Question 29

Created on Thu, 05/21/2015 - 16:43
Last updated on Sun, 12/27/2015 - 20:09
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29.1     Define delirium.

29.2     What is the prevalence of delirium in the critically ill?

29.3     What is its prognostic significance?

29.4     Briefly outline how you will manage delirium in the critically ill patient.

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College Answer

29.1     Define delirium.

A disturbance of consciousness with inattention accompanied by a change in cognition or perceptual disturbance that develops over a short period of time and fluctuates over time. DSM4. Inattention is one of the hallmarks and pivotal features of delirium.

29.2     What is the prevalence of delirium in the critically ill?

Reported as being greater that 8 out of 10 (An answer suggesting that it is highly prevalent should get some credit.

29.3     What is its prognostic significance?

The presence of delirium has been assoc with increased mortality, prolonged ICU and hospital stay, greater dependency on community services and care on discharge and higher nursing home placement rates.

29.4     Briefly outline how you will manage delirium in the critically ill patient.

Treatment of Delirium (marks) – Early recognition
Identify etiology (metabolic, infective, drugs, drug withdrawal,alcohol etc) and treat this

Non Pharmacologic treatment i.e. recurrent orientation of patients, early mobilization, early removal of catheters etc
Pharmacologic- 
Benzodiazepines Thiamine Haloperidol
decrease analgesics sedatives and anticholinergic drugs. NOTE there are NO FDA drugs approved for the treatment of delirium.

Discussion

Delirium is discussed in greater detail elsewhere ("Delirium in the ICU").

It is also covered in some depth in the answer to Question 6 from the second paper of 2013, "Define delirium and describe your management approach to this problem in the ICU. "

However, prevalence and prognostic significance are not discussed in the 2013 paper.

Thus:

Prevalence of delirium in the ICU

"An answer suggesting that it is highly prevalent should get some credit." Indeed, recent publicationsquote a figure of 32-77%.

Prognostic significance of delirium in the ICU

The 2004 Ely prospective cohort study gets brought out whenever anybody talks about the prognostic significance of delirium in the ICU. There are many others. In summary, their findings were as follows:

  • Mortality at 6 months: increases × 3.2
  • Length of hospital stay doubles
  • Every additional day of delirium increases the hazard of deatha t 1 year by about 10%.
  • Increased risk of cognitive impairment in the long term (in ~ 70%)

References

Cavallazzi, Rodrigo, Mohamed Saad, and Paul E. Marik. "Delirium in the ICU: an overview." Ann Intensive Care 2.1 (2012): 49.

Ely, E. Wesley, et al. "Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit." Jama 291.14 (2004): 1753-1762.