were avoided on the account of delirium's association with early mortality in the ICU. RESULTS: The patient-level 30-day cumulative cost of ICU delirium attributable to increased resource utilization was $17,838 (95% confidence interval, $11,132-$23,497). A combination of professional, dialysis, and bed costs accounted for the largest percentage of the incremental costs associated with ICU delirium. The 30-day cumulative incremental costs of ICU delirium that were avoided due to delirium-associated early mortality was $4654 (95% confidence interval, $2056-7869). CONCLUSIONS: Delirium is associated with substantial costs after accounting for time-varying illness severity and could be 20% higher (∼$22,500) if not for its association with early ICU mortality.

Development of the Vanderbilt Assessment for Delirium in Infants and Children to Standardize Pediatric Delirium Assessment By Psychiatrists.

BACKGROUND: Pediatric delirium assessment is complicated by variations in baseline language and cognitive skills, impairment during illness, and absence of pediatric-specific modifiers within the Diagnostic and Statistical Manual of Mental Disorders delirium criterion. OBJECTIVE: To develop a standardized approach to pediatric delirium assessment by psychiatrists. METHODS: A multidisciplinary group of clinicians used Diagnostic and Statistical Manual criterion as the foundation for the Vanderbilt Assessment for Delirium in Infants and Children (VADIC). Pediatric-specific modifiers were integrated into the delirium criterion, including key developmental and assessment variations for children. The VADIC was used in clinical practice to prospectively assess critically ill infants and children. The VADIC was assessed for content validity by the American Academy of Child and Adolescent Psychiatry Delirium Special Interest Group. RESULTS: The American Academy of Child and Adolescent Psychiatry-Delirium Special Interest Group determined that the VADIC demonstrated high content validity. The VADIC (1) preserved the core Diagnostic and Statistical Manual delirium criterion, (2) appropriately paired interactive assessments with key criterion based on development, and (3) addressed confounders for delirium. A cohort of 300 patients with a median age of 20 months was assessed for delirium using the VADIC. Delirium prevalence was 47%. CONCLUSION: The VADIC provides a comprehensive framework to standardize pediatric delirium assessment by psychiatrists. The need for consistency in both delirium education and diagnosis is highlighted given the high prevalence of pediatric delirium.

Tracheostomy risk factors and outcomes after severe traumatic brain injury.

OBJECTIVE: To determine risk factors associated with tracheostomy placement after severe traumatic brain injury (TBI) and subsequent outcomes among those who did and did not receive a tracheostomy. METHODS: This retrospective cohort study compared adult trauma patients with severe TBI (n = 583) who did and did not receive tracheostomy. A multivariable logistic regression model assessed the associations between age, sex, race, insurance status, admission GCS, AIS (Head, Face, Chest) and tracheostomy placement. Ordinal logistic regression models assessed tracheostomy's influence on ventilator days and ICU LOS. To limit immortal time bias, Cox proportional hazards models assessed mortality at 1, 3 and 12-months. RESULTS: In this multivariable model, younger age and private insurance were associated with increased probability of tracheostomy. AIS, ISS, GCS, race and sex were not risk factors for tracheostomy placement. Age showed a non-linear relationship with tracheostomy placement; likelihood peaked in the fourth decade and declined with age. Compared to uninsured patients, privately insured patients had an increased probability of receiving a tracheostomy (OR = 1.89 [95% CI = 1.09-3.23]). Mortality was higher in those without tracheostomy placement (HR = 4.92 [95% CI = 3.49-6.93]). Abbreviated injury scale-Head was an independent factor for time to death (HR = 2.53 [95% CI = 2.00-3.19]), but age, gender and insurance were not. CONCLUSIONS: Age and insurance status are independently associated with tracheostomy placement, but not with mortality after severe TBI. Tracheostomy placement is associated with increased survival after severe TBI.

Validity of a Modified Sequential Organ Failure Assessment Score Using the Richmond Agitation-Sedation Scale.

OBJECTIVES: The Sequential Organ Failure Assessment and other severity of illness scales rely on the Glasgow Coma Scale to measure acute neurologic dysfunction, but the Glasgow Coma Scale is unavailable or inconsistently applied in some institutions. The objective of this study was to assess the validity of a modified Sequential Organ Failure Assessment that uses the Richmond Agitation-Sedation Scale instead of Glasgow Coma Scale. DESIGN: Prospective cohort study. SETTING: Medical and surgical ICUs within a large, tertiary care hospital. PATIENTS: Critically ill medical/surgical ICU patients. INTERVENTIONS: We calculated daily Sequential Organ Failure Assessment scores by using electronic medical record-derived data. By using bedside nurse-recorded Glasgow Coma Scale and Richmond Agitation-Sedation Scale measures, we calculated neurologic Sequential Organ Failure Assessment scores using the original Glasgow Coma Scale-based approach and a novel Richmond Agitation-Sedation Scale-based approach, converting the 10-point Richmond Agitation-Sedation Scale to a 4-point neurologic Sequential Organ Failure Assessment score. We assessed construct validity of Richmond Agitation-Sedation Scale-based Sequential Organ Failure Assessment by analyzing correlations with established severity of illness constructs (Acute Physiology and Chronic Health Evaluation II and Glasgow Coma Scale-based Sequential Organ Failure Assessment) and predictive validity by using logistic regression to determine whether Richmond Agitation-Sedation Scale-based Sequential Organ Failure Assessment predicts ICU, hospital, and 1-year mortality. We assessed discriminative performance with c-statistics. MEASUREMENTS AND MAIN RESULTS: Among 513 patients (5,199 patient-days), Richmond Agitation-Sedation Scale-based Sequential Organ Failure Assessment was strongly correlated with Acute Physiology and Chronic Health Evaluation II acute physiology score at enrollment (r = 0.583; 95% CI, 0.518-0.642) and daily Glasgow Coma Scale-based Sequential Organ Failure Assessment scores (r = 0.963; 95% CI, 0.956-0.968). Mean Richmond Agitation-Sedation Scale-based Sequential Organ Failure Assessment scores predicted ICU mortality (areas under the curve = 0.814)-as did mean Glasgow Coma Scale-based Sequential Organ Failure Assessment (0.799)-as well as hospital and 1-year mortality. Admission Sequential Organ Failure Assessment scores, whether using Richmond Agitation-Sedation Scale or Glasgow Coma Scale, were less accurate predictors of mortality; areas under the curves for ICU mortality for Richmond Agitation-Sedation Scale-based and Glasgow Coma Scale-based Sequential Organ Failure Assessment, for example, were 0.622 and 0.608, respectively. CONCLUSION: A modified Sequential Organ Failure Assessment score that uses bedside Richmond Agitation-Sedation Scale when Glasgow Coma Scale data are not available is a valid means of assessing daily severity of illness in the ICU and may be valuable for risk-adjustment and benchmarking purposes.

The Preschool Confusion Assessment Method for the ICU: Valid and Reliable Delirium Monitoring for Critically Ill Infants and Children.

OBJECTIVES: Delirium assessments in critically ill infants and young children pose unique challenges due to evolution of cognitive and language skills. The objectives of this study were to determine the validity and reliability of a fundamentally objective and developmentally appropriate delirium assessment tool for critically ill infants and preschool-aged children and to determine delirium prevalence. DESIGN AND SETTING: Prospective, observational cohort validation study of the PreSchool Confusion Assessment Method for the ICU in a tertiary medical center PICU. PATIENTS: Participants aged 6 months to 5 years and admitted to the PICU regardless of admission diagnosis were enrolled. MEASUREMENTS AND MAIN RESULTS: An interdisciplinary team created the PreSchool Confusion Assessment Method for the ICU for pediatric delirium monitoring. To assess validity, patients were independently assessed for delirium daily by the research team using the PreSchool Confusion Assessment Method for the ICU and by a child psychiatrist using the Diagnostic and Statistical Manual of Mental Disorders criteria. Reliability was assessed using blinded, concurrent PreSchool Confusion Assessment Method for the ICU evaluations by research staff. A total of 530-paired delirium assessments were completed among 300 patients, with a median age of 20 months (interquartile range, 11-37) and 43% requiring mechanical ventilation. The PreSchool Confusion Assessment Method for the ICU demonstrated a specificity of 91% (95% CI, 90-93), sensitivity of 75% (95% CI, 72-78), negative predictive value of 86% (95% CI, 84-88), positive predictive value of 84% (95% CI, 81-87), and a reliability κ-statistic of 0.79 (0.76-0.83). Delirium prevalence was 44% using the PreSchool Confusion Assessment Method for the ICU and 47% by the reference rater. The rates of delirium were 53% versus 56% in patients younger than 2 years old and 33% versus 35% in patients 2-5 years old using the PreSchool Confusion Assessment Method for the ICU and reference rater, respectively. The short-form PreSchool Confusion Assessment Method for the ICU maintained a high specificity (87%) and sensitivity (78%) in post hoc analysis. CONCLUSIONS: The PreSchool Confusion Assessment Method for the ICU is a highly valid and reliable delirium instrument for critically ill infants and preschool-aged children, in whom delirium is extremely prevalent.

An international career development survey of critical care practitioners*.

OBJECTIVES: To understand the career development needs of an international multidisciplinary group of critical care practitioners in the 21st century. DESIGN: A web-accessible survey deployed by the In-Training Section of the Society of Critical Care Medicine. SETTING: University health sciences center. SUBJECTS: Physicians (doctor of medicine and doctor of osteopathic medicine), advance practice providers (nurse practitioner, physician assistant, nurses, pharmacists, and student members of the Society of Critical Care Medicine. INTERVENTIONS: The survey covered domains of demographics, opinions about career development, and opinions about the Society of Critical Care Medicine In-Training Section. MEASUREMENTS AND MAIN RESULTS: One thousand forty-nine of approximately 16,000 Society of Critical Care Medicine members responded to the survey (7% response rate). Continuing education (280, 26.7%), leadership skills (197, 18.8%), and scientific development (192, 18.3%) are among the most important issues for the respondents. Many critical care practitioners would like to assist Society of Critical Care Medicine's efforts in career development (948, 90.4%) and many would consider some aspect of committee involvement (796, 75.9%). The Society of Critical Care Medicine In-Training Section, whose primary mission is career development across the spectrum of providers and expertise levels, needs improved advertisement (981, 93.7%). There is strong support for upcoming Annual Congresses dedicated to career development (834, 79.5%). Of the three main methods of information dissemination for Society of Critical Care Medicine career development initiatives from the In-Training Section, respondents rank e-mail highest (762, 72.6%), followed by webpages (228, 21.7%) and I-rooms (59, 5.6%). Over half of the Society of Critical Care Medicine membership surveyed lack a career development mentor in critical care. CONCLUSIONS: This is the largest assessment of the international critical care community regarding the career development needs of 21st century critical care practitioner although the limited response rate makes this work prone to sampling bias. Career development issues are broad and in need of further development by the Society of Critical Care Medicine In-Training Section. Although these initiatives need improved marketing, the Society of Critical Care Medicine membership is willing to help support them and work to further shape them in the future.

Diagnosing delirium in critically ill children: Validity and reliability of the Pediatric Confusion Assessment Method for the Intensive Care Unit.

OBJECTIVE: To validate a diagnostic instrument for pediatric delirium in critically ill children, both ventilated and nonventilated, that uses standardized, developmentally appropriate measurements. DESIGN AND SETTING: A prospective observational cohort study investigating the Pediatric Confusion Assessment Method for Intensive Care Unit (pCAM-ICU) patients in the pediatric medical, surgical, and cardiac intensive care unit of a university-based medical center. PATIENTS: A total of 68 pediatric critically ill patients, at least 5 years of age, were enrolled from July 1, 2008, to March 30, 2009. INTERVENTIONS: None. MEASUREMENTS: Criterion validity including sensitivity and specificity and interrater reliability were determined using daily delirium assessments with the pCAM-ICU by two critical care clinicians compared with delirium diagnosis by pediatric psychiatrists using Diagnostic and Statistical Manual, 4th Edition, Text Revision criteria. RESULTS: A total of 146 paired assessments were completed among 68 enrolled patients with a mean age of 12.2 yrs. Compared with the reference standard for diagnosing delirium, the pCAM-ICU demonstrated a sensitivity of 83% (95% confidence interval, 66-93%), a specificity of 99% (95% confidence interval, 95-100%), and a high interrater reliability (κ = 0.96; 95% confidence interval, 0.74-1.0). CONCLUSIONS: The pCAM-ICU is a highly valid reliable instrument for the diagnosis of pediatric delirium in critically ill children chronologically and developmentally at least 5 yrs of age. Use of the pCAM-ICU may expedite diagnosis and consultation with neuropsychiatry specialists for treatment of pediatric delirium. In addition, the pCAM-ICU may provide a means for delirium monitoring in future epidemiologic and interventional studies in critically ill children.

Prevalence and risk factors for development of delirium in burn intensive care unit patients.

Delirium affects 60 to 80% of ventilated patients and is associated with worse clinical outcomes including death. Unfortunately, there are limited data regarding the prevalence and risk factors of delirium in critically ill burn patients. The objectives of this study were to evaluate the prevalence of delirium in ventilated burn patients, using validated instruments, and to identify its risk factors. Adult ventilated burn patients at two tertiary centers were prospectively evaluated for delirium using the Confusion Assessment Method in the Intensive Care Unit (CAM-ICU) for 30 days or until intensive care unit discharge. Patients with neurologic injuries, severe dementia, and those not expected to survive >24 hours were excluded. Markov logistic regression was used to identify the risk factors of delirium, adjusting for clinically relevant covariates. The 82 ventilated burn patients had a median (interquartile range) age of 48 (38-62) years, Acute Physiology and Chronic Health Evaluation II scores 27 (21-30), and percent burns of 20 (7-32). Prevalence of delirium was 77% with a median duration of 3 (1-6) days. Exposure to benzodiazepines was an independent risk factor for the development of delirium (odds ratio: 6.8 [confidence interval: 3.1-15], P < .001), whereas exposure to both intravenous opiates (0.5 [0.4-0.6], P < .001) and methadone (0.7 [0.5-0.9], P = .02) was associated with a lower risk of delirium. In conclusion, delirium occurred at least once in approximately 80% of ventilated burn patients. Exposure to benzodiazepines was an independent risk factor for delirium, whereas opiates and methadone reduced the risk of developing delirium, possibly through reduction of pain in these patients.

Derivation and validation of Spo2/Fio2 ratio to impute for Pao2/Fio2 ratio in the respiratory component of the Sequential Organ Failure Assessment score.

OBJECTIVE: The Sequential Organ Failure Assessment (SOFA) score is validated to measure severity of organ dysfunction in critically ill patients. However, in some practice settings, daily arterial blood gas data required to calculate the respiratory component of the SOFA score are often unavailable. The objectives of this study were to derive Spo2/Fio2 (SF) ratio correlations with the Pao2/Fio2 (PF) ratio to calculate the respiratory parameter of the SOFA score, and to validate the respiratory SOFA obtained using SF ratios against clinical outcomes. PATIENTS AND MEASUREMENTS: We obtained matched measurements of Spo2 and Pao2 from two populations: group 1-patients undergoing general anesthesia and group 2-patients from the acute respiratory distress syndrome network-low-vs. high-tidal volume for the acute respiratory management of acute respiratory distress syndrome database. Using a linear regression model, we first determined SF ratios corresponding to PF ratios of 100, 200, 300, and 400. Second, we evaluated the contribution of positive end-expiratory pressure (PEEP) on the relationship between SF and PF, for patients on PEEP in centimeters of water (cm H2O) of <8, 8-12, and >12. Third, we calculated the SOFA scores in a separate cohort of intensive care unit patients using the derived SF ratios and validated them against clinical outcomes. RESULTS: The total SOFA scores calculated using SF ratios and PF ratios were highly correlated (Spearman's rho 0.85, p < 0.001) in all patients and in the three stratified PEEP categories (<8 cm H2O, Spearman's rho 0.87, p < 0.001; PEEP 8-12 cm H20, Spearman's rho 0.85, p < 0.001; PEEP >12 cm H2O, Spearman's rho 0.85, p < 0.001). The respiratory SOFA scores based on SF ratios and PF ratios correlated similarly with intensive care unit length of stay and ventilator-free days, when validated in a cohort of critically ill patients. CONCLUSION: The total and respiratory SOFA scores obtained with imputed SF values correlate with the corresponding SOFA score using PF ratios. Both the derived and original respiratory SOFA scores similarly predict outcomes.

Prevalence and risk factors for development of delirium in surgical and trauma intensive care unit patients.

BACKGROUND: Although known to be an independent predictor of poor outcomes in medical intensive care unit (ICU) patients, limited data exist regarding the prevalence of and risk factors for delirium among surgical (SICU) and trauma ICU (TICU) patients. The purpose of this study was to analyze the prevalence of and risk factors for delirium in surgical and trauma ICU patients. METHODS: SICU and TICU patients requiring mechanical ventilation (MV) >24 hours were prospectively evaluated for delirium using the Richmond Agitation Sedation Scale (RASS) and the Confusion Assessment Method for the ICU (CAM-ICU). Those with baseline dementia, intracranial injury, or ischemic/hemorrhagic strokes that would confound the evaluation of delirium were excluded. Markov models were used to analyze predictors for daily transition to delirium. RESULTS: One hundred patients (46 SICU and 54 TICU) were enrolled. Prevalence of delirium was 73% in the SICU and 67% in the TICU. Multivariable analyses identified midazolam [OR 2.75 (CI 1.43-5.26, p = 0.002)] exposure as the strongest independent risk factor for transitioning to delirium. Opiate exposure showed an inconsistent message such that fentanyl was a risk factor for delirium in the SICU (p = 0.007) but not in the TICU (p = 0.936), whereas morphine exposure was associated with a lower risk of delirium (SICU, p = 0.069; TICU p = 0.024). CONCLUSION: Approximately 7 of 10 SICU and TICU patients experience delirium. In keeping with other recent data on benzodiazepines, exposure to midazolam is an independent and potentially modifiable risk factor for the transitioning to delirium.

Implementation, reliability testing, and compliance monitoring of the Confusion Assessment Method for the Intensive Care Unit in trauma patients.

OBJECTIVE: To implement delirium monitoring, test reliability, and monitor compliance of performing the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) in trauma patients. DESIGN AND SETTING: Prospective, observational study in a level 1 trauma unit of a tertiary care, university-based medical center. PATIENTS: Acutely injured patients admitted to the trauma unit between 1 February 2006 and 16 April 2006. MEASUREMENTS AND RESULTS: Following web-based teaching modules and group in-services, bedside nurses evaluated patients daily for depth of sedation with the Richmond Agitation-Sedation Scale (RASS) and for the presence of delirium with the CAM-ICU. On randomly assigned days over a 10-week period, evaluations by nursing staff were followed by evaluations by an expert evaluator of the RASS and the CAM-ICU to assess compliance and reliability of the CAM-ICU in trauma patients. Following the audit period the nurses completed a postimplementation survey. The expert evaluator performed 1,011 random CAM-ICU assessments within 1h of the bedside nurse's assessments. Nurses completed the CAM-ICU assessments in 84% of evaluations. Overall agreement (kappa) between nurses and expert evaluator was 0.77 (0.721-0.822; p < 0.0001), in TBI patients 0.75 (0.667-0.829; p < 0.0001) and in mechanically ventilated patients 0.62 (0.534-0.704; p < 0.0001). The survey revealed that nurses were confident in performing the CAM-ICU, realized the importance of delirium, and were satisfied with the training that they received. It also acknowledged obstacles to implementation including nursing time and failure of physicians/surgeons to address treatment approaches for delirium. CONCLUSIONS: The CAM-ICU can be successfully implemented in a university-based trauma unit with high compliance and reliability. Quality improvement projects seeking to implement delirium monitoring would be wise to address potential pitfalls including time complaints and the negative impact of physician indifference regarding this form of organ dysfunction.

Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial.

CONTEXT: Lorazepam is currently recommended for sustained sedation of mechanically ventilated intensive care unit (ICU) patients, but this and other benzodiazepine drugs may contribute to acute brain dysfunction, ie, delirium and coma, associated with prolonged hospital stays, costs, and increased mortality. Dexmedetomidine induces sedation via different central nervous system receptors than the benzodiazepine drugs and may lower the risk of acute brain dysfunction. OBJECTIVE: To determine whether dexmedetomidine reduces the duration of delirium and coma in mechanically ventilated ICU patients while providing adequate sedation as compared with lorazepam. DESIGN, SETTING, PATIENTS, AND INTERVENTION: Double-blind, randomized controlled trial of 106 adult mechanically ventilated medical and surgical ICU patients at 2 tertiary care centers between August 2004 and April 2006. Patients were sedated with dexmedetomidine or lorazepam for as many as 120 hours. Study drugs were titrated to achieve the desired level of sedation, measured using the Richmond Agitation-Sedation Scale (RASS). Patients were monitored twice daily for delirium using the Confusion Assessment Method for the ICU (CAM-ICU). MAIN OUTCOME MEASURES: Days alive without delirium or coma and percentage of days spent within 1 RASS point of the sedation goal. RESULTS: Sedation with dexmedetomidine resulted in more days alive without delirium or coma (median days, 7.0 vs 3.0; P = .01) and a lower prevalence of coma (63% vs 92%; P < .001) than sedation with lorazepam. Patients sedated with dexmedetomidine spent more time within 1 RASS point of their sedation goal compared with patients sedated with lorazepam (median percentage of days, 80% vs 67%; P = .04). The 28-day mortality in the dexmedetomidine group was 17% vs 27% in the lorazepam group (P = .18) and cost of care was similar between groups. More patients in the dexmedetomidine group (42% vs 31%; P = .61) were able to complete post-ICU neuropsychological testing, with similar scores in the tests evaluating global cognitive, motor speed, and attention functions. The 12-month time to death was 363 days in the dexmedetomidine group vs 188 days in the lorazepam group (P = .48). CONCLUSION: In mechanically ventilated ICU patients managed with individualized targeted sedation, use of a dexmedetomidine infusion resulted in more days alive without delirium or coma and more time at the targeted level of sedation than with a lorazepam infusion. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00095251.

Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients.

BACKGROUND: Delirium has recently been shown as a predictor of death, increased cost, and longer duration of stay in ventilated patients. Sedative and analgesic medications relieve anxiety and pain but may contribute to patients' transitioning into delirium. METHODS: In this cohort study, the authors designed a priori an investigation to determine whether sedative and analgesic medications independently increased the probability of daily transition to delirium. Markov regression modeling (adjusting for 11 covariates) was used in the evaluation of 198 mechanically ventilated patients to determine the probability of daily transition to delirium as a function of sedative and analgesic dose administration during the previous 24 h. RESULTS: Lorazepam was an independent risk factor for daily transition to delirium (odds ratio, 1.2 [95% confidence interval, 1.1-1.4]; P = 0.003), whereas fentanyl, morphine, and propofol were associated with higher but not statistically significant odds ratios. Increasing age and Acute Physiology and Chronic Health Evaluation II scores were also independent predictors of transitioning to delirium (multivariable P values < 0.05). CONCLUSIONS: Lorazepam administration is an important and potentially modifiable risk factor for transitioning into delirium even after adjusting for relevant covariates.

Delirium: acute cognitive dysfunction in the critically ill.

PURPOSE OF REVIEW: The management of sepsis and the multiple organ dysfunction syndrome has traditionally been centered on dysfunction of organs other than the brain (e.g., heart, lungs, or kidneys), although the brain is one of the most prevalent organs involved. Recent studies indicate that nonpulmonary acute organ dysfunction may contribute significantly to mortality and other important clinical outcomes. Acute confusional states (delirium) occur in 10 to 60% of the older hospitalized population and in 60 to 80% of patients in the intensive care unit, yet go unrecognized by the managing physicians and nurses in 32 to 66% of cases. Delirium is an important independent prognostic determinant of hospital outcomes, including duration of mechanical ventilation, nursing home placement, functional decline, and death. Recently, new monitoring instruments have been validated for monitoring of delirium in noncommunicative patients receiving mechanical ventilation. Hence, critical care physicians and nurses should routinely assess their patients for delirium and develop strategies for its prevention and treatment. RECENT FINDINGS: This state-of-the-art review discusses in depth the delirium monitoring instruments, the pathophysiology and risk factors of delirium, its prognostic implications, and strategies (including ongoing clinical trials) to prevent and treat delirium. SUMMARY: Delirium is extremely common and has significant prognostic implications in critically ill patients. Routine monitoring and a multimodal approach to prevent or reduce the prevalence of delirium are of paramount importance.