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1.
Hu Li Za Zhi ; 67(5): 89-98, 2020 Oct.
Artigo em Chinês | MEDLINE | ID: mdl-32978770

RESUMO

Patients with traumatic brain injury (TBI) have a high incidence rate of delirium, which leads to poor prognoses. This case study describes a nursing experience of implementing ABCDEF bundle care to reduce delirium in a patient with TBI. The period of nursing care was April 23 to April 30, 2019. A comprehensive assessment of this patient's physical, psychological, familial, social, and spiritual dimensions was conducted via consultation, observation, and physical assessment. The assessment results showed that the patient suffered from acute delirium and cerebral perfusion impairment. In addition, the results showed that the patient's wife suffered from caregiver role strain that was further exacerbated by family difficulties. Multiple, individualized patient-tailored nursing interventions were developed under ABCDEF bundle care to alleviate delirium during the period of nursing care. These interventions included spontaneous awakening trials, spontaneous breathing trials, coordination, delirium assessment, early mobilization, and family engagement. Furthermore, family involvement and interprofessional cooperation with social workers were conducted concurrently to alleviate economic and care burdens and mitigate caregiver role strain in the patient's wife. It is hoped that this nursing care experience helps promote increased attention towards delirium, helps improve early detection of delirium in patients with TBI, and promotes the provision of individualized bundle care that draws on different perspectives in order to achieve holistic health care.


Assuntos
Lesões Encefálicas Traumáticas/enfermagem , Delírio/prevenção & controle , Pacotes de Assistência ao Paciente/enfermagem , Lesões Encefálicas Traumáticas/psicologia , Humanos
2.
Medicine (Baltimore) ; 99(35): e21595, 2020 Aug 28.
Artigo em Inglês | MEDLINE | ID: mdl-32871875

RESUMO

BACKGROUND: Delirium is a frequent form of acute brain dysfunction in mechanically ventilated patients. Screening tools have been developed to identify delirium, but it is unclear which tool is the most accurate. Therefore, we provide a protocol of systematic evaluation to assess the accuracy of delirium screening tools in mechanically ventilated patients. METHODS: PubMed, PsycINFO, EMBASE, and the Cochrane Library will be searched. Studies involving mechanically ventilated patients which compared diagnostic tools with the Diagnostic and Statistical Manual of Mental Disorders criteria as a reference standard will be included. We will use MetaDiSC and STATA 15.1 to analyze carefully when a network meta-analysis is allowed. RESULTS: This study will provide a high-quality synthesis to assess the accuracy of different screening methods in mechanically ventilated patients. CONCLUSION: The conclusion of our systematic review will provide evidence to judge which screening method is the best for mechanically ventilated patients.


Assuntos
Encéfalo/fisiopatologia , Delírio/etiologia , Programas de Rastreamento/métodos , Respiração Artificial/efeitos adversos , Delírio/diagnóstico , Delírio/prevenção & controle , Testes Diagnósticos de Rotina/estatística & dados numéricos , Manual Diagnóstico e Estatístico de Transtornos Mentais , Feminino , Humanos , Masculino , Metanálise em Rede
3.
Medicine (Baltimore) ; 99(30): e21043, 2020 Jul 24.
Artigo em Inglês | MEDLINE | ID: mdl-32791676

RESUMO

BACKGROUND: Delirium is a frequently encountered complication, which is associated with increased mortality. Suvorexant, an approved agent for the treatment of insomnia, is recently suggested to be also effective for prevention of delirium by some authors. However, a consensus has yet to be reached. The goal of this study was to perform a meta-analysis to overall estimate the effectiveness of suvorexant in preventing delirium and its related consequences. METHODS: Eligible studies were identified by searching online databases of PubMed, EMBASE, and Cochrane Library. The pooled OR was calculated for binary outcomes (e.g., the incidence of delirium, mortality, or adverse events), while standardized mean difference (SMD) were expressed for continuous outcomes (e.g., time to delirium onset, length of stay in hospital and ICU, time on ventilation). RESULTS: Seven studies which comprised 402 suvorexant treatment patients and 487 patients with control treatment were included in this meta-analysis. Overall, pooled analysis indicated the incidence of delirium could be significantly reduced (OR, 0.30; P < .001) and time to delirium onset was significantly lengthened (SMD, 0.44; P = .006) in patients undergoing suvorexant treatment compared with controls. Suvorexant had no beneficial effects on the secondary outcomes [length of stay in hospital (SMD, -0.65; P = .161) and ICU (SMD, 0.34; P = .297), time on ventilation (SMD, 1.09; P = .318), drug-related adverse events (OR, drug-related adverse events (OR, 1.66; P = .319) and mortality (OR, 2.21; P = .261)]. Subgroup analysis also confirmed the benefit of suvorexant on the development of delirium, which was significant in any subgroup. CONCLUSION: Suvorexant should be recommended for the prevention of delirium in clinic.


Assuntos
Azepinas/uso terapêutico , Delírio/prevenção & controle , Medicamentos Indutores do Sono/uso terapêutico , Triazóis/uso terapêutico , Azepinas/efeitos adversos , Humanos , Tempo de Internação , Mortalidade , Respiração Artificial , Medicamentos Indutores do Sono/efeitos adversos , Fatores de Tempo , Triazóis/efeitos adversos
4.
Curr Opin Anaesthesiol ; 33(5): 668-673, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32796170

RESUMO

PURPOSE OF REVIEW: The current article reviews the importance of postoperative delirium (POD), focusing on the older surgical population, and summarizes the best-practice guidelines about POD prevention and treatment which have been published within the last several years. We also describe our local experience with implementing a perioperative delirium risk stratification and prevention pathway, and review implementation science principles which others may find useful as they move toward risk stratification and prevention in their own institutions. RECENT FINDINGS: There are few areas of consensus, backed by strong experimental data, in POD best-practice guidelines. Most guidelines recommend preoperative cognitive screening, nonpharmacologic delirium prevention measures, and avoidance of deliriogenic medications. The field of implementation science offers strategies for closing the evidence-practice gap, which we supplement with lessons learned from our own experience implementing a perioperative delirium risk stratification and prevention pathway. SUMMARY: POD continues to be a serious perioperative complication commonly experienced by older adults. Growing appreciation of its prognostic implications and evidence behind multidisciplinary, collaborative, and focused prevention strategies rooted in implementation science have prompted several major groups to issue consensus guidelines. Adopting best practices POD risk stratification and prevention pathways will improve perioperative care for older adults.


Assuntos
Delírio/prevenção & controle , Complicações Pós-Operatórias , Idoso , Humanos , Assistência Perioperatória
5.
Br J Anaesth ; 125(4): 492-504, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32798069

RESUMO

Postoperative delirium is a relatively common and serious complication. It increases hospital stay by 2-3 days and is associated with a 30-day mortality of 7-10%. It is most prevalent in older patients, those with existing neurocognitive disorders, and those undergoing complex or emergency procedures. Preclinical and clinical research in recent years has uncovered more about the pathophysiology of postoperative delirium and may yield more potential therapeutic options. Using the enhanced recovery pathway framework of risk stratification, risk reduction, and rescue treatment, we have reviewed the current clinical evidence on the validity of delirium prediction scores for the surgical population, the effectiveness of perioperative delirium risk reduction interventions, and management options for established delirium. Effective perioperative interventions include depth of anaesthesia monitoring, intraoperative dexmedetomidine infusion, and multimodal analgesia. Choice of general anaesthetic agent may not be associated with significant difference in delirium risk. Several other factors, such as preoperative fasting, temperature control, and blood pressure management have some association with the risk of postoperative delirium; these will require further studies. Because of the limited treatment options available for established delirium, we propose that risk assessment and perioperative risk reduction may be the most effective approaches in managing postoperative delirium.


Assuntos
Delírio/terapia , Complicações Pós-Operatórias/terapia , Comportamento de Redução do Risco , Transfusão de Sangue , Delírio/prevenção & controle , Hidratação , Humanos , Manejo da Dor , Complicações Pós-Operatórias/prevenção & controle , Cuidados Pré-Operatórios , Medição de Risco
6.
Lancet ; 396(10245): 177-185, 2020 07 18.
Artigo em Inglês | MEDLINE | ID: mdl-32682483

RESUMO

BACKGROUND: Atrial fibrillation and delirium are common consequences of cardiac surgery. Dexmedetomidine has unique properties as sedative agent and might reduce the risk of each complication. This study coprimarily aimed to establish whether dexmedetomidine reduces the incidence of new-onset atrial fibrillation and the incidence of delirium. METHODS: A randomised, placebo-controlled trial was done at six academic hospitals in the USA. Patients who had had cardiac surgery with cardiopulmonary bypass were enrolled. Patients were randomly assigned 1:1, stratified by site, to dexmedetomidine or normal saline placebo. Randomisation was computer generated with random permuted block size 2 and 4, and allocation was concealed by a web-based system. Patients, caregivers, and evaluators were all masked to treatment. The study drug was prepared by the pharmacy or an otherwise uninvolved research associate so that investigators and clinicians were fully masked to allocation. Participants were given either dexmedetomidine infusion or saline placebo started before the surgical incision at a rate of 0·1 µg/kg per h then increased to 0·2 µg/kg per h at the end of bypass, and postoperatively increased to 0·4 µg/kg per h, which was maintained until 24 h. The coprimary outcomes were atrial fibrillation and delirium occurring between intensive care unit admission and the earlier of postoperative day 5 or hospital discharge. All analyses were intention-to-treat. The trial is registered with ClinicalTrials.gov, NCT02004613 and is closed. FINDINGS: 798 patients of 3357 screened were enrolled from April 17, 2013, to Dec 6, 2018. The trial was stopped per protocol after the last designated interim analysis. Among 798 patients randomly assigned, 794 were analysed, with 400 assigned to dexmedetomidine and 398 assigned to placebo. The incidence of atrial fibrillation was 121 (30%) in 397 patients given dexmedetomidine and 134 (34%) in 395 patients given placebo, a difference that was not significant: relative risk 0·90 (97·8% CI 0·72, 1·15; p=0·34). The incidence of delirium was non-significantly increased from 12% in patients given placebo to 17% in those given dexmedetomidine: 1·48 (97·8% CI 0·99-2·23). Safety outcomes were clinically important bradycardia (requiring treatment) and hypotension, myocardial infarction, stroke, surgical site infection, pulmonary embolism, deep venous thrombosis, and death. 21 (5%) of 394 patients given dexmedetomidine and 8 (2%) of 396 patients given placebo, had a serious adverse event as determined by clinicians. 1 (<1%) of 391 patients given dexmedetomidine and 1 (<1%) of 387 patients given placebo died. INTERPRETATION: Dexmedetomidine infusion, initiated at anaesthetic induction and continued for 24 h, did not decrease postoperative atrial arrhythmias or delirium in patients recovering from cardiac surgery. Dexmedetomidine should not be infused to reduce atrial fibrillation or delirium in patients having cardiac surgery. FUNDING: Hospira Pharmaceuticals.


Assuntos
Fibrilação Atrial/prevenção & controle , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Delírio/prevenção & controle , Dexmedetomidina/administração & dosagem , Hipnóticos e Sedativos/administração & dosagem , Esquema de Medicação , Feminino , Humanos , Infusões Intravenosas , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/prevenção & controle , Resultado do Tratamento
7.
Am J Nurs ; 120(7): 25, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32590588

RESUMO

Editor's note: The mission of Cochrane Nursing is to provide an international evidence base for nurses involved in delivering, leading, or researching nursing care. Cochrane Corner provides summaries of recent systematic reviews from the Cochrane Library. For more information, see https://nursing.cochrane.org.


Assuntos
Delírio/prevenção & controle , Casas de Saúde/organização & administração , Idoso , Delírio/enfermagem , Enfermagem Baseada em Evidências , Humanos , Assistência de Longa Duração
8.
Anesth Analg ; 130(6): 1450-1460, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32384334

RESUMO

Frailty is a multidimensional syndrome characterized by decreased reserve and diminished resistance to stressors. People with frailty are vulnerable to stressors, and exposure to the stress of surgery is associated with increased risk of adverse outcomes and higher levels of resource use. As Western populations age rapidly, older people with frailty are presenting for surgery with increasing frequency. This means that anesthesiologists and other perioperative clinicians need to be familiar with frailty, its assessment, manifestations, and strategies for optimization. We present a narrative review of frailty aimed at perioperative clinicians. The review will familiarize readers with the concept of frailty, will discuss common and feasible approaches to frailty assessment before surgery, and will describe the relative and absolute associations of frailty with commonly measured adverse outcomes, including morbidity and mortality, as well as patient-centered and reported outcomes related to function, disability, and quality of life. A proposed approach to optimization before surgery is presented, which includes frailty assessment followed by recommendations for identification of underlying physical disability, malnutrition, cognitive dysfunction, and mental health diagnoses. Overall, 30%-50% of older patients presenting for major surgery will be living with frailty, which results in a more than 2-fold increase in risk of morbidity, mortality, and development of new patient-reported disability. The Clinical Frailty Scale appears to be the most feasible frailty instrument for use before surgery; however, evidence suggests that predictive accuracy does not differ significantly between frailty instruments such as the Fried Phenotype, Edmonton Frail Scale, and Frailty Index. Identification of physical dysfunction may allow for optimization via exercise prehabilitation, while nutritional supplementation could be considered with a positive screen for malnutrition. The Hospital Elder Life Program shows promise for delirium prevention, while individuals with mental health and or other psychosocial stressors may derive particular benefit from multidisciplinary care and preadmission discharge planning. Robust trials are still required to provide definitive evidence supporting these interventions and minimal data are available to guide management during the intra- and postoperative phases. Improving the care and outcomes of older people with frailty represents a key opportunity for anesthesiologists and perioperative scientists.


Assuntos
Anestesiologia/métodos , Fragilidade/cirurgia , Período Perioperatório , Idoso , Envelhecimento , Anestesiologia/normas , Delírio/prevenção & controle , Fragilidade/complicações , Fragilidade/fisiopatologia , Fragilidade/psicologia , Humanos , Assistência Centrada no Paciente , Qualidade de Vida , Índice de Gravidade de Doença
9.
Anesth Analg ; 130(6): 1524-1533, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32384342

RESUMO

Anesthetists are increasingly faced with the challenge of delivering perioperative care to frail older people. Patients with frailty undergoing surgical intervention are at a significantly increased risk of perioperative complications, mortality, and longer length of stay. Moreover, frailty is often associated with multimorbidity and a range of geriatric syndromes including functional dependency, cognitive impairment, and malnutrition which further increases risk and complexity of care. There is a growing body of evidence that prehabilitation-intervention delivered during the preoperative period to improve overall health and function-can improve postoperative outcomes for patients undergoing surgery. However, whether this vulnerable population stand to benefit from prehabilitation is less clear. We review the evidence for prehabilitation for patients with frailty including whether the risks associated with and outcomes from surgery can be modified through comprehensive geriatric assessment.


Assuntos
Delírio/prevenção & controle , Fragilidade/cirurgia , Avaliação Geriátrica/métodos , Complicações Cognitivas Pós-Operatórias/prevenção & controle , Complicações Pós-Operatórias/prevenção & controle , Período Pré-Operatório , Idoso , Disfunção Cognitiva/complicações , Delírio/diagnóstico , Idoso Fragilizado , Fragilidade/terapia , Humanos , Tempo de Internação , Desnutrição/complicações , Multimorbidade , Complicações Cognitivas Pós-Operatórias/diagnóstico , Período Pós-Operatório , Cuidados Pré-Operatórios , Fatores de Risco , Resultado do Tratamento , Populações Vulneráveis
10.
Anaesthesiol Intensive Ther ; 52(2): 132-138, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32419438

RESUMO

In March 2020, the World Health Organisation announced the COVID-19 pandemic caused by the SARS-CoV-2 virus. As well as respiratory failure, the SARS-CoV-2 may cause central nervous system (CNS) involvement, including delirium occurring in critically ill patients (ICU delirium). Due attention must be paid to this subject in the face of the COVID-19 pandemic. Delirium, the detection of which takes less than two minutes, is frequently underestimated during daily routine ICU care, but it may be a prodromal symptom of infection or hypoxia associated with severe respiratory failure. During the COVID-19 pandemic, systematic delirium monitoring using validated tests (CAM-ICU or ICDSC) may be sacrificed. This is likely to be due to the fact that the main emphasis is placed on organisational issues, i.e. the lack of ventilators, setting priorities for limited mechanical ventilation options, and a shortage of personal protective equipment. Early identification of patients with delirium is critical in patients with COVID-19 because the occurrence of delirium may be an early symptom of worsening respiratory failure or of infectious spread to the CNS mediated by potential neuroinvasive mechanisms of the coronavirus. The purpose of this review is to identify problems related to the development of delirium during the COVID-19 epidemic, which are presented in three areas: i) factors contributing to delirium in COVID-19, ii) potential pathophysiological factors of delirium in COVID-19, and iii) long-term consequences of delirium in COVID-19. This article discusses how healthcare workers can reduce the burden of delirium by identifying potential risk factors and difficulties during challenges associated with SARS-CoV-2 infection.


Assuntos
Betacoronavirus , Infecções por Coronavirus/complicações , Delírio/etiologia , Unidades de Terapia Intensiva , Pneumonia Viral/complicações , Delírio/diagnóstico , Delírio/prevenção & controle , Delírio/psicologia , Humanos , Pandemias
11.
Br J Anaesth ; 125(1): 38-46, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32416996

RESUMO

BACKGROUND: Delirium is common after cardiac surgery and is associated with adverse outcomes. Perioperative benzodiazepine use is associated with delirium and is common during cardiac surgery, which may increase the risk of postoperative delirium. We undertook a pilot study to inform the feasibility of a large randomised cluster crossover trial examining whether an institutional policy of restricted benzodiazepine administration during cardiac surgery (compared with liberal administration) would reduce delirium. METHODS: We conducted a two-centre, pilot, randomised cluster crossover trial with four 4 week crossover periods. Each centre was randomised to a policy of restricted or liberal use, and then alternated between the two policies during the remaining three periods. Our feasibility outcomes were adherence to each policy (goal ≥80%) and outcome assessment (one delirium assessment per day in the ICU in ≥90% of participants). We also evaluated the incidence of intraoperative awareness in one site using serial Brice questionnaires. RESULTS: Of 800 patients undergoing cardiac surgery during the trial period, 127/800 (15.9%) had delirium. Of these, 355/389 (91.3%) received benzodiazepines during the liberal benzodiazepine periods and 363/411 (88.3%) did not receive benzodiazepines during the restricted benzodiazepine periods. Amongst the 800 patients, 740 (92.5%) had ≥1 postoperative delirium assessment per day in the ICU. Of 521 patients screened for intraoperative awareness, one patient (0.2%), managed during the restricted benzodiazepine period (but who received benzodiazepine), experienced intraoperative awareness. CONCLUSIONS: This pilot study demonstrates the feasibility of a large, multicentre, randomised, cluster crossover trial examining whether an institutional policy of restricted vs liberal benzodiazepine use during cardiac surgery will reduce postoperative delirium. CLINICAL TRIAL REGISTRATION: NCT03053869.


Assuntos
Anestesia em Procedimentos Cardíacos/métodos , Benzodiazepinas/administração & dosagem , Delírio/prevenção & controle , Complicações Pós-Operatórias/prevenção & controle , Idoso , Canadá , Análise por Conglomerados , Estudos Cross-Over , Relação Dose-Resposta a Droga , Feminino , Humanos , Masculino , Projetos Piloto
13.
Med Clin North Am ; 104(3): 491-501, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32312411

RESUMO

Delirium is a prevalent acute neurocognitive condition in patients with progressive life-limiting illness. Delirium remains underdetected; a systematic approach to screening is essential. Delirium at the end of life requires a comprehensive assessment. Consider the potential for reversibility, illness trajectory, patient preference, and goals of care before proceeding with investigations and interventions. Management should be interdisciplinary, and nonpharmacologic therapy is fundamental. For patients with refractory and severe agitation or perceptual disturbance, judicious use of medication may also be required. Carers and family should be seen as partners in care and be involved in shared decision making about care.


Assuntos
Delírio/tratamento farmacológico , Delírio/prevenção & controle , Cuidados Paliativos/métodos , Assistência Terminal/métodos , Antipsicóticos/efeitos adversos , Antipsicóticos/uso terapêutico , Delírio/epidemiologia , Delírio/fisiopatologia , Delírio do Despertar/tratamento farmacológico , Delírio do Despertar/epidemiologia , Humanos , Programas de Rastreamento/métodos , Planejamento de Assistência ao Paciente/normas , Transtornos da Percepção/tratamento farmacológico , Transtornos da Percepção/epidemiologia , Prevalência
15.
Medicine (Baltimore) ; 99(17): e19896, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32332664

RESUMO

BACKGROUND: Delirium is a common postoperative complication in older patients undergoing thoracic surgery and presages poor outcomes. Postoperative pain is an important factor in the progression of delirium. The purpose of this study was to test whether continuous thoracic paravertebral block (PVB), a more effective approach for analgesia, could decrease the incidence of delirium in elderly patients undergoing esophagectomy. METHODS: A total of 180 geriatric patients undergoing esophagectomy were randomly divided into 2 groups and treated with PVB or patient-controlled analgesia (PCA). Perioperative plasma CRP, IL-1ß, IL-6, and TNF-α levels were detected in all patients. Pain intensity was measured by a numerical rating scale. Delirium was assessed using the confusion assessment method. RESULTS: The incidence of postoperative delirium was significantly lower in the PVB group than in the PCA group. Patients in the PVB group had lower plasma CRP, IL-1ß, IL-6, and TNF-α levels and less pain when coughing after surgery. CONCLUSIONS: Ultrasound-guided continuous thoracic paravertebral block improved analgesia, reduced the inflammatory reaction and decreased the occurrence of delirium after surgery.


Assuntos
Delírio/prevenção & controle , Esofagectomia/normas , Bloqueio Nervoso/métodos , Ultrassonografia/normas , Idoso , Idoso de 80 Anos ou mais , Analgesia Controlada pelo Paciente/métodos , Analgesia Controlada pelo Paciente/normas , Delírio/tratamento farmacológico , Esofagectomia/métodos , Feminino , Geriatria/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Bloqueio Nervoso/normas , Complicações Pós-Operatórias/tratamento farmacológico , Complicações Pós-Operatórias/prevenção & controle , Estudos Prospectivos , Ultrassonografia/métodos , Ultrassonografia/estatística & dados numéricos
16.
J Clin Nurs ; 29(13-14): 2363-2377, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32220101

RESUMO

AIMS AND OBJECTIVES: To explore older inpatients' experiences and perceptions of delirium and nonpharmacological delirium prevention strategies (NDPS). BACKGROUND: Delirium is a distressing and serious complication in hospitalised older adults. NDPS (supporting nutrition, mobility and cognitive participation) have strong supporting evidence. Few studies have explored older inpatients' perspectives of these strategies. This information may assist staff to better support patient participation in NDPS. DESIGN: Qualitative study using an interpretive descriptive (ID) methodological approach to explore older patient's experience of delirium and NDPS. METHODS: Structured interviews of inpatients aged over 65 years across 6 medical and surgical wards explored patients' experiences and perceptions of delirium and prevention activities related to nutrition, mobility and cognition; and barriers and enablers to participation. Reporting used COREQ. RESULTS: Twenty-three participants were included (12 male, 11 reported delirium experience). Participants reported a range of physiological, emotional and psychological responses to delirium, hearing about delirium was different to experiencing it. Most participants were aware of the benefits of maintaining nutrition and hydration, physical activity and cognitive engagement in hospital. Barriers included poor symptom control, inflexible routines and inconsistent communication, whilst enablers included access to equipment, family involvement, staff encouragement and individual goals. These were organised into themes: outlook, feeling well enough, hospital environment, feeling informed and listened to, and support networks. CONCLUSION: A more patient-centred approach to delirium prevention requires consideration of older people's values, needs, preferences and fit within the hospital environment and routines. Feeling informed, listened to and receiving support from staff and family carers can improve older inpatients' engagement in NPDS to prevent delirium in hospital. RELEVANCE TO CLINICAL PRACTICE: Nurses are ideally placed to improve patient participation in NDPS through holistic assessment and care, addressing symptoms, providing clear information about delirium and delirium prevention, and facilitating family carer support and patient interactions.


Assuntos
Enfermagem de Cuidados Críticos/métodos , Delírio/prevenção & controle , Relações Enfermeiro-Paciente , Assistência Centrada no Paciente/métodos , Idoso , Idoso de 80 Anos ou mais , Delírio/enfermagem , Delírio/psicologia , Feminino , Hospitalização , Humanos , Masculino , Pesquisa Qualitativa
17.
PLoS One ; 15(2): e0229018, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32053678

RESUMO

BACKGROUND: Several studies have suggested that monitoring the depth of anaesthesia might prevent the development of postoperative cognitive decline. We aimed to conduct a meta-analysis to investigate the effects of bispectral index (BIS) monitoring in anaesthesia. METHODS: We searched in six major electronic databases. Trials were included if they discussed anaesthesia with and without BIS monitoring or low (<50) and high (≥50) BIS levels and which measured the risk of postoperative delirium (POD) and/or postoperative cognitive dysfunction (POCD). RESULTS: We included fourteen studies in the systematic review, eight of which were eligible for meta-analysis. BIS proved to be protective against POD at 1 day postoperatively in a cohort of 2138 patients (16.1% vs. 22.8% for BIS vs. no BIS groups, respectively; relative risk [RR] 0.71; 95% confidence interval [CI] 0.59 to 0.85, without significant between-study heterogeneity I2 = 0.0%, P = 0.590). The use of BIS was neutral for POCD at 1 week but protective for POCD at 12 weeks (15.8% vs. 18.8% for BIS vs. no BIS groups, respectively; RR = 0.84, CI: 0.66 to 1.08), without significant between-study heterogeneity (I2 = 25.8%, P = 0.260). The neutral association at 1 week proved to be underpowered with trial sequential analysis. In the comparison of low BIS versus high BIS, the incidence of POD at 1 day was similar in the groups. CONCLUSION: Our findings suggest a protective effect of BIS compared to not using BIS regarding the incidence of POD at 1 day and POCD at 12 weeks. However, limitations of the evidence warrant further investigation to identify those groups of patients by age, comorbid conditions and other individual variables who would benefit the most from the use of BIS monitoring.


Assuntos
Monitores de Consciência , Complicações Pós-Operatórias/diagnóstico , Delírio/diagnóstico , Delírio/prevenção & controle , Humanos , Complicações Cognitivas Pós-Operatórias/diagnóstico , Complicações Cognitivas Pós-Operatórias/prevenção & controle , Complicações Pós-Operatórias/prevenção & controle
19.
Crit Care Resusc ; 22(1): 63-71, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32102644

RESUMO

BACKGROUND: The best sedative medication to reduce delirium, mortality and long term brain dysfunction in mechanically ventilated septic patients is unclear. This multicentre, double-blind, randomised trial investigates the short term and long term effects of dexmedetomidine versus propofol for sedation in mechanically ventilated severely septic patients. OBJECTIVES: To describe the statistical analysis plan for this randomised clinical trial comprehensively and place it in the public domain before unblinding. METHODS: To ensure that analyses are not selectively reported, we developed a comprehensive statistical analysis plan before unblinding. This trial has an enrolment target of 420 severely septic and mechanically ventilated adult patients, randomly assigned to dexmedetomidine or propofol in a 1:1 ratio. Enrolment was completed in January 2019, and the study was estimated to be completed in September 2019. The primary endpoint is days alive without delirium or coma during first 14 study days. Secondary outcomes include 28-day ventilator-free days, 90-day all-cause mortality and cognitive function at 180 days. Time frames all begin on the day of randomisation. All analyses will be conducted on an intention-to-treat basis. CONCLUSION: This study will compare the effects of two sedatives in mechanically ventilated severely septic patients. In keeping with the guidance on statistical principles for clinical trials, we have developed a comprehensive statistical analysis plan by which we will adhere, as this will avoid bias and support transparency and reproducibility. TRIAL REGISTRATION: ClinicalTrials.gov (NCT01739933).


Assuntos
Delírio/induzido quimicamente , Respiração Artificial/estatística & dados numéricos , Insuficiência Respiratória/complicações , Sepse/complicações , Adulto , Estado Terminal , Delírio/diagnóstico , Delírio/prevenção & controle , Método Duplo-Cego , Mortalidade Hospitalar , Humanos , Hipnóticos e Sedativos/administração & dosagem , Hipnóticos e Sedativos/efeitos adversos , Unidades de Terapia Intensiva , Avaliação de Resultados em Cuidados de Saúde , Reprodutibilidade dos Testes , Respiração Artificial/efeitos adversos , Insuficiência Respiratória/terapia , Sepse/mortalidade
20.
Cochrane Database Syst Rev ; 2: CD010569, 2020 02 07.
Artigo em Inglês | MEDLINE | ID: mdl-32031676

RESUMO

BACKGROUND: Hip fracture is a major injury that causes significant problems for affected individuals and their family and carers. Over 40% of people with hip fracture have dementia or cognitive impairment. The outcomes of these individuals after surgery are poorer than for those without dementia. It is unclear which care and rehabilitation interventions achieve the best outcomes for these people. This is an update of a Cochrane Review first published in 2013. OBJECTIVES: (a) To assess the effectiveness of models of care including enhanced rehabilitation strategies designed specifically for people with dementia following hip fracture surgery compared to usual care. (b) To assess for people with dementia the effectiveness of models of care including enhanced rehabilitation strategies that are designed for all older people, regardless of cognitive status, following hip fracture surgery, compared to usual care. SEARCH METHODS: We searched ALOIS (www.medicine.ox.ac.uk/alois), the Cochrane Dementia and Cognitive Improvement Group Specialised Register, MEDLINE (OvidSP), Embase (OvidSP), PsycINFO (OvidSP), CINAHL (EBSCOhost), Web of Science Core Collection (ISI Web of Science), LILACS (BIREME), ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform on 16 October 2019. SELECTION CRITERIA: We included randomised and quasi-randomised controlled trials evaluating the effectiveness of any model of enhanced care and rehabilitation for people with dementia after hip fracture surgery compared to usual care. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials for inclusion and extracted data. We assessed risk of bias of the included trials. We synthesised data only if we considered the trials to be sufficiently homogeneous in terms of participants, interventions, and outcomes. We used the GRADE approach to rate the overall certainty of evidence for each outcome. MAIN RESULTS: We included seven trials with a total of 555 participants. Three trials compared models of enhanced care in the inpatient setting with conventional care. Two trials compared an enhanced care model provided in inpatient settings and at home after discharge with conventional care. Two trials compared geriatrician-led care in-hospital to conventional care led by the orthopaedic team. None of the interventions were designed specifically for people with dementia, therefore the data included in the review were from subgroups of people with dementia or cognitive impairment participating in randomised controlled trials investigating models of care for all older people following hip fracture. The end of follow-up in the trials ranged from the point of acute hospital discharge to 24 months after discharge. We considered all trials to be at high risk of bias in more than one domain. As subgroups of larger trials, the analyses lacked power to detect differences between the intervention groups. Furthermore, there were some important differences in baseline characteristics of participants between the experimental and control groups. Using the GRADE approach, we downgraded the certainty of the evidence for all outcomes to low or very low. The effect estimates for almost all comparisons were very imprecise, and the overall certainty for most results was very low. There were no data from any study for our primary outcome of health-related quality of life. There was only very low certainty for our other primary outcome, activities of daily living and functional performance, therefore we were unable to draw any conclusions with confidence. There was low-certainty that enhanced care and rehabilitation in-hospital may reduce rates of postoperative delirium (odds ratio 0.04, 95% confidence interval (CI) 0.01 to 0.22, 2 trials, n = 141) and very low-certainty associating it with lower rates of some other complications. There was also low-certainty that, compared to orthopaedic-led management, geriatrician-led management may lead to shorter hospital stays (mean difference 4.00 days, 95% CI 3.61 to 4.39, 1 trial, n = 162). AUTHORS' CONCLUSIONS: We found limited evidence that some of the models of enhanced rehabilitation and care used in the included trials may show benefits over usual care for preventing delirium and reducing length of stay for people with dementia who have been treated for hip fracture. However, the certainty of these results is low. Data were available from only a small number of trials, and the certainty for all other results is very low. Determining the optimal strategies to improve outcomes for this growing population of patients should be a research priority.


Assuntos
Demência/complicações , Fraturas do Quadril/reabilitação , Equipe de Assistência ao Paciente , Atividades Cotidianas , Idoso , Idoso de 80 Anos ou mais , Delírio/prevenção & controle , Fraturas do Quadril/cirurgia , Humanos , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto
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