Delirium: case report (original) (raw)
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Delirium in intensive care: an under-diagnosed reality
Revista Brasileira de Terapia Intensiva, 2013
Delirium occurs in up to 80% of patients admitted to intensive care units. Although under-diagnosed, delirium is associated with a significant increase in morbidity and mortality in critical patients. Here, we review the main
Delirium occurs in up to 80% of patients admitted to intensive care units. Although under-diagnosed, delirium is associated with a significant increase in morbidity and mortality in critical patients. Here, we review the main ABSTRACT Keywords: Delirium; Intensive Care; Sleep; Central nervous system; Antipsychotics agents risk factors, clinical manifestations and preventative and therapeutic approaches (pharmacological and nonpharmacological) for this illness. 138 Faria RS, Moreno RP Rev Bras Ter Intensiva. 2013;25(2):137-147
Cornell Assessment of Pediatric Delirium
Critical Care Medicine, 2014
Objective: To determine validity and reliability of the Cornell Assessment of Pediatric Delirium, a rapid observational screening tool. Design: Double-blinded assessments were performed with the Cornell Assessment of Pediatric Delirium completed by nursing staff in the PICU. These ratings were compared with an assessment by consultation liaison child psychiatrist using the Diagnostic and Statistical Manual IV criteria as the "gold standard" for diagnosis of delirium. An initial series of duplicate Cornell Assessment of Pediatric Delirium assessments were performed in blinded fashion to assess interrater reliability. Nurses recorded the time required to complete the Cornell Assessment of Pediatric Delirium screen. Setting: Twenty-bed general PICU in a major urban academic medical center over a 10-week period, March-May 2012. Patients: One hundred eleven patients stratified over ages ranging from 0 to 21 years and across developmental levels. Intervention: Two hundred forty-eight paired assessments completed. Measurements and Main Results: The Cornell Assessment of Pediatric Delirium had an overall sensitivity of 94.1% (95% CI, 83.8-98.8%) and specificity of 79.2% (95% CI, 73.5-84.9%). Overall Cronbach's α of 0.90 was observed, with a range of 0.87-0.90 for each of the eight items, indicating good internal consistency. A scoring cut point of 9 demonstrated good interrater reliability of the Cornell Assessment of Pediatric Delirium when comparing results of the screen between nurses (overall κ = 0.94; item range κ = 0.68-0.78). In patients without significant developmental delay, sensitivity was 92.0% (95% CI, 85.7-98.3%) and specificity was 86.5% (95% CI, 75.4-97.6%). In developmentally delayed children, the Cornell Assessment of Pediatric Delirium showed decreased specificity of 51.2% (95% CI, 24.7-77.8%) but sensitivity remained high at 96.2% (95% CI, 86.5-100%). The Cornell Assessment of Pediatric Delirium takes less than 2 minutes to complete. Conclusions: With an overall prevalence rate of 20.6% in our study population, delirium is a common problem in pediatric critical care. The Cornell Assessment of Pediatric Delirium is a valid, rapid, observational nursing screen that is urgently needed for the detection of delirium in PICU settings.
Principles and Practice of Sedation in Intensive Care Unit (ICU)
Apollo Medicine, 2011
Is defined as a sustained state of apprehension & autonomic arousal in response to real or perceived threats [1]. Fear of suffering, fear of death, loss of control & frustation due to inability to effectively communicate are typical causes of anxiety in critically ill patients. Symptoms & signs include headache, nausea, insomnia, anorexia, dyspnoea, palpitations, dizziness, dry mouth, chest pain, hyperventilation, pallor, tachycardia, tremulousness and / or hyper vigilance. Pain Routine patient care (suctioning, repositioning, physiotherapy), immobility, trauma, surgery, endotracheal tubes & other monitoring devices can all produce pain. Clinical evidence of pain may include grimacing, withdrawal, combativeness, diaphoresis, hyperventilation &/or tachycardia. Delirium Is an organic mental syndrome defined as an acute, potentially reversible impairment of consciousness & cognitive function that fluctuates in severity [1]. Delirium is rather common in ICU patients but is frequently under recognized especially in older individuals & is mostly under treated [3,4]. Delirious patients have impaired short term memory, abnormal perception & intermittent disorientation which is usually worse at night. EEG may show diffuse slowing of electrical activity of brain. It is a risk factor for prolonged hospitalization & mortality in critically ill patients [5]. Risk factors for delirium include:
Intensive Care Medicine, 2009
Context: If delirium is not diagnosed, it is unlikely that any effort will be made to reverse it. Given evidence for under-diagnosis, tools that aid recognition are required. Objective: Relating three presentations of pediatric delirium (PD) to standard criteria and developing a diagnostic algorithm. Results: Delirium-inducing factors, disturbance of consciousness and inattention are common in PICU patients: a pre-delirious state is present in most. An algorithm is introduced, containing (1) evaluation of the sedation-agitation level, (2) psychometric assessment of behavior and (3) opinion of the caregivers. Discussion: It may be argued that the behavioral focus of the algorithm would benefit from the inclusion of neurocognitive measures. Limitations: No sufficiently validated diagnostic instrument covering the entire algorithm is available yet. Conclusion: This is the first proposal for a PD diagnostic algorithm. Given the high prevalence of predelirious states at the PICU, daily evaluation is mandatory. Future algorithmic refinement is urgently required.
Considering Causes for Hypoactive Delirium
Australasian Journal of Neuroscience, 2019
Delirium triples mortality risk, however, rates are considerably higher in the setting of hypoactive delirium (Bui et al., 2017). Further complicating hypoactive delirium, survivors frequently have greater risk for long term cognitive impairment (Bush et al., 2017; Lipowski, 1983; van den Boogaard, Schoonhoven, van der Hoeven, van Achterberg, & Pickkers, 2012). A study by Avelino-Silva (2018) found 38% of hospitalized patients will die within 12 months of hospitalization. Of the 38% who died, delirium occurred in 47% of hospital admissions (Avelina-Silva, 2018). When comparing delirium subtype, hypoactive delirium was associated with 33% of the
Detecting pediatric delirium: development of a rapid observational assessment tool
Intensive Care Medicine, 2012
Objective: Development of a novel screening tool for the detection of delirium in pediatric intensive care unit (PICU) patients of all ages by comparison with psychiatric assessment based on the reference standard Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria. Methods: This was a prospective blinded pilot study investigating the feasibility of the Cornell Assessment of Pediatric Delirium (CAP-D) performed in a PICU at a university hospital. Fifty patients, ages 3 months to 21 years, admitted to the PICU over a 6-week period were included. No interventions were performed. Results: After informed consent was obtained, two study teams independently assessed for delirium by completing the CAP-D and by conducting psychiatric evaluation based on the DSM-IV criteria. Concordance between the CAP-D and DSM-IV criteria was excellent, at 97%. Prevalence of delirium in this sample was 29%. Conclusion: The CAP-D may be a valid screen for identification of delirium in PICU patients of all ages. Further studies are required to explore its validity, inter-rater reliability, and feasibility of use as a nursing screen.
Delirium and Developmental Disability
Pediatric Critical Care Medicine, 2020
Objectives: Children with developmental disabilities are at high risk for developing delirium when critically ill. However, existing pediatric delirium screening tools were designed for children with typical development. The objective of this study was to improve the specificity of the Cornell Assessment for Pediatric Delirium, to allow for accurate detection of delirium in developmentally delayed children admitted to the PICU. We hypothesized that the Cornell Assessment for Pediatric Delirium, when combined with fluctuation in level of awareness as measured by the Richmond Agitation-Sedation Scale, would be valid and reliable for the diagnosis of delirium in developmentally delayed children. Design: Prospective observational double-blind cohort study. Setting: Tertiary care academic PICU. Patients: Children with moderate to severe developmental delay. Interventions: Each child was evaluated by the bedside nurse with the Cornell Assessment for Pediatric Delirium once every 12 hours and the Richmond Agitation-Sedation Scale every 4 hours. Cornell Assessment for Pediatric Delirium (score ≥ 9) + Richmond Agitation-Sedation Scale fluctuation (change in Richmond Agitation-Sedation Scale score of at least 2 points during a 24-hr period) was compared with the criterion standard psychiatric evaluation for diagnosis of delirium. Measurements and Main Results: Forty children participated; 94 independent paired assessments were completed. The psychiatrists' diagnostic evaluations were compared with the detection of delirium by the Cornell Assessment for Pediatric Delirium and Richmond Agitation-Sedation Scale. Specificity of the Cornell Assessment for Pediatric Delirium + Richmond Agitation-Sedation Scale fluctuation was 97% (CI, 90-100%), positive predictive value of Cornell Assessment for Pediatric Delirium + Richmond Agitation-Sedation Scale fluctuation was 89% (CI, 65-99%); and negative predictive value remained acceptable at 87% (95% CI, 77-94%). In addition, to confirm interrater reliability of the criterion standard, 11 assessments were performed by two or more psychiatrists in a blinded fashion. There was perfect agreement (κ = 1), indicating reliability in psychiatric diagnosis of delirium in developmentally delayed children. Conclusion: When used in conjunction with Richmond Agitation-Sedation Scale score fluctuation, the Cornell Assessment for Pediatric Delirium is a sensitive and specific tool for the detection of delirium in children with developmental delay. This allows for reliable delirium screening in this hard-to-assess population.