Mayur B Patel1,2,3,4, Josef Bednarik5,6, Patricia Lee7, Yahya Shehabi8, Jorge I Salluh9, Arjen J Slooter10, Kate E Klein11, Yoanna Skrobik12, Alessandro Morandi13,14, Peter E Spronk15, Andrew M Naidech16, Brenda T Pun1,17, Fernando A Bozza18, Annachiara Marra1,17,19, Sayona John20, Pratik P Pandharipande1,2,21,22, E Wesley Ely1,2,17. 1. Critical Illness, Brain dysfunction, and ICU Survivorship (CIBS) Center, Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN. 2. Geriatric Research Education and Clinical Center (GRECC), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN. 3. Section 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. 4. Surgical Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN. 5. Department of Neurology, University Hospital Brno, Brno, Czech Republic. 6. Applied Neuroscience Research Group, Central European Institute of Technology, Masaryk University, Brno, Czech Republic. 7. Center for Knowledge Management, Vanderbilt University Medical Center, Nashville, TN. 8. University New South Wales, Clinical School of Medicine, Prince of Wales Hospital, Randwick, NSW, Australia. 9. D'Or Institute for Research and Education, Rio De Janeiro, Brazil. 10. Department of Intensive Care Medicine, Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands. 11. Novant Health Presbyterian Medical Center, Charlotte, NC. 12. Department of Medicine, McGill University, Montreal, QC, Canada. 13. Department of Rehabilitation and Aged Care of the Fondazione Camplani, Ancelle Hospital, Cremona, Italy. 14. Geriatric Research Group, Brescia, Italy. 15. Department of Intensive Care, Gelre Ziekenhuizen (Lukas), the Netherlands. 16. Departments 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. 17. Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN. 18. Intensive Care Lab, Instituto Nacioinal de Infectologia Evandro, Chagas (INI), Fundacao Oswaldo Cruz, (FIOCRUZ), Rio De Janeiro, Brazil. 19. Department of Neurosciences and Department of Public Health, University of Naples, Naples, Italy. 20. Section of Neurocritical Care, Department of Neurological Sciences, Rush University Medical Center, Chicago, IL. 21. Department of Anesthesiology, Division of Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN. 22. Anesthesiology Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN.
Abstract
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.
OBJECTIVES: The Society of Critical Care Medicine recommends routine delirium monitoring, based on data in critically illpatients without primary neurologic injury. We sought to answer whether there are valid and reliable tools to monitor delirium in neurocritically illpatients 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 illpatients (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 neurocriticallypatients 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 illpatients 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 illpatients.
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