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Delirium Monitoring in Neurocritically Ill Patients

A Systematic Review*

Patel, Mayur B., MD, MPH, FACS1,2,3,4; Bednarik, Josef, MD, PhD5,6; Lee, Patricia, MLS7; Shehabi, Yahya, PhD, FCICM, EMBA8; Salluh, Jorge I., MD, PhD9; Slooter, Arjen J., MD, PhD10; Klein, Kate E., MS, ACNP-BC, RN, CCRN11; Skrobik, Yoanna, MD, FRCP(c), MSc, FCCM12; Morandi, Alessandro, MD, MPH13,14; Spronk, Peter E., MD, PhD15; Naidech, Andrew M., MD, MSPH16; Pun, Brenda T., RN, DNP1,17; Bozza, Fernando A., MD, PhD18; Marra, Annachiara, MD1,17,19; John, Sayona, MD20; Pandharipande, Pratik P., MD, MSCI, FCCM1,2,21,22; Ely, E. Wesley, MD, MPH, FCCM1,2,17

doi: 10.1097/CCM.0000000000003349
Review Article
Editor's Choice

Objectives: The Society of Critical Care Medicine recommends routine delirium monitoring, based on data in critically ill patients without primary neurologic injury. We sought to answer whether there are valid and reliable tools to monitor delirium in neurocritically ill patients and whether delirium is associated with relevant clinical outcomes (e.g., survival, length of stay, functional independence, cognition) in this population.

Data Sources: We systematically reviewed Cumulative Index to Nursing and Allied Health Literature, Web of Science, and PubMed.

Study Selection and Data Extraction: Inclusion criteria allowed any study design investigating delirium monitoring in neurocritically ill patients (e.g., neurotrauma, ischemic, and/or hemorrhagic stroke) of any age. We extracted data relevant to delirium tool sensitivity, specificity, negative predictive value, positive predictive value, interrater reliability, and associated clinical outcomes.

Data Synthesis: Among seven prospective cohort studies and a total of 1,173 patients, delirium was assessed in neurocritically patients using validated delirium tools after considering primary neurologic diagnoses and associated complications, finding a pooled prevalence rate of 12–43%. When able to compare against a common reference standard, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, the test characteristics showed a sensitivity of 62–76%, specificity of 74–98%, positive predictive value of 63–91%, negative predictive value of 70–94%, and reliability kappa of 0.64–0.94. Among four studies reporting multivariable analyses, delirium in neurocritically patients was associated with increased hospital length of stay (n = 3) and ICU length of stay (n = 1), as well as worse functional independence (n = 1) and cognition (n = 2), but not survival.

Conclusions: These data from studies of neurocritically ill patients demonstrate that patients with primary neurologic diagnoses can meet diagnostic criteria for delirium and that delirious features may predict relevant untoward clinical outcomes. There is a need for ongoing investigations regarding delirium in these complicated neurocritically ill patients.

1Critical Illness, Brain dysfunction, and ICU Survivorship (CIBS) Center, Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN.

2Geriatric Research Education and Clinical Center (GRECC), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN.

3Section of Surgical Sciences, Departments of Surgery, Neurosurgery, Hearing & Speech Sciences, Division of Trauma, Surgical Critical Care, and Emergency General Surgery, Vanderbilt Brain Institute, Vanderbilt University Medical Center, Nashville, TN.

4Surgical Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN.

5Department of Neurology, University Hospital Brno, Brno, Czech Republic.

6Applied Neuroscience Research Group, Central European Institute of Technology, Masaryk University, Brno, Czech Republic.

7Center for Knowledge Management, Vanderbilt University Medical Center, Nashville, TN.

8University New South Wales, Clinical School of Medicine, Prince of Wales Hospital, Randwick, NSW, Australia.

9D’Or Institute for Research and Education, Rio De Janeiro, Brazil.

10Department of Intensive Care Medicine, Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands.

11Novant Health Presbyterian Medical Center, Charlotte, NC.

12Department of Medicine, McGill University, Montreal, QC, Canada.

13Department of Rehabilitation and Aged Care of the Fondazione Camplani, Ancelle Hospital, Cremona, Italy.

14Geriatric Research Group, Brescia, Italy.

15Department of Intensive Care, Gelre Ziekenhuizen (Lukas), the Netherlands.

16Departments of Neurology (Stroke and Neurocritical Care), Neurological Surgery, Anesthesiology, Medical Social Sciences, and Preventive Medicine (Health and Biomedical Informatics), Northwestern University, Feinberg School of Medicine, Chicago, IL.

17Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN.

18Intensive Care Lab, Instituto Nacioinal de Infectologia Evandro, Chagas (INI), Fundacao Oswaldo Cruz, (FIOCRUZ), Rio De Janeiro, Brazil.

19Department of Neurosciences and Department of Public Health, University of Naples, Naples, Italy.

20Section of Neurocritical Care, Department of Neurological Sciences, Rush University Medical Center, Chicago, IL.

21Department of Anesthesiology, Division of Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN

22Anesthesiology Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN.

*See also p. 1881.

Drs. Patel, Lee, Marra, Pandharipande, and Ely contributed to review structure; Drs. Patel and Lee contributed to literature search; Drs. Patel, Lee, Pandharipande, and Ely contributed data sheets; Drs. Patel, Pandharipande, and Ely contributed to title and abstract screening; Drs. Patel, Pandharipande, and Ely contributed to full text screening; Drs. Patel, Pandharipande, and Ely contributed to data extraction; Drs. Patel, Pandharipande, and Ely contributed to bias assessments; Drs. Patel, Lee, and Ely contributed to systematic review coordination; and all contributed to critical revisions to article.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).

Supported, in part, by Veterans Affairs Tennessee Valley Geriatric Research, Education and Clinical Center (Nashville, TN) and the National Institutes of Health AG027472, AG035117, HL111111, GM120484 (Bethesda, MD).

Dr. Patel’s institution received funding from National Institutes of Health (NIH) HL111111 and NIH GM120484; he received funding from Pfizer/Hospira (education presentation); and he disclosed that funding was provided by federal sources including the Veterans Affairs (VA) Tennessee Valley Geriatric Research, Education and Clinical Center (Nashville, TN) and the NIH AG027472, AG035117, HL111111, GM120484 (Bethesda, MD). Drs. Patel and Ely received support for article research from the NIH. Ms. Klein’s institution received funding from Hill Rom Co. Dr. Naidech received support for article research from the Agency for Healthcare Research and Quality (K18 HS023437). Dr. Pun received funding from the Society of Critical Care Medicine, the American Association of Critical Care Medicine, and the France Foundation to provide continuing education. Dr. John disclosed other support from CSL Behring (speaker). Dr. Pandharipande’s institution received funding from Hospira. Dr. Ely’s institution received funding from NIH and VA funding, and he received funding from Orion Laboratories, Abbott Laboratories, and Pfizer. Dr. Pandharipande has received a research grant from Hospira Inc, in collaboration with the NIH. Dr. Ely has conducted Continuing Medical Education activities sponsored by Abbott, Hospira, and Orion. The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: wes.ely@vanderbilt.edu

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