Delirium in the ICU: What About the Floor?

Delirium was first described in the 1800s as acute, fluctuating confusion. Recent studies note an incidence of 15% in adult intensive care unit patients. Here we present the first prospective study to evaluate the incidence and risk factors for delirium in patients admitted to the trauma surgeon (TS) in non-critical care areas (NCCAs). Patients 18 years or older admitted to any TS in the designated NCCA were evaluated and consented for participation over a 3-month period. Participants were screened with the Confusion Assessment Method (CAM) every 12 hr. Those positive for delirium (CAM+) were administered the CAM-Severity. In addition, 69 other previously identified risk factors were evaluated. Over 3 months, 148 patients were evaluated, 12 of whom were CAM+ (8%). Of patients 65 years or older, 21% screened positive for delirium. Age, education level, presence of Foley catheter, respiratory distress, orthopedic operation, and lack of ambulation were risk factors associated with delirium (p < .05). Among all TS patients in the NCCA, we found delirium to be present in 8%. Our nurses identified a 21% incidence of delirium in patients 65 years or older. Given this significant incidence, screening at-risk patients in the NCCA should be considered.

Appropriate Imaging for Geriatric Trauma.

BACKGROUND: Trauma is the leading cause of preventable death in the United States. Early detection of life-threatening injuries leads to improved survival. Computed tomography (CT) scanning has become the modality of choice for early detection of injuries in the stable patient. Some studies have associated selective imaging (Selective-CT) with equivalent outcomes compared to whole body imaging (Pan-CT) with lower costs and radiation exposure. Within the geriatric population, however, the utility of Pan-CT remains controversial. Therefore, the aim of this study was to determine if a difference exists between Selective-CT and Pan-CT imaging in the geriatric trauma patient. METHODS: A retrospective analysis of Level 3 (G60) trauma activations presenting to our urban Level I trauma center between June 2016 and June 2019 was performed. Pan-CT was defined by ICD-10 codes indicating a head, cervical spine, chest, abdomen, and pelvis CT series. Patients with missing images and those who were transferred from other institutions were excluded. Logistic regression controlling for age, gender, injury type, severity, and Glasgow Coma Score was performed. RESULTS: A total of 1014 patients met inclusion criteria. Of these, 30.9% underwent Pan-CT (n = 314), 48.9% had Selective-CT (n = 497), and 20.2% received no CT imaging (n = 203). After logistic regression, no clinically significant variations in emergency department length of stay (LOS), hospital LOS, ICU LOS, ventilator days, discharge disposition, missed injury rate, or mortality rate were observed between imaging strategies. CONCLUSIONS: Pan-CT provides no clinically significant advantage over Selective-CT in the geriatric trauma patient.

Study of Alteplase for Respiratory Failure in SARS-CoV-2 COVID-19: A Vanguard Multicenter, Rapidly Adaptive, Pragmatic, Randomized Controlled Trial.

BACKGROUND: Pulmonary vascular microthrombi are a proposed mechanism of COVID-19 respiratory failure. We hypothesized that early administration of tissue plasminogen activator (tPA) followed by therapeutic heparin would improve pulmonary function in these patients. RESEARCH QUESTION: Does tPA improve pulmonary function in severe COVID-19 respiratory failure, and is it safe? STUDY DESIGN AND METHODS: Adults with COVID-19-induced respiratory failure were randomized from May14, 2020 through March 3, 2021, in two phases. Phase 1 (n = 36) comprised a control group (standard-of-care treatment) vs a tPA bolus (50-mg tPA IV bolus followed by 7 days of heparin; goal activated partial thromboplastin time [aPTT], 60-80 s) group. Phase 2 (n = 14) comprised a control group vs a tPA drip (50-mg tPA IV bolus, followed by tPA drip 2 mg/h plus heparin 500 units/h over 24 h, then heparin to maintain aPTT of 60-80 s for 7 days) group. Patients were excluded from enrollment if they had not undergone a neurologic examination or cross-sectional brain imaging within the previous 4.5 h to rule out stroke and potential for hemorrhagic conversion. The primary outcome was Pao2 to Fio2 ratio improvement from baseline at 48 h after randomization. Secondary outcomes included Pao2 to Fio2 ratio improvement of > 50% or Pao2 to Fio2 ratio of ≥ 200 at 48 h (composite outcome), ventilator-free days (VFD), and mortality. RESULTS: Fifty patients were randomized: 17 in the control group and 19 in the tPA bolus group in phase 1 and eight in the control group and six in the tPA drip group in phase 2. No severe bleeding events occurred. In the tPA bolus group, the Pao2 to Fio2 ratio values were significantly (P < .017) higher than baseline at 6 through 168 h after randomization; the control group showed no significant improvements. Among patients receiving a tPA bolus, the percent change of Pao2 to Fio2 ratio at 48 h (16.9% control [interquartile range (IQR), -8.3% to 36.8%] vs 29.8% tPA bolus [IQR, 4.5%-88.7%]; P = .11), the composite outcome (11.8% vs 47.4%; P = .03), VFD (0.0 [IQR, 0.0-9.0] vs 12.0 [IQR, 0.0-19.0]; P = .11), and in-hospital mortality (41.2% vs 21.1%; P = .19) did not reach statistically significant differences when compared with those of control participants. The patients who received a tPA drip did not experience benefit. INTERPRETATION: The combination of tPA bolus plus heparin is safe in severe COVID-19 respiratory failure. A phase 3 study is warranted given the improvements in oxygenation and promising observations in VFD and mortality. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT04357730; URL: www. CLINICALTRIALS: gov.

Don't call me crazy! Delirium occurs outside of the intensive care unit.

INTRODUCTION: Delirium has been well studied among patients in the intensive care unit (ICU); however, data beyond the ICU is limited. The purpose of this study is to prospectively evaluate the incidence and associated risk factors for delirium in noncritical care areas (NCCA). METHODS: After institutional review board approval, a prospective cohort study was conducted at our urban Level I Trauma Center from December 2015 to February 2016. All patients admitted to the designated study area by a trauma surgeon were included. The Confusion Assessment Method (CAM) was administered every 12 hours until discharge. Delirious patients (CAM+) were administered the CAM-S to quantify the severity of delirium. Demographics, laboratory data, and inpatient medication lists were analyzed. RESULTS: Of 148 participants, 12 (8%) were CAM+ and 136 (92%) were CAM-. The average CAM-S of CAM+ patients was 7 ± 3. Included patients were aged 52 ± 20 years and 45% were men. Of patients 65 years or older, 9 (21%) were CAM+. Medications associated with delirium were: albuterol (p = 0.01), atorvastatin (p = 0.01), duloxetine (p = 0.04), sertraline (p = 0.04), folic acid (p = 0.01), thiamine (p = 0.01), vitamin D (p < 0.001), haloperidol (p = 0.04), metoprolol (p = 0.02), and vancomycin (p = 0.02). Abnormal laboratory values associated with delirium included: Albumin (p = 0.03; odds ratio [OR], 7.94, 95% confidence interval [CI], 1.1-63.20), Calcium (p = 0.01; OR, 4.95; 95% CI, 1.5-16.7), Sodium (p = 0.04; OR, 3.91; 95% CI, 1.13-13.5), hematocrit (p = 0.04), and mean corpuscular hemoglobin concentration (p < 0.05; OR, 5.29; 95% CI, 1.19-23.46). CONCLUSIONS: Our study demonstrated an 8% incidence of delirium overall in NCCA, increasing to 21% in patients 65 years or older. Many risk factors identified among NCCA patients are consistent with the ICU literature; however, our CAM+ patients had additional risk factors which have not been previously associated with the development of delirium. Screening of NCCA patients for delirium should be considered. LEVEL OF EVIDENCE: Prognostic and Epidemological, level IV.

Risky business? Investigating outcomes of patients undergoing urgent laparoscopic appendectomy on antithrombotic therapy.

INTRODUCTION: The literature regarding outcomes in patients on irreversible antithrombotic therapy (IAT) undergoing urgent laparoscopic appendectomy is limited. The aim of this multicenter retrospective study was to examine the impact of prehospital IAT on outcomes in this population. METHODS: From 2010 to 2014, seven institutions from the Southwest Surgical Multicenter Trials (SWSC MCT) group conducted a retrospective study to evaluate the clinical course of all patients on IAT who underwent urgent/emergent laparoscopic appendectomy. The IAT+ group was subdivided into IAT+ (Aspirin only) and IAT+ (Aspirin-Plavix). These groups were matched 1:1 to controls. The primary outcomes were estimated blood loss (EBL) and transfusion requirement. Secondary outcomes included infections (SSI - Surgical Site Infection, DSI - Deep Space Infection, and OSI - Organ Space Infection), hospital length of stay (HLOS), complications, 30-day readmissions, and mortality. RESULTS: Out of the 2903 patients included in the study, 287 IAT+ patients were identified and matched in a 1:1 ratio to 287 IAT-patients. In the IAT+ vs IAT-analysis, no significant differences in EBL (p = 1.0), transfusion requirement during the preoperative (p = 0.5), intraoperative (p = 0.3) or postoperative periods (p = 0.5), infectious complications (SSI; p = 1.0, DSI; p = 1.0, and OSI; p = 0.1), overall complications (p = 0.3), HLOS (p = 0.7), 30-day readmission (p = 0.3), or mortality (p = 0.1) were noted. Similarly, outcomes in the IAT+ (Aspirin only) and IAT+ (Aspirin-Plavix) subgroups failed to demonstrate any significant differences when compared to controls. CONCLUSIONS: Our analysis suggests that IAT is not associated with worse outcomes in urgent/emergent laparoscopic appendectomy. Prehospital use of IAT should not be used to delay laparoscopic appendectomy.