ABSTRACT
INTRODUCTION: Until now, there has been no gold standard for monitoring delirium in intensive care unit (ICU) patients. In this prospective cohort study, a new score, the Delirium Detection Score (DDS), for severity of delirium in the ICU was evaluated. METHODS: After ethical approval and written informed consent, intensive care doctors and nurses assessed 1073 consecutive patients in surgical ICUs using the DDS together with the Ramsay Sedation Scale (RSS). The DDS is composed of eight criteria (orientation, hallucination, agitation, anxiety, seizures, tremor, paroxysmal sweating, and altered sleep- wake rhythm). Additionally, intensive care doctors had to document the Sedation-Agitation Scale (SAS) combined with a defined clinical assessment. For interrater reliability, pair of evaluators assessed patients in a blinded fashion at the same time. RESULTS: RSS1 (9%) was associated with a significantly (p < 0.001) higher DDS than RSS levels 2-6. The DDS increased with the severity of delirium (p < 0.001). The receiver operating characteristics (ROC) for the differentiation between no delirium (SAS < 4) and symptoms of delirium at all (SAS 5-7) showed an area under the curve (AUC) of 0.802 (95% confidential interval (CI): 0.719-0.898; p < 0.001) and 69% sensitivity and 75% specificity was determined. For reliability, a Cronbach's alpha of 0.667 was calculated. The paired comparisons revealed an intraclass correlation between 0.642 and 0.758. CONCLUSION: The DDS demonstrated good validity with excellent sensitivity and specificity for delirium. The severity of delirium can be more accurately estimated by the DDS. By its composition of several items, the DDS might help to start a symptom-guided therapy immediately.
Subject(s)
Delirium/diagnosis , Psychiatric Status Rating Scales , Severity of Illness Index , Aged , Critical Illness/psychology , Critical Illness/therapy , Delirium/etiology , Delirium/therapy , Female , Humans , Intensive Care Units , Length of Stay , Male , Middle Aged , Reproducibility of Results , Respiration, Artificial , Sensitivity and Specificity , Treatment OutcomeABSTRACT
OBJECTIVE: To examine the effect of bolus vs. continuous infusion adjustment on severity and duration of alcohol withdrawal syndrome (AWS), the medication requirements for AWS treatment, and the effect on ICU stay in surgical intensive care unit (ICU) patients. DESIGN AND SETTING: Prospective randomized, double-blind controlled trial in a surgical ICU. PATIENTS: 44 patients who developed AWS after admission to the ICU. INTERVENTIONS: Patients were randomized to either (a). a continuous infusion course of intravenous flunitrazepam (agitation), intravenous clonidine (sympathetic hyperactivity), and intravenous haloperidol (productive psychotic symptoms) if needed (infusion-titrated group), or (b). the same medication (flunitrazepam, clonidine, or haloperidol) bolus adjusted in response to the development of the signs and symptoms of AWS (bolus-titrated group). MEASUREMENTS AND RESULTS: The administration of "as-needed" medication was determined using a validated measure of the severity of AWS (Clinical Institute of Withdrawal Assessment). Although the severity of AWS did not differ between groups initially, it significantly worsened over time in the infusion-titrated group. This required a higher amount of flunitrazepam, clonidine, and haloperidol. ICU treatment was significantly shorter in the bolus-titrated group (median difference 6 days) due to a lower incidence of pneumonia (26% vs. 43%). CONCLUSIONS: We conclude that symptom-orientated bolus-titrated therapy decreases the severity and duration of AWS and of medication requirements, with clinically relevant benefits such as fewer days of ventilation, lower incidence of pneumonia, and shorter ICU stay.
