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Delir-Prophylaxe und Behandlung
Abstract
ist eine akute hirnorganische Dysfunktion mit einer vorübergehenden Aufmerksamkeits-und Gedächtnisstörung. In den letzten Jahren konnten die pathophysiologischen Mecha-nismen, die eine maßgebliche Rolle bei der Entwicklung eines Delirs spielen, zumindest teilweise beschrieben werden. Ein Delir ist mit einem längeren intensivstationären Aufenthalt, mit höheren Krankenhauskosten, mit einer höheren Sterblichkeit sowie Langzeitstörungen der kognitiven Funktion assoziiert. Das Delir tritt bei 80% aller beatmeten und bei 50% aller nicht-beatmeten Patienten auf und führt zu einer Verschlechterung des Behandlungsergebnisses. Das bedeutet im Einzelnen eine längere Beatmungsdauer, eine längere Krankenhausaufent-haltsdauer und eine erhöhte Sterblichkeit. Das Erkennen von Risikofaktoren, die Prävention und der Beginn einer zeitnahen symptomorientierten Therapie haben somit einen hohen Stel-lenwert. Präoperative Risikoprofile können in den klinischen Alltag im Rahmen der präoperativen Visite inkludiert werden. Eine pharmakologische Prophylaxe wird aufgrund fehlender Langzeitergebnisse nicht generell empfohlen. Im Einzelfall kann sie aber bei geriatrischen Patienten angewendet werden. Dieses Manuskript soll einen Überblick über die aktuellsten Strategien zur Prävention und Therapie des Delirs geben.
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Introduction Delirium is frequently diagnosed in critically ill patients
and is associated with adverse outcome. Impaired cholinergic
neurotransmission seems to have an important role in the development
of delirium. We aimed to establish the eff ect of the cholinesterase
inhibitor rivastigmine on the duration of delirium in critically ill patients.
Methods Patients (aged ≥18 years) who were diagnosed with delirium
were enrolled from six ICUs in the Netherlands, and treated between
November 2008 and January 2010. Patients were randomised (1:1
ratio) to receive an increasing dose of rivastigmine or placebo,
starting at 0.75 ml (1.5 mg rivastigmine) twice daily and increasing
in increments to 3 ml (6 mg rivastigmine) twice daily from day 10
onwards, as an adjunct to usual care based on haloperidol. The trial
pharmacist generated the randomisation sequence by computer, and
consecutively numbered bottles of the study drug according to this
sequence to conceal allocation. The primary outcome was the duration
of delirium during hospital admission. Analysis was by intention to
treat. Duration of delirium was censored for patients who died or were
discharged from hospital while delirious. Patients, medical staff , and
investigators were masked to treatment allocation. Members of the
data safety and monitoring board (DSMB) were unmasked and did
interim analyses every 3 months.
Results Although a sample size of 440 patients was planned, after
inclusion of 104 patients with delirium who were eligible for the
intention-to-treat analysis (n = 54 on rivastigmine, n = 50 on placebo),
the DSMB recommended that the trial be halted because mortality in
the rivastigmine group (n = 12, 22%) was higher than in the placebo
group (n = 4, 8%; P = 0.07). Median duration of delirium was longer in
the rivastigmine group (5.0 days, IQR 2.7 to 14.2) than in the placebo
group (3.0 days, IQR 1.0 to 9.3; P = 0.06).
Conclusions Rivastigmine did not decrease duration of delirium
and might have increased mortality so we do not recommend use of
rivastigmine to treat delirium in critically ill patients.
Das postoperative Delir stellt sowohl im Aufwachraum als auch auf der Intensivstation die haufigste psychiatrische Erkrankung dar. Insbesondere bei beatmeten Patienten sind Pravalenzraten von uber 80% beschrieben. Patienten die wahrend ihrer Behandlung im Krankenhaus an einem Delir erkranken, haben ein 3-fach erhohtes Risiko, in den folgenden 6 Monaten zu versterben. Ohne validierte Untersuchungsmethoden wird das Delir in den meisten Fallen nicht erkannt. Die Detektion eines Delirs ist in diesem Falle jedoch unabdingbare Voraussetzung fur die fruhzeitige adaquate medizinische Behandlung des Patienten. Der folgende Artikel legt seinen Schwerpunkt auf das Delir bei kritisch kranken Patienten und gibt einen Uberblick uber wichtige zur Verfugung stehende Messinstrumente des Delirs. Hierbei werden vor allem auch inhaltliche Unterschiede zwischen verschiedenen Scores herausgearbeitet, die bei der Auswahl eines geeigneten Messinstruments fur die klinische Routine helfen konnen. Alle in diesem Artikel vorgestellten Delirscores liegen in einer vom Originalautor freigegebenen deutschen Ubersetzung vor. The reported incidence of delirium in critically ill patients ranges widely – from 11% to 87%. Both in the recovery room as well as in the intensive care unit postoperative delirium is the most common psychiatric disease. Patients with ICU delirium have a significant higher 6-month mortality rate. Recent studies could show that the use of a validated delirium assessment tool significantly improves the ability of physicians and nurses to detect delirium in ICU patients. The following article gives a review about different assessment tools of ICU delirium and focuses on the differences between validated delirium scores.
Objective:
To revise the "Clinical Practice Guidelines for the Sustained Use of Sedatives and Analgesics in the Critically Ill Adult" published in Critical Care Medicine in 2002.
Methods:
The American College of Critical Care Medicine assembled a 20-person, multidisciplinary, multi-institutional task force with expertise in guideline development, pain, agitation and sedation, delirium management, and associated outcomes in adult critically ill patients. The task force, divided into four subcommittees, collaborated over 6 yr in person, via teleconferences, and via electronic communication. Subcommittees were responsible for developing relevant clinical questions, using the Grading of Recommendations Assessment, Development and Evaluation method (http://www.gradeworkinggroup.org) to review, evaluate, and summarize the literature, and to develop clinical statements (descriptive) and recommendations (actionable). With the help of a professional librarian and Refworks database software, they developed a Web-based electronic database of over 19,000 references extracted from eight clinical search engines, related to pain and analgesia, agitation and sedation, delirium, and related clinical outcomes in adult ICU patients. The group also used psychometric analyses to evaluate and compare pain, agitation/sedation, and delirium assessment tools. All task force members were allowed to review the literature supporting each statement and recommendation and provided feedback to the subcommittees. Group consensus was achieved for all statements and recommendations using the nominal group technique and the modified Delphi method, with anonymous voting by all task force members using E-Survey (http://www.esurvey.com). All voting was completed in December 2010. Relevant studies published after this date and prior to publication of these guidelines were referenced in the text. The quality of evidence for each statement and recommendation was ranked as high (A), moderate (B), or low/very low (C). The strength of recommendations was ranked as strong (1) or weak (2), and either in favor of (+) or against (-) an intervention. A strong recommendation (either for or against) indicated that the intervention's desirable effects either clearly outweighed its undesirable effects (risks, burdens, and costs) or it did not. For all strong recommendations, the phrase "We recommend …" is used throughout. A weak recommendation, either for or against an intervention, indicated that the trade-off between desirable and undesirable effects was less clear. For all weak recommendations, the phrase "We suggest …" is used throughout. In the absence of sufficient evidence, or when group consensus could not be achieved, no recommendation (0) was made. Consensus based on expert opinion was not used as a substitute for a lack of evidence. A consistent method for addressing potential conflict of interest was followed if task force members were coauthors of related research. The development of this guideline was independent of any industry funding.
Conclusion:
These guidelines provide a roadmap for developing integrated, evidence-based, and patient-centered protocols for preventing and treating pain, agitation, and delirium in critically ill patients.
To review recent findings and developments in strategies for prevention and treatment of postoperative delirium.
Current advances in the field include improved knowledge about predisposing and precipitating factors, evidence for efficacy of multicomponent prevention programmes, refinement of perioperative procedures, and promising pharmacological approaches for prophylaxis and management of postoperative delirium.
Postoperative delirium is a common and serious complication in elderly patients. Preoperative assessment of risk profiles and tailored multimodal prevention approaches proved effective and should be integrated into clinical practice. Despite promising recent findings, at present, the routine use of pharmacological prophylaxis cannot be recommended. Validated and easy-to-use bedside diagnostic tools are available and should be regularly applied for delirium screening in the first days after surgery. In patients developing delirium, causal conditions and contributing factors need to be identified and addressed. Whereas administration of antipsychotics may represent an option for symptomatic treatment, further studies are needed to evaluate the effects of pharmacological approaches on long-term outcomes in elderly patients with delirium.
Postoperative cognitive dysfunction (POCD) is defined as a cognitive decline occurring after surgical intervention. POCD must be distinguished from postoperative delirium, the latter syndrome being characterized by a disrupted sleep-wake rhythm, variable levels of consciousness and altered psychomotor activities. The exact diagnosis of POCD is difficult to make, since the presurgical cognitive state needs to be assessed to confirm a significant change of mental status after surgery. The incidence varies between 0% and 66%, depending on the test procedures used and the patient group. Like postoperative delirium syndrome, POCD is associated with an increased risk of mortality. An early phase within the first week is distinguished from a late phase. Increasing age and co-morbidity have been identified as important risk factors, as have extensive surgical interventions and long-duration anaesthesia. To prevent POCD, surgical trauma should be minimized (e.g. with minimally invasive techniques), while short-acting anaesthetics may be of great benefit. Pro-inflammatory cytokines or metabolites in the central nervous system may play a major role in the development of POCD.
Eine Patientin berichtet von Ängsten und Schlafproblemen seit der Rekonstruktion des anterioren Mundbodens bei Plattenepithelkarzinom
vor 9Monaten. Diese wurden durch ein damals nichtdiagnostiziertes postoperatives Delir (POD) mit Wahnvorstellungen und Halluzinationen
ausgelöst. Erst 9Monate später berichtete die Patientin von ihren Erfahrungen. Bereits eine psychotherapeutische Sitzung
führte zu einer stabilen Reduktion der Ängste. Zur Vermeidung von längerfristigen psychischen Störungen sollten Intensivpatienten
konkret nach POD-Symptomen befragt und aufgeklärt werden.
A patient reported anxiety and sleeping problems 9 months after reconstruction of the anterior floor of the mouth following
tumor surgery. These symptoms had been initiated by a postoperative delirium with hallucinations, which had not been detected
during its occurrence. One session of psychotherapy 9 months later reduced the symptoms. Patients in intensive care units
should be asked and informed about delirium symptoms. This might prevent long-term psychological distress.
SchlüsselwörterPostoperative Komplikationen–Intensivstationen–Halluzinationen–Ängste–Psychotherapie
KeywordsPostoperative complications–Intensive care units–Hallucinations–Anxiety–Psychotherapy
The aim of this randomized, parallel-arm trial was to study the effect of treating subsyndromal delirium with risperidone on the incidence of clinical delirium in elderly patients who underwent on-pump cardiac surgery.
One hundred one patients aged 65 yr or older who experienced subsyndromal delirium after on-pump cardiac surgery were randomized using a computer-generated list to receive 0.5 mg risperidone (n = 51) or placebo (n = 50) every 12 h by mouth. Patients were assessed at 8 h by a blinded observer using the Intensive Care Delirium Screening Checklist, and those scoring more than 3 were evaluated by a blinded psychiatrist to confirm delirium. Patients in either group who experienced delirium were treated according to the same algorithm. Initially, risperidone was administered and if symptoms were not controlled, haloperidol was administered. The primary outcome was the proportion of patients who experienced delirium in either group.
Seven (13.7%) patients in the risperidone group experienced delirium versus 17 (34%) in the placebo group (P = 0.031) Competing-risks regression analysis showed that failure to treat subsyndromal delirium with risperidone was an independent risk factor for delirium (subhazard ratio, 3.83; 95% CI, 1.63-8.98; P = 0.002). Two (3.9%) patients in the risperidone group experienced extrapyramidal manifestations versus one (2%) in the placebo group (P = 1.0).
Administration of risperidone to elderly patients who experienced subsyndromal delirium after on-pump cardiac surgery was associated with significantly lower incidence of delirium. Larger studies are required to determine whether early administration of risperidone during the subsyndromal phase of delirium would influence the clinical course of such patients.