Assessment and report of individual symptoms in studies of delirium in postoperative populations: a systematic review.

OBJECTIVES: Delirium is most often reported as present or absent. Patients with symptoms falling short of the diagnostic criteria for delirium fall into 'no delirium' or 'control' groups. This binary classification neglects individual symptoms and may be hindering identification of the pathophysiology underlying delirium. This systematic review investigates which individual symptoms of delirium are reported by studies of postoperative delirium in adults. METHODS: Medline, EMBASE and Web of Science databases were searched on 03 June 2021 and 06 April 2023. Two reviewers independently examined titles and abstracts. Each paper was screened in duplicate and conflicting decisions settled by consensus discussion. Data were extracted, qualitatively synthesised and narratively reported. All included studies were quality assessed. RESULTS: These searches yielded 4,367 results. After title and abstract screening, 694 full-text studies were reviewed, and 62 deemed eligible for inclusion. This review details 11,377 patients including 2,049 patients with delirium. In total, 78 differently described delirium symptoms were reported. The most reported symptoms were inattention (N = 29), disorientation (N = 27), psychomotor agitation/retardation (N = 22), hallucination (N = 22) and memory impairment (N = 18). Notably, psychomotor agitation and hallucinations are not listed in the current Diagnostic and Statistical Manual for Mental Disorders-5-Text Revision delirium definition. CONCLUSIONS: The 78 symptoms reported in this systematic review cover domains of attention, awareness, disorientation and other cognitive changes. There is a lack of standardisation of terms, and many recorded symptoms are synonyms of each other. This systematic review provides a library of individual delirium symptoms, which may be used to inform future reporting.

Improving morbidity and mortality in hip fragility fractures.

PURPOSE OF REVIEW: Hip fragility fractures (HFF) carry high morbidity and mortality for patients and will increase in frequency and in proportion to the average patient age. Provision of effective, timely care for these patients can decrease their morbidity and mortality and reduce the large burden they place on the healthcare system. RECENT FINDINGS: There are associative relationships between prefracture frailty, postoperative delirium and increased morbidity and mortality. The use of a multidisciplinary approach to HFF care has shown improved outcomes in care with focus on modifiable factors including admission to specialty care floor, use of peripheral nerve blocks preoperatively and Anesthesia and Physical Therapy involvement in the care team. Peripheral nerve blocks including pericapsular nerve group (PENG) blocks have shown benefit in lowering morbidity and mortality. SUMMARY: HFF are associated with >40% chance of continued pain and inability to return to prefracture functional status at 1 year as well as >30% mortality at 2 years. In this opinion piece, we will discuss how a multidisciplinary approach that includes Anesthesia as well as utilization of peripheral nerve blocks can help to lessen postoperative issues and improve recovery.

Enhancing delirium assessment and management through nursing education interventions: A scoping review.

AIM/OBJECTIVE: The purpose of this scoping review was to explore the characteristics and outcomes of education interventions for nurses focused on delirium assessment and management. BACKGROUND: Delirium is a prevalent acute and reversible neuropsychiatric syndrome in hospitalized patients. Delirium can cause cognitive, psychiatric and physical impairments and result in prolonged hospital stay, increased risk of readmission and elevated morbidity and mortality rates. Nurses play an essential role in managing delirium. There is a lack of understanding of the existing nursing educational interventions on delirium management. DESIGN: The study was a scoping review. METHODS: In this scoping review, we used Arksey and O'Malley's (2005) scoping review framework. We searched articles published between 2019 and 2023 in Academic Search Premier, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and MEDLINE using the following CINAHL/MeSH suggested subject terms: "delirium" in conjunction with "education" "intervention" and "nurse", "nurses" or "nursing." Studies on improving nursing knowledge and practices regarding delirium were included while those focusing on nursing students were excluded. Initial screening involved evaluating article titles and abstracts for relevance from 164 identified articles, followed by a full-text review of 42 articles. Finally, 17 articles were selected for comprehensive analysis. We extracted relevant information from each article and charted the findings in an evidence table. RESULTS: The 17 selected articles showcased a variety of interventions used to educate nursing staff, such as workshops, simulations, group discussions, online modules and one-on-one coaching. Educational interventions primarily focused on delirium definition, risk factors, assessment and management. These educational interventions enhanced nurses' perception of delirium, boosting their confidence and knowledge in managing delirium. These interventions also led to increased compliance with delirium assessment and management protocols, which ultimately resulted in improved documentation accuracy and patient outcomes. CONCLUSIONS: Findings from this scoping review suggest that nursing administration need to provide support and education for delirium prevention and management to enhance nursing staff confidence and competence in assessing and managing delirium. The use of interactive educational techniques has demonstrated profound benefits in schema development, expertize promotion and critical thinking. These findings have significant implications for future research, including the identification of essential nursing competencies for educational interventions and the assessment of long-term knowledge retention and its application in nursing practice.

Delirium risk screening and assessment among older patients in general wards and the emergency department: a best practice implementation project.

OBJECTIVES: The aim of this project was to improve compliance with evidence-based criteria regarding risk of delirium and the assessment of delirium among older patients in the general hospitalization wards and the emergency department. INTRODUCTION: More than 50% of older hospitalized patients experience delirium. Some studies have highlighted the need to implement an orientation protocol in the emergency department and to continue this in the general wards, with the aim of decreasing the delirium rate among older patients admitted to hospital. METHODS: The project followed the JBI evidence implementation framework. We conducted a baseline audit, a half-way audit, and final audit of 50 patients at risk of delirium admitted to the emergency department and the general wards, respectively. The audits measured compliance with eight criteria informed by the available evidence. RESULTS: In the final audit, three of the eight criteria achieved more than 50% compliance in the general wards: pressure injury screening (96%); monitoring changes (74%); and performing interventions (76%). In the emergency department, worse results were reported because of the service conditions. The exception was the criterion on the training of nurses on the topic, with 98%. The integration of a tool to screen for delirium in older patients in the hospital's electronic clinical history records increased the percentage of compliance with audit criteria regarding the use of the scale and delirium detection (rising from 0% to 32% in the final audit in the general wards). CONCLUSION: Through the implementation of this project, validated and evidence-based evaluation will ensure that nurses are supported through appropriate measures to reduce patient confusion and aggression resulting from delirium.

Development and validation of an international preoperative risk assessment model for postoperative delirium.

BACKGROUND: Postoperative delirium (POD) is a frequent complication in older adults, characterised by disturbances in attention, awareness and cognition, and associated with prolonged hospitalisation, poor functional recovery, cognitive decline, long-term dementia and increased mortality. Early identification of patients at risk of POD can considerably aid prevention. METHODS: We have developed a preoperative POD risk prediction algorithm using data from eight studies identified during a systematic review and providing individual-level data. Ten-fold cross-validation was used for predictor selection and internal validation of the final penalised logistic regression model. The external validation used data from university hospitals in Switzerland and Germany. RESULTS: Development included 2,250 surgical (excluding cardiac and intracranial) patients 60 years of age or older, 444 of whom developed POD. The final model included age, body mass index, American Society of Anaesthesiologists (ASA) score, history of delirium, cognitive impairment, medications, optional C-reactive protein (CRP), surgical risk and whether the operation is a laparotomy/thoracotomy. At internal validation, the algorithm had an AUC of 0.80 (95% CI: 0.77-0.82) with CRP and 0.79 (95% CI: 0.77-0.82) without CRP. The external validation consisted of 359 patients, 87 of whom developed POD. The external validation yielded an AUC of 0.74 (95% CI: 0.68-0.80). CONCLUSIONS: The algorithm is named PIPRA (Pre-Interventional Preventive Risk Assessment), has European conformity (ce) certification, is available at http://pipra.ch/ and is accepted for clinical use. It can be used to optimise patient care and prioritise interventions for vulnerable patients and presents an effective way to implement POD prevention strategies in clinical practice.

Delirium in trauma ICUs: a review of incidence, risk factors, outcomes, and management.

PURPOSE OF REVIEW: This article reviews the impact and importance of delirium on patients admitted to the ICU after trauma, including the latest work on prevention and treatment of this condition. As the population ages, the incidence of geriatric trauma will continue to increase with a concomitant rise in the patient and healthcare costs of delirium in this population. RECENT FINDINGS: Recent studies have further defined the risk factors for delirium in the trauma ICU patient population, as well as better demonstrated the poor outcomes associated with the diagnosis of delirium in these patients. Recent trials and meta-analysis offer some new evidence for the use of dexmedetomidine and quetiapine as preferred agents for prevention and treatment of delirium and add music interventions as a promising part of nonpharmacologic bundles. SUMMARY: Trauma patients requiring admission to the ICU are at significant risk of developing delirium, an acute neuropsychiatric disorder associated with increased healthcare costs and worse outcomes including increased mortality. Ideal methods for prevention and treatment of delirium are not well established, especially in this population, but recent research helps to clarify optimal prevention and treatment strategies.

Cost-effectiveness of clinical interventions for delirium: A systematic literature review of economic evaluations.

OBJECTIVE: Little is known about the economic value of clinical interventions for delirium. This review aims to synthesise and appraise available economic evidence, including resource use, costs, and cost-effectiveness of interventions for reducing, preventing, and treating delirium. METHODS: Systematic review of published and grey literature on full and partial economic evaluations. Study quality was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS). RESULTS: Fourteen economic evaluations (43% full, 57% partial) across nine multicomponent and nonpharmacological intervention types met inclusion criteria. The intervention costs ranged between US$386 and $553 per person in inpatient settings. Multicomponent delirium prevention intervention and the Hospital Elder Life Program (HELP) reported statistically significant cost savings or cost offsets somewhere else in the health system. Cost savings related to inpatient, outpatient, and out-of-pocket costs ranged between $194 and $6022 per person. The average CHEERS score was 74% (±SD 10%). CONCLUSION: Evidence on a joint distribution of costs and outcomes of delirium interventions was limited, varied and of generally low quality. Directed expansion of health economics towards the evaluation of delirium care is necessary to ensure effective implementation that meets patients' needs and is cost-effective in achieving similar or better outcomes for the same or lower cost.

Incremental medical cost of delirium in elderly patients with cognitive impairment: analysis of a nationwide administrative database in Japan.

OBJECTIVES: Delirium is a neuropsychiatric disorder that commonly occurs in elderly patients with cognitive impairment. The economic burden of delirium in Japan has not been well characterised. In this study, we assessed incremental medical costs of delirium in hospitalised elderly Japanese patients with cognitive impairment. DESIGN: Retrospective, cross-sectional, observational study. SETTING: Administrative data collected from acute care hospitals in Japan between April 2012 and September 2020. PARTICIPANTS: Hospitalised patients ≥65 years old with cognitive impairment were categorised into groups-with and without delirium. Delirium was identified using a delirium identification algorithm based on the International Classification of Diseases 10th Revision codes or antipsychotic prescriptions. OUTCOME MEASURES: Total medical costs during hospitalisation were compared between the groups using a generalised linear model. RESULTS: The study identified 297 600 hospitalised patients ≥65 years of age with cognitive impairment: 39 836 had delirium and 257 764 did not. Patient characteristics such as age, sex, inpatient department and comorbidities were similar between groups. Mean (SD) unadjusted total medical cost during hospitalisation was 979 907.7 (871 366.4) yen for patients with delirium and 816 137.0 (794 745.9) yen for patients without delirium. Adjusted total medical cost was significantly greater for patients with delirium compared with those without delirium (cost ratio=1.09, 95% CI: 1.09 to 1.10; p<0.001). Subgroup analyses revealed significantly higher total medical costs for patients with delirium compared with those without delirium in most subgroups except patients with hemiplegia or paraplegia. CONCLUSIONS: Medical costs during hospitalisation were significantly higher for patients with delirium compared with those without delirium in elderly Japanese patients with cognitive impairment, regardless of patient subgroups such as age, sex, intensive care unit admission and most comorbidities. These findings suggest that delirium prevention strategies are critical to reducing the economic burden as well as psychological/physiological burden in cognitively impaired elderly patients in Japan.

[Non-pharmacological prevention and treatment of delirium in the intensive care unit].

Delirium is an acute brain dysfunction that is a common and difficult-to-eliminate problem in the ICU. It is an important factor leading to prolonged hospital stay, increased treatment costs, and long-term cognitive impairment. Nonetheless, compared with the treatment of respiratory failure and its primary disease, the prevention and treatment measurements of delirium have not received enough attention, and its management strategies are still controversial. Evidence-based medicine currently does not support pharmacological approaches to preventing or treating delirium. Instead, it adopts a combination of multiple nonpharmacological methods to manage delirium in ICU patients through standardized evaluation and monitoring under the guidance of doctors and the cooperation of patients and their families.

[Delirium-assessment, prevention and treatment : Task in the interprofessional intensive care unit team]. / Delir ­ Beurteilung, Vorbeugung und Behandlung : Aufgabe im interprofessionellen Team der Intensivstation.

Postoperative delirium is a challenge for patients, relatives, nurses, physicians, and healthcare systems. Delirium is associated with increased mortality, longer hospitalization, reduced quality of life, and higher average treatment costs. Consequently, the most recent version of the German Guideline on Analgesia, Sedation and Delirium Management in Intensive Care Medicine (DAS Guideline 2020) emphasizes the importance of delirium prevention. In particular, nonpharmacological interventions play a special role in this regard for basically all patients receiving intensive care. The DAS Guideline stresses the importance of regular systematic screening with validated instruments to recognize developing delirium early and take the appropriate measures in time, as the duration of delirious conditions influences both mortality and quality of life. If delirium manifests, intervention must be immediate and symptom-oriented.

Improving the Detection, Assessment, Management and Prevention of Delirium in Hospices (the DAMPen-D study): protocol for a co-design and feasibility study of a flexible and scalable implementation strategy to deliver guideline-adherent delirium care.

INTRODUCTION: Delirium is a complex condition in which altered mental state and cognition causes severe distress and poor clinical outcomes for patients and families, anxiety and stress for the health professionals and support staff providing care, and higher care costs. Hospice patients are at high risk of developing delirium, but there is significant variation in care delivery. The primary objective of this study is to demonstrate the feasibility of an implementation strategy (designed to help deliver good practice delirium guidelines), participant recruitment and data collection. METHODS AND ANALYSIS: Three work packages in three hospices in the UK with public involvement in codesign, study management and stakeholder groups: (1) experience-based codesign to adapt an existing theoretically-informed implementation strategy (Creating Learning Environments for Compassionate Care (CLECC)) to implement delirium guidelines in hospices; (2) feasibility study to explore ability to collect demographic, diagnostic and delirium management data from clinical records (n=300), explanatory process data (number of staff engaged in CLECC activities and reasons for non-engagement) and cost data (staff and volunteer hours and pay-grades engaged in implementation activities) and (3) realist process evaluation to assess the acceptability and flexibility of the implementation strategy (preimplementation and postimplementation surveys with hospice staff and management, n=30 at each time point; interviews with hospice staff and management, n=15). Descriptive statistics, rapid thematic analysis and a realist logic of analysis will be used be used to analyse quantitative and qualitative data, as appropriate. ETHICS AND DISSEMINATION: Ethical approval obtained: Hull York Medical School Ethics Committee (Ref 21/23), Health Research Authority Research Ethics Committee Wales REC7 (Ref 21/WA/0180) and Health Research Authority Confidentiality Advisory Group (Ref 21/CAG/0071). Written informed consent will be obtained from interview participants. A results paper will be submitted to an open access peer-reviewed journal and a lay summary shared with study site staff and stakeholders. TRIAL REGISTRATION NUMBER: ISRCTN55416525.

Nurse-Driven Assessment, Prevention, and Management of Delirium on an Acute Inpatient Neurology Unit.

BACKGROUND: Delirium commonly affects hospitalized patients and is associated with increased hospital length of stay, discharge to skilled care, cost, morbidity, and mortality. LOCAL PROBLEM: At our organization, there was no formal delirium assessment performed by the nursing staff outside of the intensive care unit. METHODS: Assessment of nurses' knowledge about delirium, a nurse-driven delirium screening protocol, and patient education were implemented on an adult inpatient neurology unit. Knowledge change, protocol implementation, and patient-level outcomes were assessed. INTERVENTIONS: Staff nurse delirium education and a nurse-driven delirium screening protocol were implemented. RESULTS: No change in nursing knowledge occurred pre/postintervention. Falls, falls with injury, and restraint and sitter usage decreased. Changes in length of stay varied over the intervention period. The trend to discharge to home increased, while the trend to discharge to skilled nursing care decreased. CONCLUSIONS: Formal delirium screening protocols may add organizational value by positively impacting patient outcomes.

Comparative salary-related costs of a brief app-directed delirium identification protocol by hospitalists, nurses, and nursing assistants.

BACKGROUND: Systematic screening can improve delirium identification among hospitalized older adults. Prior studies have shown clinicians and health system leaders may believe they do not have the time and resources for assessment. We conducted a comparative salary-related cost analysis of an adaptive delirium identification protocol directed by an iPad app. METHODS: We recruited 527 older adult medicine patients from an urban academic medical center (n = 269) and a rural community hospital (n = 258). Physicians and nurses completed the two-step Ultra-brief Confusion Assessment Method (UB-CAM) protocol (with or without a skip pattern), while certified nursing assistants completed only the UB-2 ultra-brief screen. The sample included 527 patients (average age 80, 57% women, 35% with dementia). Time required to administer the protocol was collected automatically by the iPad app. Salary-related costs of screening were determined by multiplying the time required by the hourly wage for the three disciplines, as obtained from national and regional published healthcare salary cost data. Cost estimates for entire hospital implementation were also calculated. RESULTS: Participants were screened on 924 hospital days by 399 clinicians (53 physicians, 236 nurses, 110 CNAs). For the UB-2, CNAs cost per screen was lower than the other clinician types ($0.37 per screen vs. $0.73 for nurses and $2.39 for hospitalists). For the UB-CAM with skip (UB-CAM), costs per protocol were $1.10 for nurses vs. $3.61 for physicians. The annual salary-related costs of hospital-wide implementation of a nurse-based UB-CAM protocol in a medium-sized (300-bed) hospital was $63,015 plus $4356 for initial and annual training. CONCLUSIONS: CNAs and nurses had the lowest salary-associated costs for app-directed CAM-based delirium screening and identification, respectively. Salary-related annual hospital costs for the most efficient protocols in a medium-sized hospital were less than the annual cost of hiring 1 FTE of the discipline performing the protocols.

A complex intervention to promote prevention of delirium in older adults by targeting caregiver's participation during and after hospital discharge - study protocol of the TRAnsport and DElirium in older people (TRADE) project.

BACKGROUND: Among potentially modifiable risk factors for delirium, transfers between wards, hospitals and other facilities have been mentioned with low evidence. TRADE (TRAnsport and DElirium in older people) was set up to investigate i) the impact of transfer and/or discharge on the onset of delirium in older adults and ii) feasibility and acceptance of a developed complex intervention targeting caregiver's participation during and after hospital discharge or transfer on cognition and the onset of delirium in older adults. METHODS: The study is designed according to the guidelines of the UK Medical Research Council (MRC) for development and evaluation of complex interventions and comprises two steps: development and feasibility/piloting. The development phase includes i) a multicenter observational prospective cohort study to assess delirium incidence and cognitive decline associated with transfer and discharge, ii) a systematic review of the literature, iii) stakeholder focus group interviews and iv) an expert workshop followed by a Delphi survey. Based on this information, a complex intervention to better and systematically involve family caregivers in discharge and transport was developed. The intervention will be tested in a pilot study using a stepped wedge design with a detailed process and health economic evaluation. The study is conducted at four acute care hospitals in southwest Germany. Primary endpoints are the delirium incidence and cognitive function. Secondary endpoints include prevalence of caregiver companionship, functional decline, cost and cost effectiveness, quality of discharge management and quality of admission management in admitting hospitals or nursing homes. Data will be collected prior to discharge as well as after 3, 7 and 90 days. DISCUSSION: TRADE will help to evaluate transfer and discharge as a possible risk factor for delirium. In addition, TRADE evaluates the impact and modifiability of caregiver's participation during patient's transfer or discharge on delirium incidence and cognitive decline providing the foundation for a confirmatory implementation study. TRIAL REGISTRATION: DRKS (Deutsches Register für klinische Studien) DRKS00017828 . Registered on 17th September 2019. Retrospectively registered.

Early Recognition of Preventable Factors Associated with Delirium Saves Lives and Costs.

Delirium is a complex diagnosis characterized by inattention accompanied by either disorganized thinking or an altered level of consciousness. Delirium affects approximately 15% of older adults in the hospital. Delirium is associated with a 62% greater risk of mortality within 1 year of discharge and a significant increase in health care costs. Although the Diagnostic and Statistical Manual of Mental Health-5 has defined delirium, its characteristics, and has recommended diagnostic tools, one of the greatest challenges has been instituting timely and effective treatments. Effective management of delirium includes nonpharmacologic and pharmacologic interventions simultaneously instituted to control agitation while exploring causation.

Orthogeriatric co-management reduces incidence of delirium in hip fracture patients.

Hip fracture patients often display an acute confusional state (delirium) which is associated with worse outcomes. In this observational study, we found that co-management of hip fracture patients by a multidisciplinary team including a geriatrician and an orthopaedic surgeon could reduce the incidence of delirium. INTRODUCTION: Delirium after hip fracture is common and is associated with negative outcomes. We investigated if orthogeriatric co-management reduced the incidence of delirium in hip fracture patients. METHODS: In this single-centre, prospective observational study, we compared the incidence of delirium and subsyndromal delirium (SSD) before (usual care group, n = 94) and after (orthogeriatric group, n = 103) the introduction of orthogeriatric co-management as an integrated care model. The outcome measure 'no delirium/SSD/delirium' was treated as an ordinal variable and analysed using the chi-squared test and multivariable ordinal logistic regression. RESULTS: The groups had similar baseline characteristics except for a higher proportion of patients with pre-existing cognitive impairment in the usual care group (51% vs. 37%, p = 0.045). Fewer patients in the orthogeriatric group developed SSD or delirium (no delirium: 59% vs. 40%/SSD: 6% vs. 13%/delirium: 35% vs. 47%; p = 0.021). The number needed to treat (NNT) to avoid one case of SSD or delirium was 5.3 (95% CI: 3.1 to 19.7). In a multivariable analysis adjusted for age, sex, ASA class, pre-existing cognitive impairment, time to surgery, type of surgery, and medical or surgical complications, the odds ratio for the development of SSD/delirium was lower in the orthogeriatric group (OR = 0.46, 95% CI: 0.23-0.89, p = 0.023). CONCLUSION: Orthogeriatric co-management as an integrated care model reduced the incidence of SSD/delirium in hip fracture patients.

Consolidated framework for advancing implementation science for the implementation process and adherence assessment of a non-pharmacological delirium prevention program.

OBJECTIVE: To evaluate the contribution of applying the theoretical framework of implementation science for adherence to non-pharmacological interventions to prevent delirium. METHODS: A quasi-experimental prospective design was conducted from March 2017 to October 2018 in a teaching hospital. Participants included 149 healthcare staff and 72 elderly inpatients. A non-pharmacological delirium prevention program was designed, applied and evaluated in accordance with the consolidated framework for advancing implementation research (CFIR). The primary outcome was the global adherence rate to 12 predefined indicators, comparing measurements at baseline (O1), after training (O2) and at a 6-month follow-up (O3) assessed by an external reviewer. Staff knowledge and beliefs about delirium were assessed using a validated tool, and delirium incidence was evaluated using the confusion assessment method. RESULTS: Overall adherence increased from 58.2% (O1) to 77.9% (O2) and 75.6% (O3) (O2 vs. O1: p < 0.001 and O3 vs. O1: p < 0.001). Staff perceptions regarding implementation of non-pharmacological interventions increased from 74.8% to 81.9% (p = 0.004). Delirium incidence was non-significantly reduced from 20% (O1) to 16% (O3) (p = 0.99). CONCLUSIONS: Implementation of a delirium prevention program using a CFIR model was useful in improving adherence to activities included in this program, as well as improving the knowledge and beliefs regarding delirium by healthcare workers. The impact of this implementation strategy on the incidence of delirium should be evaluated in a larger scale multicenter trial.

Delirium Assessment in Critically Ill Older Adults: Considerations During the COVID-19 Pandemic.

Older adults are particularly vulnerable during the Coronavirus disease 2019 (COVID-19) pandemic, because higher age increases risk for both delirium and COVID-19-related death. Despite the health care system limitations and the clinical challenges of the pandemic, delirium screening and management remains an evidence-based cornerstone of critical care. This article discusses practical recommendations for delirium screening in the COVID-19 pandemic era, tips for training health care workers in delirium screening, validated tools for detecting delirium in critically ill older adults, and approaches to special populations of older adults (eg, sensory impairment, dementia, acute neurologic injury).

A multimodal sevoflurane-based sedation regimen in combination with targeted temperature management in post-cardiac arrest patients reduces the incidence of delirium: An observational propensity score-matched study.

BACKGROUND: Recent studies suggest that volatile anaesthetics are safe, efficient, and reliable alternatives to the use of intravenous anaesthetics for out-of-hospital cardiac arrest (OHCA) patients admitted to the intensive care unit (ICU). We hypothesised that volatile anaesthetics may reduce the incidence of delirium rather than intravenous sedatives. This retrospective study aimed to investigate whether sevoflurane combined with higher targeted temperature management could decrease the incidence of delirium when compared with intravenous anaesthetics with lower targeted temperature management. METHODS: Using a propensity score-matched analysis, we retrospectively compared a target temperature management (32-34 °C) method along with intravenous sedation (TTM-33/IV) and a modified target temperature management (34-36 °C) method along with sevoflurane sedation (mTTM-36/sevo). We used the confusion assessment method for the ICU to measure the incidence of delirium. We calculated the time-dependent risk on delirium using the multivariate Cox regression model. RESULTS: The incidence of delirium was significantly lower (p = 0.001) in OHCA patients of the mTTM-36/sevo group (9/56, 16.1%) than in those of the TTM-33/IV group (25/67, 37.3%). Mechanical ventilation and lengths of stay in the ICU (p < 0.001) and hospital stay (p = 0.04) were shorter in the mTTM-36/sevo group. Patients in the TTM-33/IV group required more midazolam, propofol, and fentanyl. We observed no significant difference in mortality. CONCLUSION: A multimodal sevoflurane-based sedation regimen together with targeted temperature management resulted in a lower incidence of delirium and a shorter duration for mechanical ventilation and ICU length of stay than did the treatment with intravenous sedation combined with the classical cooling protocol.