ABSTRACT
BACKGROUND: Delirium commonly affects critically ill patients and is associated with high morbidity and mortality. Some studies have suggested that ramelteon may prevent delirium, but ramelteon's impact on treating delirium is unknown. OBJECTIVE: To compare outcomes of critically ill delirious patients treated with ramelteon versus those who were not. METHODS: Retrospective cohort study of 322 intensive care unit patients stratified based on ramelteon exposure after a nonnegative Confusion Assessment Method-ICU score. MAIN OUTCOMES: Primary outcomes were hours alive without delirium or coma and likelihood of delirium-coma resolution. Secondary outcomes were ventilator-free hours, likelihood of extubation, and mortality. RESULTS: Hazard ratios for delirium-coma resolution, extubation, and 10-day mortality were 1.05 (95% confidence interval 0.54-2.01), 1.20 (95% confidence interval 0.47-3.03), and 0.31 (95% confidence interval 0.07-1.32), respectively. Median delirium-coma free hours did not differ between ramelteon exposed and unexposed patients. Median ventilator-free hours were higher in the ramelteon group, however, ramelteon was administered postextubation in 92% of cases. CONCLUSIONS: Ramelteon was not associated with increased likelihood of delirium-coma resolution, extubation, or changes in mortality.
Subject(s)
Critical Illness/psychology , Delirium/drug therapy , Indenes/therapeutic use , Melatonin/antagonists & inhibitors , Delirium/etiology , Delirium/mortality , Female , Humans , Male , Middle Aged , Retrospective Studies , Survival Analysis , Treatment OutcomeABSTRACT
BACKGROUND: Previous studies have demonstrated that proactive psychiatric consultation reduces hospital length of stay (LOS) in the general medical setting; however this model has not been studied in the intensive care unit (ICU). OBJECTIVE: To compare outcomes between a conventional consultation model and a proactive psychiatric consultation model. METHODS: Two medical ICUs (MICUs) were randomized to proactive psychiatric consultation vs conventional consultation psychiatric models. Proactive consultation included embedding a psychiatrist into daily MICU team rounds on all patients. In the conventional consultation MICU, psychiatric consultations were activated when deemed necessary. Primary outcomes were hospital LOS and MICU LOS. Secondary outcomes included delirium-coma-free hours and ventilator-free hours. RESULTS: A total of 429 patients were admitted to the proactive consultation MICU; 393 patients were admitted to the conventional consultation MICU. The consultation rate for the intervention group was 24.2% vs 6.1% in the control group (p < 0.001). Time to psychiatric consultation was shorter in the intervention group. Median hospital LOS was 6.92 days, interquartile range 3.70-14.31 in the intervention group vs 7.69 days, interquartile range 3.95-16.21 in the control group (pâ¯=â¯0.113). MICU LOS, delirium-coma-free hours, and ventilator-free hours were not significantly different between the 2 groups. Among the respiratory failure subgroup, hospital LOS was shorter in the intervention vs control group (median 9.46 days, interquartile range 4.95-17.56 vs 12.29 days, interquartile range 6.58-21.10, pâ¯=â¯0.011). CONCLUSIONS: Proactive psychiatric consultation in a MICU was associated with decreased time to consultation among all patients and shorter hospital LOS among patients with respiratory failure.
Subject(s)
Intensive Care Units/organization & administration , Length of Stay/statistics & numerical data , Mental Disorders/diagnosis , Referral and Consultation/organization & administration , Delirium/diagnosis , Delirium/therapy , Female , Humans , Intensive Care Units/statistics & numerical data , Male , Mental Disorders/therapy , Middle Aged , Prospective Studies , Referral and Consultation/statistics & numerical data , Respiratory Insufficiency/psychology , Respiratory Insufficiency/therapyABSTRACT
OBJECTIVE: To investigate the effect of early versus late versus no antipsychotic administration on intensive care unit (ICU) delirium. METHODS: This retrospective cohort study was conducted in 2 adult medical ICUs at a single tertiary care center in Boston, Massachusetts, from October 1, 2015, to May 31, 2016. The study included 322 patients stratified into those who first received antipsychotics < 48 hours after first positive or unscorable (due to sedation) modified Confusion Assessment Method (CAM-ICU-m) (early), > 48 hours after first positive or unscorable CAM-ICU-m (late), and never received antipsychotics. Primary outcomes were hours alive without delirium or coma and likelihood of delirium-coma resolution. Secondary outcomes included ventilator-free hours, likelihood of extubation, and 10-day mortality. In post hoc exploratory analyses, outcomes were reanalyzed excluding comatose patients. RESULTS: Mean ± SD delirium-coma-free hours were 63 ± 87 for patients who received antipsychotics early, 66 ± 92 for those who received antipsychotics late, and 89 ± 107 for those who never received antipsychotics (P = .71). Antipsychotic exposure did not impact delirium-coma resolution. Mean ventilator-free hours were 103 ± 87 for patients who received antipsychotics early, 90 ± 83 for those who received antipsychotics late, and 89 ± 101 for patients who never received antipsychotics (P = .11). The hazard ratio (HR) for 10-day mortality among patients who received antipsychotics early was 0.68 (95% CI, 0.37-1.22) and 0.30 (95% CI, 0.10-0.88) for those who received antipsychotics late compared to those who never received antipsychotics (P = .03). After excluding comatose patients, the effect of antipsychotics on 10-day mortality was no longer observed (early HR = 0.57, 95% CI, 0.30-1.07; late HR = 0.57, 95% CI, 0.28-1.18; never HR = 1 [reference]; P = .14). CONCLUSION: Antipsychotics were not associated with changes in delirium-coma-free hours or ventilator-free hours.
Subject(s)
Antipsychotic Agents/administration & dosage , Delirium/therapy , Antipsychotic Agents/adverse effects , Coma/mortality , Coma/therapy , Critical Illness , Delirium/mortality , Female , Follow-Up Studies , Humans , Intensive Care Units , Male , Middle Aged , Retrospective Studies , Time Factors , Treatment OutcomeSubject(s)
Anticonvulsants/adverse effects , Epilepsy/drug therapy , Piracetam/analogs & derivatives , Pregnancy Complications/chemically induced , Psychoses, Substance-Induced/physiopathology , Adult , Anticonvulsants/administration & dosage , Comorbidity , Epilepsy/epidemiology , Female , Humans , Levetiracetam , Piracetam/administration & dosage , Piracetam/adverse effects , Pregnancy , Pregnancy Complications/drug therapy , Pregnancy Complications/epidemiology , Psychoses, Substance-Induced/diagnosis , Substance-Related Disorders/epidemiologyABSTRACT
Hyperthyroidism has profound effects on mental health. The literature is sparse, however, with regard to suicide attempts related to untreated hyperthyroidism. This case report illustrates the presentation of a patient in the intensive care unit after a life-threatening Tylenol overdose presumed to be secondary to adjustment disorder. During the patient's hospitalization, she experienced anxiety, heart palpitations, tachycardia and diaphoresis. The psychiatric consultant, endocrinology consultant and inpatient psychiatry teams helped to diagnose Graves' disease, significantly changing her treatment and trajectory.
