Abstract
Delirium is the most common manifestation of brain dysfunction in critically ill patients. In the intensive care unit (ICU), duration of delirium is independently predictive of excess death, length of stay, cost of care, and acquired dementia. There are numerous neurotransmitter/functional and/or injury-causing hypotheses rather than a unifying mechanism for delirium. Without using a validated delirium instrument, delirium can be misdiagnosed (under, but also overdiagnosed and trivialized), supporting the recommendation to use a monitoring instrument routinely. The best-validated ICU bedside instruments are CAM-ICU and ICDSC, both of which also detect subsyndromal delirium. Both tools have some inherent limitations in the neurologically injured patients, yet still provide valuable information about delirium once the sequelae of the primary injury settle into a new post-injury baseline. Now it is known that antipsychotics and other psychoactive medications do not reliably improve brain function in critically ill delirious patients. ICU teams should systematically screen for predisposing and precipitating factors. These include exacerbations of cardiac/respiratory failure or sepsis, metabolic disturbances (hypoglycemia, dysnatremia, uremia and ammonemia) receipt of psychoactive medications, and sensory deprivation through prolonged immobilization, uncorrected vision and hearing deficits, poor sleep hygiene, and isolation from loved ones so common during COVID-19 pandemic. The ABCDEF (A2F) bundle is a means to facilitate implementation of the 2018 Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (PADIS) Guidelines. In over 25,000 patients across nearly 100 institutions, the A2F bundle has been shown in a dose-response fashion (i.e., greater bundle compliance) to yield improved survival, length of stay, coma and delirium duration, cost, and less ICU bounce-backs and discharge to nursing homes.
Keywords: Antipsychotics; Cognitive impairment; Critical care; Delirium; ICU Liberation.
【저자키워드】 Critical care, delirium, Cognitive impairment, Antipsychotics, ICU Liberation., 【초록키워드】 Critical care, intensive care, COVID-19 pandemic, intensive care unit, Sepsis, medications, discharge, Brain, ICU, Dementia, survival, Critically ill, delirium, Sleep, implementation, Patient, Isolation, Compliance, Factors, death, Cognitive impairment, nursing homes, medication, information, Care, patients, hypoglycemia, mechanism, critically ill patients, Injury, Deprivation, Disruption, hygiene, Predictive, dysfunction, Hearing, Sedation, Adult patients, limitation, Dysnatremia, Coma, hypotheses, Agitation, metabolic disturbances, Sleep Hygiene, uremia, Immobility, precipitating factors, IMPROVE, greater, shown, detect, include, facilitate, less, hypothese, inherent, baseline, metabolic disturbance, 【제목키워드】 clinical manifestations, outcomes, management, Critical,