Síndrome confusional agudo y confusional subsindromático en terapia intensiva: evolución intrahospitalaria y a los tres meses del alta / Delirium and subsyndromal delirium in the intensive care unit: In-hospital outcomes and prognosis at discharge

Antecedentes y objetivo Las características y la evolución de los pacientes con confusional subsindromático (CSS) en la internación aún continúa en discusión. El objetivo fue describir la incidencia de síndrome confusional agudo (SCA) y CSS en terapia intensiva (UTI), analizar su asociación con la presencia de factores de riesgo y explorar diferencias en la evolución hospitalaria y a los tres meses del alta. Pacientes y métodos Estudio prospectivo con seguimiento telefónico tres meses luego del alta. Se aplicó el CAM-ICU para definir tres grupos: sin delirio (de referencia), CSS y SCA. Resultados En 270 pacientes, el 22,96% presentaron SCA y el 17,03%, CSS. Factores relacionados con mayor riesgo de SCA: deterioro cognitivo (p=0,000), edad ≥75años (p=0,019), motivo de ingreso neurológico (p=0,003), shock (p=0,043), escaras (p=0,010), polifarmacia (0,017), ARM (p=0,001) y reposo digestivo (p=0,028); con mayor riesgo de CSS: baja escolaridad (p=0,014), Charlson >5 (p=0,028), AIVD <8 (p=0,001), alimentación enteral (p=0,000) y motivo de ingreso no cardiovascular (p=0,019). La mortalidad global fue del 6% en el grupo sin delirio, del 8% en CSS (p=0,516) y del 30% en SCA (p=0,000). La mediana de internación en UTI fue de 2días (rango 1-2) en el grupo sin delirio, 3 (2-4) días en CSS (p=0,0001) y 3 (2-7) días en SCA (p=0,0001). A los tres meses del alta, las AIVD estaban conservadas en el 50% del grupo sin delirio, en el 30% de CSS (p=0,026) y en el 26% de SCA (p=0,005). Conclusiones El CSS presentó un pronóstico intermedio entre el grupo sin delirio y el SCA. Se aconseja su diagnóstico para mejor clasificación de riesgo (AU)

Background and objective The characteristics and outcomes of patients with subsyndromal delirium (SSD) at hospitalization are still under discussion. The objectives were to describe the incidence of delirium and SSD in the intensive care unit (ICU), to analyze the association with risk factors and to explore outcomes of delirium and SSD at hospitalization and three months after discharge. Patients and methods A prospective study, with telephone follow-up three months after discharge. The study included 270 patients over one year. Delirium and SSD were assessed with the CAM-ICU. Results 22.96% developed delirium and 17.03% SSD. The main risk factors associated with the development of delirium were cognitive impairment (P=.000), age ≥75years (P=.019), neurological admission (P=.003), shock (P=.043), bedsores (P=.010), polypharmacy (P=.017), ARM (P=.001) and fast (P=.028), and with the development of SSD were low schooling (P=.014), Charlson >5 (P=.028), AIVD <8 (P=.001), enteral feeding (P=.000) and non-cardiovascular admission (P=.019). Overall mortality was 6% in the group without delirium (reference), 8% in SSD (P=.516) and 30% in delirium (P=.000). Median ICU length of stay was 2 (IQR, 1-2) days in the group without delirium, 3 (IQR, 2-4) days in SSD (P=.0001), and 3 (IQR, 2-7) days in delirium group (P=.0001). Three months after discharge, instrumental ADL were preserved in 50% of the group without delirium, 30% of SSD (P=.026) and 26% of delirium (P=.005). Conclusions The SSD group presented an intermediate prognosis between no delirium and delirium groups. It is advisable to promote its diagnosis for better risk classification (AU)

Delirium and subsyndromal delirium in the intensive care unit: In-hospital outcomes and prognosis at discharge. / Síndrome confusional agudo y confusional subsindromático en terapia intensiva: evolución intrahospitalaria y a los tres meses del alta.

BACKGROUND AND OBJECTIVE: The characteristics and outcomes of patients with subsyndromal delirium (SSD) at hospitalization are still under discussion. The objectives were to describe the incidence of delirium and SSD in the intensive care unit (ICU), to analyze the association with risk factors and to explore outcomes of delirium and SSD at hospitalization and three months after discharge. PATIENTS AND METHODS: A prospective study, with telephone follow-up three months after discharge. The study included 270 patients over one year. Delirium and SSD were assessed with the CAM-ICU. RESULTS: 22.96% developed delirium and 17.03% SSD. The main risk factors associated with the development of delirium were cognitive impairment (P=.000), age ≥75years (P=.019), neurological admission (P=.003), shock (P=.043), bedsores (P=.010), polypharmacy (P=.017), ARM (P=.001) and fast (P=.028), and with the development of SSD were low schooling (P=.014), Charlson >5 (P=.028), AIVD <8 (P=.001), enteral feeding (P=.000) and non-cardiovascular admission (P=.019). Overall mortality was 6% in the group without delirium (reference), 8% in SSD (P=.516) and 30% in delirium (P=.000). Median ICU length of stay was 2 (IQR, 1-2) days in the group without delirium, 3 (IQR, 2-4) days in SSD (P=.0001), and 3 (IQR, 2-7) days in delirium group (P=.0001). Three months after discharge, instrumental ADL were preserved in 50% of the group without delirium, 30% of SSD (P=.026) and 26% of delirium (P=.005). CONCLUSIONS: The SSD group presented an intermediate prognosis between no delirium and delirium groups. It is advisable to promote its diagnosis for better risk classification.

Estudio del síndrome confusional agudo en los registros de enfermería en pacientes geriátricos hospitalizados con interconsulta a psiquiatría / Study of delirium based on nursing records in hospitalized geriatric patients with psychiatric interconsultation

Objetivos: Analizar, a partir de los registros de enfermería, las variables asociadas con la aparición del síndrome confusional agudo (SCA) en pacientes geriátricos de un hospital general.Metodología:Estudio descriptivo transversal y retrospectivo realizado en el Hospital Royo Villanova, de Zaragoza, entre 2011-2014. Población de estudio: N = 881 diagnosticados de SCA (2,2% del total de ingresos); se obtuvo una muestra total de n = 79 pacientes de 60 años o más, con diagnóstico de SCA por psiquiatría de enlace.Resultados:La edad media de los pacientes fue de 82,8 años. La detección de SCA se realizó en los pacientes tras 1,1 a 3,5 días de media desde el ingreso. Las puntuaciones del Índice de Barthel fueron de 40,9 a 60,8. Los fallecimientos durante el episodio de SCA fueron entre el 10,3% y el 15%. El cuadro de SCA fue mayoritariamente de tipo hiperactivo y se inició por la noche y por la tarde. Los síntomas más frecuentes de SCA registrados por enfermería fueron alteraciones motoras (agitación, inquietud) y desorientación.Conclusión:Enfermería registra el SCA antes de la petición de colaboración al servicio de psiquiatría, la cual se da en escaso número. Estos registros son precisos y certeros y coinciden con los términos médicos. Serían necesarios nuevos estudios de investigación que permitan minimizar el infradiagnóstico y no solo detectar SCA del tipo hiperactivo, ya que todos conducen a aumentar la morbimortalidad de nuestros pacientes. (AU)

Objectives: To analyze, from the nursing records, the variables associated with the appearance of Acute Confusional Syndrome (here after SCA) in geriatric patients of a general hospital in the city of Zaragoza.Methodology:Descriptive cross-sectional and retrospective study conducted at the Royo Villanova hospital in Zaragoza between 2011-2014. Study population: N = 881 diagnosed with ACS (2.2% of total income). A total sample of n = 79 was obtained, patients ≥ 60 years, with a diagnosis of ACS by Link Psychiatry.Results:The average age of the patients was 82.8 years. The detection of ACS was performed in patients after 1.1 to 3.5 days on average from admission. Barthel Index scores were 40.9 to 60.8. The exitus during the episode of ACS were 10.3% / 15%. The SCA chart was mostly hyperactive and debuted at night and in the afternoon. The most frequent symptoms of ACS recorded by nursing were motor disorders (agitation, restlessness) and disorientation.Conclusions:Nursing usually register ACS before the request for collaboration to the psychiatry service, which occurs rarely. Besides these records are accurate and match with the medical terms. New research studies are required to minimize underdiagnosis and not only to detect hyperactivity ACS because all types lead to increased morbidity and mortality of our patients. (AU)

Prospective Study of Factors Associated With Postoperative Delirium After Urgent Abdominal Surgery. / Estudio prospectivo de los factores asociados al delirium en el postoperatorio de la cirugía abdominal urgente.

INTRODUCTION: Delirium is a frequent complication in elderly patients after urgent abdominal surgery. METHODS: Prospective study of consecutive patients aged ≥65years who had undergone urgent abdominal surgery from 2017-2019. The following variables were recorded: age, sex, ASA, physiological state, cognitive impairment, frailty (FRAIL Scale), functional dependence (Barthel Scale), quality of life (Euroqol-5D-VAS), nutritional status (MNA-SF), preoperative diagnosis, type of surgery (BUPA Classification), approach and diagnosis of postoperative delirium (Confusion Assessment Method). Univariate and multivariate analyses were performed to analyze the correlation of these variables with delirium. RESULTS: The study includes 446 patients with a median age of 78years, 63.6% were ASA ≥III and 8% had prior cognitive impairment. 13.2% were frail and 5.4% of the patients had a severe or total degree of dependence. 13.6% developed delirium in the postoperative period. In the univariate analysis, all the variables were statistically significant except for sex, type of surgery (BUPA) and duration. In the multivariate analysis the associated factors were: age (P<.001; OR: 1,08; 95%CI: 1,038-1,139), ASA (P=.026; OR: 3.15; 95%CI: 1.149-8.668), physiological state (P<.001; OR: 5.8; 95%CI: 2.176-15.457), diagnosis (P=.006) and cognitive impairment (P<.001; OR: 5.8; 95%CI: 2.391-14.069). CONCLUSION: The factors associated with delirium are age, ASA, physiological state in the emergency room, preoperative diagnosis and prior cognitive impairment.

Electroencephalographic monitoring in the critically ill patient: What useful information can it contribute? / Monitorización electroencefalográfica en el paciente crítico: ¿qué información útil puede aportar?

Monitoring is a crucial part of the care of the critically ill patient. It detects organ dysfunction and provides guidance on the therapeutic approach. Intensivists closely monitor the function of various organ systems, and the brain is no exception. Continuous EEG monitoring is a noninvasive and uninterrupted way of assessing cerebral cortical activity with good spatial and excellent temporal resolution. The diagnostic effectiveness of non-convulsive status epilepticus as a cause of unexplained consciousness disorder has increased the use of continuous EEG monitoring in the neurocritical care setting. However, non-convulsive status epilepticus is not the only indication for the assessment of cerebral cortical activity. This study summarizes the indications, usage and methodology of continuous EEG monitoring in the intensive care unit, with the aim of allowing practitioners to become familiarized the technique.

Syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis (HaNDL) in a patient with confusional symptoms, diffuse EEG abnormalities, and bilateral vasospasm in transcranial Doppler ultrasound: A case report and literature review. / Síndrome de cefalea transitoria con déficits neurológicos asociados y pleocitosis en líquido cefalorraquídeo (HaNDL) con cuadro confusional, EEG compatible con afectación difusa y datos de vasoespasmo bilateral en estudio Doppler transcraneal: presentación de un caso y revisión de la literatura.

INTRODUCTION: HaNDL syndrome (transient headache and neurological deficits with cerebrospinal fluid lymphocytosis) is characterised by one or more episodes of headache and transient neurological deficits associated with cerebrospinal fluid lymphocytosis. To date, few cases of HaNDL manifesting with confusional symptoms have been described. Likewise, very few patients with HaNDL and confusional symptoms have been evaluated with transcranial Doppler ultrasound (TCD). TCD data from patients with focal involvement reveal changes consistent with vasomotor alterations. DEVELOPMENT: We present the case of a 42-year-old man who experienced headache and confusional symptoms and displayed pleocytosis, diffuse slow activity on EEG, increased blood flow velocity in both middle cerebral arteries on TCD, and single-photon emission computed tomography (SPECT) findings suggestive of diffuse involvement, especially in the left hemisphere. CONCLUSIONS: To our knowledge, this is the first description of a patient with HaNDL, confusional symptoms, diffuse slow activity on EEG, and increased blood flow velocity in TCD. Our findings suggest a relationship between cerebral vasomotor changes and the pathophysiology of HaNDL. TCD may be a useful tool for early diagnosis of HaNDL.

Emergency electroencephalogram: Usefulness in the diagnosis of nonconvulsive status epilepticus by the on-call neurologist. / Uso de la electroencefalografía urgente por el neurólogo de guardia: utilidad en el diagnóstico del estatus epiléptico no convulsivo.

INTRODUCTION: We aim to describe the use of emergency electroencephalogram (EmEEG) by the on-call neurologist when nonconvulsive status epilepticus (NCSE) is suspected, and in other indications, in a tertiary hospital. SUBJECTS AND METHODS: Observational retrospective cohort study of emergency EEG (EmEEG) recordings with 8-channel systems performed and analysed by the on-call neurologist in the emergency department and in-hospital wards between July 2013 and May 2015. Variables recorded were sex, age, symptoms, first diagnosis, previous seizure and cause, previous stroke, cancer, brain computed tomography, diagnosis after EEG, treatment, patient progress, routine control EEG (rEEG), and final diagnosis. We analysed frequency data, sensitivity, and specificity in the diagnosis of NCSE. RESULTS: The study included 135 EEG recordings performed in 129 patients; 51.4% were men and their median age was 69 years. In 112 cases (83%), doctors ruled out suspected NCSE because of altered level of consciousness in 42 (37.5%), behavioural abnormalities in 38 (33.9%), and aphasia in 32 (28.5%). The EmEEG diagnosis was NCSE in 37 patients (33%), and this was confirmed in 35 (94.6%) as the final diagnosis. In 3 other cases, NCSE was the diagnosis on discharge as confirmed by rEEG although the EmEEG missed this condition at first. EmEEG performed to rule out NCSE showed 92.1% sensitivity, 97.2% specificity, a positive predictive value of 94.6%, and a negative predictive value of 96%. CONCLUSIONS: Our experience finds that, in an appropriate clinical context, EmEEG performed by the on-call neurologist is a sensitive and specific tool for diagnosing NCSE.

El delirium: una actualización para Internistas y Psiquiatras

RESUMEN A lo largo del tiempo, al delirium se lo ha conocido por diversos nombres: falla cerebral aguda, síndrome cerebral orgánico agudo, síndrome confusional o psicosis postquirúrgica. No obstante, el término preferido en la actualidad es delirium (de latín delirare, que significa "arar fuera del surco"). El delirium, como síndrome, es un conjunto de signos y síntomas de inicio agudo caracterizado por deterioro cognitivo fluctuante, con enturbiamiento de la conciencia y capacidad disminuida de mantener y cambiar la atención de un punto a otro. Numerosos estudios han demostrado que los pacientes que desarrollan delirium tienen un riesgo aumentado de resultados adversos tanto durante la hospitalización como tras el alta. Este riesgo es independiente de cualquier comorbilidad existente, de la severidad de la enfermedad, la edad u otras variables asociadas. Asimismo, el delirium está asociado a un incremento en la mortalidad, aumento del tiempo de hospitalización y desarrollo de disfunciones cognitivas posteriores al alta. Este artículo de revisión presenta una actualización acerca de la fisiopatología del delirium, de las herramientas de reconocimiento del cuadro y de su tratamiento. Todas estas informaciones resultan útiles en el manejo diario de este tipo de pacientes, tanto por médicos internistas como por médicos psiquiatras.

ABSTRACT Over time, delirium has been known by several names: acute brain failure, acute organic brain syndrome, confusional syndrome, or post-surgical psychosis. However, the currently preferred term is delirium (from the Latin term delirare, which means "to go out of the furrow"). Delirium, as a syndrome, is a set of signs and symptoms of acute onset characterized by fluctuating cognitive impairment, clouding of consciousness and diminished ability to maintain and shift attention from one point to another. Numerous studies have shown that patients who develop delirium have an increased risk of adverse outcomes both during hospitalization and after discharge. This risk is independent of any existing comorbidity, severity of disease, age or other associated variables. Likewise, delirium is associated with an increase in mortality, increase in hospitalization time and the development of cognitive dysfunctions after discharge. This review article presents an update on the pathophysiology of delirium, the tools for recognizing the condition and its treatment. All this information is useful in the daily management of this type of patients, by both internists and psychiatrists.

Utilidad de la punción lumbar en el paciente con síndrome confusional agudo y fiebre / Usefulness of the lumbar puncture in patients with acute confusional state and fever

Los estados confusionales agudos son motivo de consulta frecuente en pacientes añosos. Se evaluó la utilidad de la punción lumbar en pacientes con fiebre y síndrome confusional agudo (SCA) cuando existe un origen extrameníngeo que explique la fiebre. Criterios de inclusión: pacientes mayores de 50 años, de ambos sexos, con fiebre y SCA admitidos entre junio de 2005 y noviembre de 2006. Se excluyeron pacientes con infección por HIV o que hubieren estado internados en las últimas 72 horas. Se realizó punción lumbar (previa realización de TAC) y se analizó el líquido cefalorraquídeo (LCR). Se incluyeron 30 pacientes. 20 pacientes tuvieron una causa extrameníngea demostrada de la fiebre (66.6%). Se diagnosticaron 6 pacientes con meningitis (20%). El análisis bacteriológico directo del LCR fue positivo en 3 pacientes (10%): en 2 casos se aisló un coco gram positivo y en el restante un bacilo gram negativo. El cultivo de LCR fue positivo en dos casos (6.6%): en un caso se aisló un Streptococcus pneumoniae y en otro Escherichia coli. El hallazgo de una causa clara de fiebre no descarta la posibilidad de meningitis concomitante. Se encontró una asociación entre la presencia de hemocultivos positivos y la de meningitis, tanto en un caso de neumonía por Streptococcus neumoniae como en una infección urinaria por Escherichia coli (p=0.0022, test exacto de Fisher). Conclusión: los pacientes añosos con SCA y fiebre podrían requerir la realización de punción lumbar como parte de la evaluación inicial, independientemente de encontrarse una causa extrameníngea de la fiebre.

Acute Confusional State (ACS) is a frequent cause for seeking professional help among elderly patients. We evaluated the usefulness of lumbar puncture in patients with acute confusional state and fever, when an evident extrameningeal cause of fever is present. All patients over 50 years of age, from both sexes, with fever and ACS, who were admitted to hospital in a period between June 2005 and November 2006, were included. Patients with a history of HIV infection and patients who had been hospitalized within the previous 72 hours were excluded. Lumbar puncture was performed, and the cerebrospinal fluid (CSF) was analyzed. Thirty patients were included. Twenty of the included patients (66.6%) had a demonstrable extrameningeal fever cause. Six patients (20%) with meningitis were detected. The CSF bacteriologic smear was positive in 3 patients (10%); in two cases a gram positive coccus was identified and in one case a gram negative bacillus. The CSF culture was positive in two patients (6.6%) for Escherichia coli (o and Streptococcus pneumoniae. The finding of a clear cause for fever does not rule out the possibility of meningitis. We found an association between the positive blood cultures and the presence of meningitis, both in a case of pneumococcal pneumonia and in a case of urinary tract infection due to Escherichia coli (p=0.0022, Fisher’s Exact test). We conclude that all elderly patients with ACS and fever may require performing a lumbar puncture as part of the initial assessment, regardless of the finding of a extrameníngeal cause of fever.

Rendimiento diagnóstico de la tomografía de cráneo en pacientes con delirium / Clinical yield of computed tomography brain scan in patients with delirium

RESUMEN Objetivos: Determinar el rendimiento de la tomografía axial computada de cráneo en el diagnóstico etiológico de delirium y qué factores son predictores de causa intracraneana del mismo. Material y métodos: Estudio transversal, observacional. Criterios de inclusión: pacientes con diagnóstico de delirium a los cuales se les haya realizado una Tomografía de cráneo como parte de la valoración etiológica. Criterios de exclusión: factores que imposibiliten la entrevista. Como herramienta diagnóstica se utilizó el CAM (Confusion Assesment Method). Resultados: Se incluyeron en el estudio 114 pacientes. La tomografía confirmó la causa de delirium en 18,4 % de los casos. Las variables que se asociaron con tomografía alterada fueron déficit focal neurológico y antecedentes de Trauma de cráneo. En 2.6% de los pacientes la tomografía confirmó una causa intracraneana de delirium a pesar de no tener signos focales neurológicos ni antecedente de traumatismo de cráneo. Conclusiones: La tomografía de cráneo es una herramienta de gran valor, pero no debería realizarse de urgencia, en forma rutinaria, en todos los pacientes con delirium. La tomografía debe indicarse de urgencia cuando existe antecedente de traumatismo de cráneo, hallazgo de signos focales neurológicos al examen o no se encuentra un factor precipitante. En los pacientes ancianos y/o con deterioro cognitivo previo debe tenerse presente que los factores precipitantes de delirium más frecuentes son extra-craneanos.

ABSTRACT Objectives: To determine the yield of computed tomography brain scan in the etiological diagnosis of delirium, and to determine which factors are predictors of the intracranial cause of delirium. Material and methods: Cross-sectional study, observational. Inclusion criteria: Patients diagnosed with delirium that have undergone a cranial tomography as part of etiological assessment. Exclusion criteria: Factors that prevent the interview. The CAM (Confusion Assessment Method) has been used as a diagnostic tool. Results: 114 patients were included in the study. The tomography confirmed the cause of delirium in 18% of the cases. The variables that were associated with altered tomography were focal neurological deficit and a history of head trauma. 2.6% of patients’ tomography confirmed an intracranial cause of delirium in spite of not having focal neurological signs or history of head trauma. Conclusions: The tomography is a valuable tool, but it should not be made urgently, routinely, in all patients with delirium. The tomography should be requested urgently when there is a history of head trauma, findings of focal neurological signs or a precipitating factor is not found. It should be noted that in elderly patients with previous cognitive impairment, the most common precipitating factors of delirium are nonintracranial.

Síndrome confusional agudo postanestesia en el paciente geriátrico de urgencia / Acute confusional postanesthesia in geriatric patient emergency

Introducción: el Síndrome Confusional Agudo o delirio es una enfermedad frecuente, se encuentra entre el 10-15 por ciento de los pacientes médico-quirúrgicos y esta proporción se eleva al 30 por ciento en los pacientes geriátricos. Objetivo: valorar la presencia de Síndrome Confusional Agudo postanestésico o delirio en el geriátrico de urgencia. Métodos: se realizó un estudio descriptivo, prospectivo en 100 pacientes ancianos atendidos en el servicio de anestesiología del Hospital Dr. Gustavo Aldereguía Lima de Cienfuegos, durante el período enero del 2012 a Junio del 2013. Se identificaron las complicaciones perioperatorias y se aplicó el test de Pfeiffer a los pacientes antes y 1 horas de aplicado el proceder anestésico. Resultados: al aplicar el test de Pfeiffer en los pacientes que recibieron anestesia general se encontró que el mayor número de enfermos presentó deterioro leve en un 42 por ciento, seguido por el deterioro moderado para un 33 por ciento. La anestesia regional mostró mayor número de enfermo sin grado de deterioro. En la distribución de las complicaciones postoperatorias se evidenció que predominó la confusión mental en 30 por ciento de los casos, seguidas de hipotensión, hipertensión y taquicardia en un mayor número de pacientes. Conclusiones: el estado confusional agudo en el paciente atendido por los servicios de urgencia obedece a varios factores en los que el estado previo del enfermo y las diferentes modificaciones a que es sometido el mismo a punto de partida de las exigencias de la intervención quirúrgica son elementos favorecedores de su aparición(AU)

Introduction: The Syndrome Sharp Confusional (SCA) or delirium is a frequent illness, it is among 10-15 percent of the medical patients - surgical, and this proportion rises to 30 percent in the patient geriatrics.Objective: To value the presence of Syndrome Confusional Sharp postanestésico or delirium in the geriatric of urgency. Method: He/she was carried out a descriptive study, prospective in 100 old patients assisted in the service of anesthesiology of the Hospital Dr. Gustavo Aldereguía Lima of Cienfuegos, during the period January of the 2012 to June of the 2013. The complications perioperatorias were identified and the test was applied before from Pfeiffer to the patients and 1 hours of having applied proceeding anesthetic. Results: When applying the test of Pfeiffer in the patients that received general anesthesia it was found that the biggest number of sick persons presented light deterioration in 42 percent, continued by the moderate deterioration for 33 percent. The regional anesthesia howed bigger number of sick without grade of deterioration. In the distribution of the postoperative complications it was evidenced that the mental confusion prevailed in 30 percent of the cases, followed by hypotension, hypertension and taquicardia in a bigger number of patient. Conclusions: The state sharp confusional in the patient assisted by the services of urgency obeys several factors in those that the sick person's previous state and the different modifications to that it is subjected the same one about to departure of the demands of the surgical intervention is elements favorecedores of its appearance(AU)

Síndrome confusional agudo en pacientes posquirúrgicos de cirugía de revascularización miocárdica / Acute confusional state in postoperative surgical patients myocardial revascularization

Se realizó un estudio de investigación con un diseño cuantitativo, analítico, retrospectivo, transversal, conmetodología de Casos y Controles, seleccionando una muestra de 90 pacientes, a través de un muestreo aleatorio simple de un total de 246 pacientes posquirúrgicos de revascularización miocárdica, los cuales fueron distribuidos en grupo de casos y grupo de controles. En el grupo casos se incluyeron 30 pacientes, mientras que en el grupo control se incluyeron 60 pacientes. Esto fue realizado en el Instituto de Cardiología de Juana Francisca Cabral, de la ciudad de Corrientes, capital. Las operaciones estadísticas utilizadas fueron porcentajes, promedios; y para establecer las asociaciones, OddsRatio, el nivel de significación fue de p< 0,05, se utilizó el programa “SPPS, versión 17.0”. Cuando se analizó la CEC (Circulación Extracorpórea), en relación al Síndrome Confusional Agudo, se encontró que los pacientes que requirieron CEC tienen 1,75 veces más de probabilidades de desarrollar S.C.A. que los pacientes que no requirieron CEC, con Intervalo de Confianza = 0,71 – 4,17 y P= 0,162 (NS= no significativo). Al analizar el antecedente de tabaquismo, se observó que los pacientes con antecedente de tabaquismo, tienen 1,83 veces más de probabilidades de desarrollar S.C.A. en el posoperatorio de cirugía de revascularización miocárdica con circulación extracorpórea, que de los pacientes sin antecedente de tabaquismo, con un Intervalo de Confianza = 0,58 – 3,36 y P= 0,3 (NS= no significativo). Por último, al analizar la variable sexo, se encontró que el grupo de mujeres tienen 2,11 veces más de probabilidades de desarrollar S.C.A., en el posoperatorio de cirugía de revascularización miocárdica con circulación extracorpórea, que los pacientes del sexo masculino, con Intervalo de Confianza = 0,78 – 7,09 y P= 0,10 (NS= no significativo...

A research study was conducted with quantitative, analytical, retrospective, cross-sectional design with CaseControlmethodology, selecting a sample of 90 patients, through simple random sampling a total of 246 patientspostoperative myocardial revascularization, the which were distributed in the case group and control group. In the case group included 30 patients, whereas in the control group 60 patients were included. This was done at the Institute of Cardiology of Juana Francisca Cabral, city of Corrientes, capital. The statistics operations were used percentages, averages; and to establish partnerships, Odds Ratio, the level ofsignificance was p <0.05, the program was used "SPPS, version 17.0."When the CEC was analyzed in relation to acute confusional syndrome, found that patients who required CPB are1.75 times more likely to develop SCA Patients who required NO CEC, with confidence interval = 0.71 to 4.17 and P= 0.162 (NS = not significant).When analyzing the History of Smoking, it was observed that patients with a history of Tobacco, have 1.83 timesmore likely to develop SCA in the postoperative CABG with cardiopulmonary bypass patients without a history of smoking, a confidence interval = 0.58 to 3.36 and P = 0.3 (NS = not significant). Finally when analyzing the gender variable, it was found that in the group of women, are 2.11 times more likely to develop SCA in the postoperative CABG with cardiopulmonary bypass, that male patients with confidence interval = 0.78 to 7.09 and P = 0.10 (NS = not significant)...

Comportamiento del Delirium en el anciano. Policlínico "Pedro Fonseca", La Lisa, 2012 / Delirium behavior in the elder. Policlínico "Pedro Fonseca", La Lisa, 2012

Introducción: el Síndrome Confusional Agudo o Delirium es un síndrome cerebral orgánico de etiología multifactorial, caracterizado por alteraciones fluctuantes de la conciencia, atención, percepción, pensamiento, memoria, con incremento o reducción de la actividad psicomotora y un desorden en el ciclo sueño-vigilia. Objetivo: caracterizar los ancianos con delirium, según grupo de edades, sexo y manifestaciones clínicas e identificar las principales causas que le dieron origen. Material y Método: se realizó un estudio descriptivo de los pacientes con 60 años o más, quienes asistieron a la consulta de Medicina Interna presentando manifestaciones clínicas de delirium, desde enero hasta diciembre de 2012. La información fue obtenida de las hojas de cargo, así como de entrevistas realizadas a pacientes o familiares, en planillas previamente diseñadas. Universo de estudio 894 pacientes y la muestra 43. Se estudiaron las variables edad, sexo, sus manifestaciones clínicas, exámenes complementarios y las causas que provocaron el delirium. A partir de una hoja de cálculo Excel 2007, se establece la frecuencia por sexos de las variables estudiadas. Resultados: existe un aumento del delirium asociado al factor edad, predominando el sexo femenino; los síntomas de mayor referencia estuvieron relacionados con la actividad motora, trastornos de la memoria, el lenguaje, alucinaciones y obnubilación. Conclusión: el diagnóstico de esta entidad es clínico y se corrobora por complementarios.

Introduction: the Acute confusion syndrome or Delirium is an organic cerebral syndrome with multi causal aetiology characterized fluctuating disorder of consciousness, attention, perception, thinking and memory, with increment or reduction of psychomotor activity and a cycle dream-wakefulness. Objective: to characterize the elder with delirium according to age, gender and clinical manifestation as well as identify the main original causes. Material and Methods: a descriptive trial including patient with 60 year old and elder attended to the Internal Medicine outpatient consult showing clinical manifestation of Delirium from January to December 2012. Information was obtained from the appointment list as well as the forms previously designed. The study´s Universe was 894 patients and the sample included 43 patients. Variables studied were: age, sex, clinical manifestation, lab test and causes that provoking Delirium. From the Excel 2007 calculation sheet were determined the frequency by sex of the studied variables. Results: there is an increasing number of Delirium associated to the age factor mainly represented by female, the main referred clinical symptom were related to the motor activity, memory disorder, language, hallucination and obnubilation. Conclusion: the diagnosis of this entity is clinical and it is prove by complementary test.

Comportamiento del Delirium en el anciano. Policlínico Pedro Fonseca, La Lisa, 2012 / Delirium behavior in the elder. Policlínico Pedro Fonseca, La Lisa, 2012

Introducción: el Síndrome Confusional Agudo o Delirium es un síndrome cerebral orgánico de etiología multifactorial, caracterizado por alteraciones fluctuantes de la conciencia, atención, percepción, pensamiento, memoria, con incremento o reducción de la actividad psicomotora y un desorden en el ciclo sueño-vigilia.Objetivo: caracterizar los ancianos con delirium, según grupo de edades, sexo y manifestaciones clínicas e identificar las principales causas que le dieron origen.Material y Método: se realizó un estudio descriptivo de los pacientes con 60 años o más, quienes asistieron a la consulta de Medicina Interna presentando manifestaciones clínicas de delirium, desde enero hasta diciembre de 2012. La información fue obtenida de las hojas de cargo, así como de entrevistas realizadas a pacientes o familiares, en planillas previamente diseñadas. Universo de estudio 894 pacientes y la muestra 43. Se estudiaron las variables edad, sexo, sus manifestaciones clínicas, exámenes complementarios y las causas que provocaron el delirium. A partir de una hoja de cálculo Excel 2007, se establece la frecuencia por sexos de las variables estudiadas. Resultados: existe un aumento del delirium asociado al factor edad, predominando el sexo femenino; los síntomas de mayor referencia estuvieron relacionados con la actividad motora, trastornos de la memoria, el lenguaje, alucinaciones y obnubilación. Conclusión: el diagnóstico de esta entidad es clínico y se corrobora por complementarios(AU)

Introduction: the Acute confusion syndrome or Delirium is an organic cerebral syndrome with multi causal aetiology characterized fluctuating disorder of consciousness, attention, perception, thinking and memory, with increment or reduction of psychomotor activity and a cycle dream-wakefulness. Objective: to characterize the elder with delirium according to age, gender and clinical manifestation as well as identify the main original causes. Material and Methods: a descriptive trial including patient with 60 year old and elder attended to the Internal Medicine outpatient consult showing clinical manifestation of Delirium from January to December 2012. Information was obtained from the appointment list as well as the forms previously designed. The study´s Universe was 894 patients and the sample included 43 patients. Variables studied were: age, sex, clinical manifestation, lab test and causes that provoking Delirium. From the Excel 2007 calculation sheet were determined the frequency by sex of the studied variables. Results: there is an increasing number of Delirium associated to the age factor mainly represented by female, the main referred clinical symptom were related to the motor activity, memory disorder, language, hallucination and obnubilation. Conclusion: the diagnosis of this entity is clinical and it is prove by complementary test(AU)

Prevalencia y factores de riesgo del síndrome confusional agudo en el adulto mayor en emergencias médicas / Risk Factors and Prevalence of the Acute Confusional Syndrome on Elders at Medical Emergencies

Introducción: el síndrome confusional agudo es un problema de salud que afecta al adulto mayor asociado a mayor mortalidad, estadía hospitalaria, y costo para el sistema de salud. Objetivo: determinar la prevalencia del síndrome confusional agudo y los factores predisponentes y precipitantes para su aparición en pacientes ancianos admitidos en el servicio de Medicina Interna. Métodos: se realizó un estudio descriptivo de todos los pacientes mayores de 60 años admitidos por el servicio de emergencia del Hospital Universitario Dr. Miguel Enríquez, durante el periodo: enero - diciembre del 2013 empleando el Confusion Assessment Method como instrumento para el diagnóstico del delirium, identificando los factores de riesgo y principales etiologías. Resultados: el delirium estuvo presente en un 22.5 por ciento de los pacientes principalmente entre los 75 - 89 años de edad, predominando entre los factores precipitantes la comorbilidad y la polimedicación y entre los factores desencadenantes las infecciones y los trastornos hidroelectrolíticos. Conclusiones: el síndrome confusional agudo constituyó un problema de salud en el paciente anciano admitido en emergencias(AU)

Introduction: the Acute Confusional Syndrome is a health problem that affects to elders and it is associated to a major mortality, hospital stay and cost to the Health System. Objective: to determine the prevalence of the acute Confusional syndrome and the rushing and tending factors for its appearance in elder patients admitted at Internal Medicine Service. Methods: a descriptive study was done to all the patients older than 60 years that were admitted at Emergencies from Dr. Miguel Enriquez University Hospital, during the period January December, 2013. It was used the Confusion Assessment Method as instrument for the diagnosis of delirium and the main etiologies and risk factors were identified. Results: Delirium was present in 22.5 percent of the patients mainly among the patients with 75 to 89 years old; prevailing the comorbidity and the polymedication and between the trigger factors the infections and hydroelectrolitic disorders. Conclusions: the Acute Confusional Syndrome was a health problem on the elder patient patients admitted at Emergencies(AU)

Factores asociados a síndrome confusional agudo en adultos mayores internados en emergencia de un hospital terciario / Acute confusional state-associated factors in older adults admitted to a tertiary hospital emergency unit

Introducción: El síndrome confusional agudo es un problema frecuente en el adulto mayor, incrementado por patologías agudas. Objetivos: Determinar la frecuencia del síndrome confusional agudo en adultos mayores no críticos hospitalizados en un servicio de emergencia e identificar factores asociados. Diseño: Estudio transversal. Lugar: Servicio de Emergencia del Hospital Nacional Edgardo Rebagliati Martins, Lima, Perú. Participantes: Pacientes de 60 años o más. Intervenciones: Siguiendo normas de buenas prácticas clínicas, se entrevistó entre mayo y agosto 2010 a paciente/cuidador de 172 pacientes de 60 años o más, hospitalizados en salas de emergencia; se revisó la historia clínica. Principales medidas de resultados: Detectar síndrome confusional agudo mediante el Confussion Assessment Method. Resultados: La frecuencia de síndrome confusional agudo fue 34,9%, según categoría de adulto mayor: enfermo 6%, frágil 28%, complejo 58% (p<0,001). Se encontró antecedente de demencia en 30% de pacientes con síndrome confusional, deterioro cognitivo previo en 45%, síndrome confusional previo en 40,2%, dependencia funcional parcial 46% y total 39%, deterioro cognitivo moderado 27% y severo 40%. El 41,7% de pacientes con síndrome confusional presentó deshidratación moderada-severa (p=0,001) y 20% sepsis, como diagnósticos de ingreso (p=0,003). Las patologías de ingreso más frecuentes fueron infecciosas, cardiovasculares y metabólicas. No se encontró diferencia significativa en sexo, grado de instrucción, estado civil, pluripatología, hospitalización previa, polifarmacia, estado nutricional, presencia de sonda urinaria o nasogástrica, destino al egreso de emergencia ni estancia hospitalaria. Conclusiones: Existe alta frecuencia de síndrome confusional agudo en adultos mayores hospitalizados en servicios de emergencia, siendo factores asociados la demencia, deterioro cognitivo previo, confusión previa, dependencia funcional, categoría geriátrico complejo, deshidratación moderada-severa y sepsis.

Introduction: Acute confusional state is a frequent problem in the elderly and is increased by acute pathologies. Objectives: To determine the frequency of acute confusional state in non-critical elderly emergency service inpatients and to identify associated factors. Design: Cross sectional study. Setting: Emergency Unit, Hospital Nacional Edgardo Rebagliati Martins, Lima, Peru. Participants: Sixty-year-old or older patients hospitalized in an emergency unit. Interventions: Between May and August 2010 and according to procedures of good clinical practices, 172 60-year-old or older patients hospitalized in an emergency unit or their caregivers were interviewed and clinical records were reviewed. Main outcome measures: Acute confusional state detection with the Confusion Assessment Method. Results: The frequency of acute confusional state according to category of elderly was 34.9%: ill 6%, fragile 28% and complex 58% (p <0,001). There was history of dementia in 30% of patients with acute confusional state, cognitive previous deterioration in 45%, previous acute confusional state in 40.2%, functional partial dependence in 46% and total dependence in 39%, cognitive moderate deterioration in 27% and severe in 40%; 41.7% of patients with acute confusional state presented moderate -severe dehydration (p=0.001) and 20% sepsis at admission (p=0.003). The most frequent pathologies at admission were infectious, cardiovascular and metabolic. There was no significant difference in sex, instruction degree, marital status, pluripathology, previous hospitalization, polymedication, nutritional condition, use of urinary or nasogastric tubes, destiny at discharge, or hospital stay. Conclusions: High frequency of acute confusional state existed in elderly patients, being associated factors dementia, previous cognitive deterioration, previous confusional state, functional dependence, complex geriatric category, moderate - severe dehydration and sepsis.

Incidence and predictive factors of delirium in hospitalised neurological patients.

INTRODUCTION: Delirium is a condition with a high prevalence in hospitalised patients (10%-30%), and it has important prognostic implications. There are few prospective studies of the incidence of delirium in Spain, and most of these were carried out in surgical wards or intensive care units. Our objective is to calculate the incidence of delirium in a neurological department and describe characteristics of affected patients. METHODS: Longitudinal descriptive study including all patients admitted to the neurology department in an 8-week period. The CAM score for diagnosing delirium was recorded on the first, second and fifth day of hospitalisation and we recorded demographic data, medical history, analytical data (including inflammatory markers), use of anticholinergic treatments, cognitive and functional state at admission, reason for admission, length of stay, and other events during hospitalisation. RESULTS: We studied 115 patients and found an incidence of delirium of 16.52%. There was a significant correlation between delirium and age, cognitive state at admission according to the Pfeiffer test, functional situation at admission according to the Canadian Neurological Scale, kidney failure, history of stroke, anticholinergic treatment, erythrocyte sedimentation rate, and C-reactive protein. These patients were also hospitalised for longer periods of time. CONCLUSIONS: These results confirm a high incidence of delirium in our geographical area. Although additional studies with larger samples are needed, we would like to emphasise the importance of several risk factors which may enable early detection of patients who are at risk for developing delirium during hospitalisation. This would permit preventive action and early treatment for these patients.

[Lung-brain interaction in the mechanically ventilated patient]. / Interacción pulmón-cerebro en el paciente ventilado mecánicamente.

Patients with acute lung injury or acute respiratory distress syndrome (ARDS) admitted to the ICU present neuropsychological alterations, which in most cases extend beyond the acute phase and have an important adverse effect upon quality of life. The aim of this review is to deepen in the analysis of the complex interaction between lung and brain in critically ill patients subjected to mechanical ventilation. This update first describes the neuropsychological alterations occurring both during the acute phase of ICU stay and at discharge, followed by an analysis of lung-brain interactions during mechanical ventilation, and finally explores the etiology and mechanisms leading to the neurological disorders observed in these patients. The management of critical patients requires an integral approach focused on minimizing the deleterious effects over the short, middle or long term.

Síndrome confusional agudo como forma de presentación de un absceso espinal / Acute confusional syndrome presenting as a spinal abscess

Fundamento: La alteración del nivel de conciencia puede ser producida por múltiples causas, es un síndrome que requiere de una actuación ordenada, rápida y eficaz; ya que se trata de una urgencia médica en la que el tiempo siempre va en contra del paciente. La aproximación al paciente geriátrico con alteración del nivel de conciencia debe ir encaminada al tratamiento de su causa y prevención de sus complicaciones. Objetivo. Presentar un caso poco frecuente con un absceso espinal que debutó con un síndrome confusional agudo. Caso Clínico: Paciente de 62 años de edad que inicia de forma aguda con cambio en su comportamiento, insomnio, abandono de hábitos cotidianos, se le olvida donde deja las cosas y está muy irritable. Al examen físico. Se encuentra: Trastornos en la perceptividad y esfera cognitiva, dolor a la percusión, movilización de las espinosas dorsales I Y II (DI-DII). Se practicó una Resonancia magnética nuclear (RMN) de región dorsal, la cual demostró la presencia de una lesión en el espacio epidural que se extendía desde el segundo al sexto segmento (DII a DVI) .Se llevó de forma urgente al salón de operaciones, se realizó abordaje posterior al raquis dorsal, a través del cual se evacuó un absceso epidural. En un período de 12 días las manifestaciones neuropsiquiatrías desaparecieron. Conclusiones. El síndrome confusional agudo es una patología que se puede ver entre el 10-15 por ciento de los pacientes con una enfermedad médico-quirúrgico, incidencia que se eleva hasta el 30 por ciento en los ancianos, y puede ser la forma de presentación poco frecuente de una infección intrarraquídea. El diagnóstico oportuno y tratamiento eficaz impidieron la progresión de las manifestaciones neurológicas y revirtieron la sintomatología.