[Show abstract][Hide abstract] ABSTRACT: Delirium is often unrecognized in ICU patients and associated with poor outcome. Screening for ICU delirium is recommended by several medical organizations to improve early diagnosis and treatment. The Confusion Assessment Method for the ICU (CAM-ICU) has high sensitivity and specificity for delirium when administered by research nurses. However, test characteristics of the CAM-ICU as performed in routine practice are unclear.
To investigate the diagnostic value of the CAM-ICU in daily practice.
Teams of three delirium experts including psychiatrists, geriatricians, and neurologists visited 10 ICUs twice. Based on cognitive examination, inspection of medical files, and Diagnostic and Statistic Manual of Mental Disorders, 4th edition, Text Revision criteria for delirium, the expert teams classified patients as awake and not delirious, delirious, or comatose. This served as a gold standard to which the CAM-ICU as performed by the bedside ICU-nurses was compared. Assessors were unaware of each other's conclusions.
Fifteen delirium experts assessed 282 patients of whom 101 (36%) were comatose and excluded. In the remaining 181 (64%) patients, the CAM-ICU had a sensitivity of 47% (95% confidence interval [CI], 35%-58%); specificity of 98% (95% CI, 93%-100%); positive predictive value of 95% (95% CI, 80%-99%); and negative predictive value of 72% (95% CI, 64%-79%). The positive likelihood ratio was 24.7 (95% CI, 6.1-100) and the negative likelihood ratio was 0.5 (95% CI, 0.4-0.8).
Specificity of the CAM-ICU as performed in routine practice seems to be high but sensitivity is low. This hampers early detection of delirium by the CAM-ICU.
Full-text · Article · May 2011 · American Journal of Respiratory and Critical Care Medicine
[Show abstract][Hide abstract] ABSTRACT: 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 effect of the cholinesterase inhibitor rivastigmine on the duration of delirium in critically ill patients.
Patients (aged ≥18 years) who were diagnosed with delirium were enrolled from six intensive care units 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. This trial is registered with ClinicalTrials.gov, number NCT00704301.
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 2·7-14·2) than in the placebo group (3·0 days, IQR 1·0-9·3; p=0·06).
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.
ZonMw, the Netherlands Brain Foundation, and Novartis.
[Show abstract][Hide abstract] ABSTRACT: A patient with Prinzmetal's variant angina (PVA) developed a cardiac arrest due to coronary vasospasm and subsequent myocardial infarction. After resuscitation postanoxic brain injury was diagnosed. After an initial improvement of consciousness he deteriorated rapidly on the seventh day after admission due to severe brain ischaemia apparently caused by cerebral vasospasm, until ultimately brain death was diagnosed. To our knowledge, the association between PVA and cerebral vasospasm has never been described. The combination suggests that this patient had a generalized vasospastic disorder.
[Show abstract][Hide abstract] ABSTRACT: Delirium in the ICU can compromise the recovery process, prolong ICU and hospital stay and increase mortality. Therefore, recognition of delirium is of utmost importance.
To ascertain current attitude pertaining to delirium in critically ill patients a simple questionnaire was sent to all intensive care units (ICUs) throughout the Netherlands.
Seventy-five questionnaires were sent and 44 returned. A delirium protocol was present in the majority of cases (n=35, 80%), although implementation had occurred in only 22 ICUs (50%). The reported general incidence of delirium varied widely (25% of ventilated patients (n=33, 75%) and in patients older than 70 (n=38, 86%). Most participating centres reported that they could certainly (n=9, 20%) or most certainly (n=22, 50%) identify delirium. A geriatrician or a psychiatrist predominantly diagnosed delirium (n=30, 68%), while a diagnostic instrument such as the CAM -ICU was used in a minority of cases (n=11, 25%). A geriatrician or a psychiatrist was consulted when patients were agitated (n=40, 90%), or when routine pharmacological treatment had failed (n=40, 91%).
In the Netherlands, delirium is considered an important problem in the ICU, although its incidence is estimated to be low by the ICU team. The diagnosis of delirium is most frequently established by a geriatrician or psychiatrist after consultation, while diagnostic instruments are infrequently used. Efforts should be undertaken to implement delirium protocols and a routinely applied diagnostic instrument in the ICU.
Full-text · Article · Jul 2009 · The Netherlands Journal of Medicine