Long-term outcomes of delirium in critically ill surgical patients: A multicenter prospective cohort study.

OBJECTIVE: To identify the mortality rates and dependency rate (functional outcomes) of delirious patients at 12-months after surgical intensive care unit (SICU) admission and to determine the independent risk factors of 12-months mortality and dependency rate in a cohort of SICU patients. METHODS: A prospective, multi-center study was conducted in 3 university-based hospitals. Critically-ill surgical patients who were admitted to SICU and followed-up at 12-months after ICU admission were enrolled. RESULTS: A total of 630 eligible patients were recruited. 170 patients (27%) had postoperative delirium (POD). The overall 12-months mortality rate in this cohort was 25.2%. Delirium group showed significantly higher mortality rates than non-delirium group at 12-months after ICU admission (44.1% vs 18.3%, P < 0.001). Independent risk factors of 12-months mortality were age, diabetes mellitus, preoperative dementia, high Sequential Organ Failure Assessment (SOFA) score and POD. POD was associated with 12-months mortality (adjusted hazard ratio, 1.49; 95% confidence interval 1.04-2.15; P = 0.032). The dependency rate defined as the Basic Activities Daily Living (B-ADL) ≤70 was 52%. Independent risk factors of B-ADL were age ≥ 75 years, cardiac disease, preoperative dementia, intraoperative hypotension, on mechanical ventilator and POD. POD was associated with dependency rate at 12-months. (adjusted risk ratio, 1.26; 95%CI 1.04-1.53; P = 0.018). CONCLUSIONS: Postoperative delirium was an independent risk factor of death and was also associated with dependent state at 12 months after a surgical intensive care unit admission in critically ill surgical patients.

Correlation Between Brain Trauma Foundation Guidelines and Published Severe Traumatic Brain Injury Research.

Four editions of the Brain Trauma Foundation's (BTF) evidence-based guidelines have been published to guide clinical management after severe traumatic brain injury (TBI) and increase TBI research. We reviewed the association between published clinical severe TBI research and BTF guideline year of publication and guideline chapter topics. Using PubMed, we searched for peer-reviewed articles on severe TBI research published between 1975 and 2019. The frequency and study design of publications on chapter topics included in all 4 BTF guideline editions was collected and the relationship with published TBI research examined using linear regression and the coefficient of determination (r2). A total of 845 relevant articles were identified, with an average of 19 articles published per year. There was an increase in the overall number of publications (r2=0.72), with the largest increase occurring between the third and the fourth guideline editions (r2=0.70, 31 articles/y). Across all 4 guideline editions, 54% (n=460) of publications were retrospective studies, 27.2% (n=230) prospective studies, 12% (n=101) randomized controlled trials, and 7.6% (n=64) meta-analyses/systematic reviews. Publication of retrospective study numbers increased the most (r2=0.61), followed by prospective observational studies and meta-analyses/systematic reviews (r2=0.47 each), and randomized controlled trials (r2=0.39). The 3 most highly published guideline chapter topic areas were ventilator-associated pneumonia (r2=0.70), hyperosmolar therapy (r2=0.47), and decompressive craniectomy (r2=0.41). In summary, the TBI research output increased over time and was associated with BTF guideline release. However, the increase in published TBI research was not consistent between serial editions of the BTF guidelines, and many studies did not incorporate high-quality prospective research designs.

Diagnosis of postoperative delirium in older adults using the Confusion Assessment Method for the intensive care unit in non-intensive care unit settings: A test modification might improve its diagnostic performance.

AIM: To evaluate the diagnostic performance of the Confusion Assessment Method for the intensive care unit (CAM-ICU) among postoperative older patients in non-ICU settings. METHODS: The CAM-ICU was used by trained staff to prospectively evaluate postoperative patients for delirium. The patients were aged ≥60 years, were in general wards and had no critical illnesses. The assessments occurred for 7 consecutive days after surgery. The results were compared with delirium diagnoses obtained by geriatricians using Diagnostic and Statistical Manual of Mental Disorders 5th edition criteria as the reference standard. RESULTS: The sensitivity of delirium detection for the CAM-ICU was 31.6% (95% confidence interval [CI] 12.6-56.6), while the specificity was 97.6% (95% CI 94.9-99.1), positive predictive value was 50.0% (95% CI 26.3-73.7) and negative predictive value was 95.0% (95% CI 93.3-96.3). Feature 4 (disorganized thinking) yielded the highest sensitivity (60%; 95% CI 14.7-94.7), whereas feature 2 (inattention) had low sensitivity (36.8%; 95% CI 16.3-61.6). Further analyses to explore the highest sensitive criteria showed that if CAM-ICU diagnoses were made by the presence of any two out of feature 1 (acute change or fluctuation of cognition), feature 3 (altered level of consciousness) or feature 4, the sensitivity increased substantially to 80.0% (95% CI 28.4-99.5), with a reasonably high specificity of 81.8% (95% CI 48.2-97.7). CONCLUSIONS: Modification of the flow of delirium diagnosis using the CAM-ICU appears to offer a better sensitivity for detecting delirium in non-ICU settings. Furthermore, changing feature 2 to evaluate patients' attention levels over a longer period of time might yield a better diagnostic performance. Geriatr Gerontol Int 2019; 19: 762-767.