Emergentní delirium (ED) je častá pooperační komplikace u dětí, která se projevuje dezorientací, poruchou percepce a psychomotorickým neklidem. Incidence emergentního deliria je uváděna 10–50 %. Ačkoliv je ED self-limiting stavem, může způsobit řadu pooperačních komplikací včetně sebepoškození, dehiscence operační rány, krvácení a dalších obtíží pro ošetřující personál. I přes rozsáhlý výzkum zůstává přesná patofyziologie vzniku ED neznámá. PAED skóre je jediným validovaným nástrojem pro diagnostiku ED. Tento přehledový článek shrnuje rizikové faktory vzniku ED a současné možnosti jeho farmakologické a nefarmakologické prevence a léčby. Korespondující autor: doc. MUDr. Jan Pavlíček, Ph.D., MHA Klinika dětského lékařství Fakultní nemocnice Ostrava Tř. 17. listopadu 1789 708 52 Ostrava-Poruba jan.pavlicek@fno.cz
Emergence delirium (ED) is a common postoperative complication in children, characterized by desorientation, perception and psychomotor disorder. The described incidence of emergence delirium varies between 10-50 %. Although ED is self-limiting, it can induce postoperative complications, including self-injury, dehiscence of surgical wound, bleeding and other difficulties for medical staff. Despite extensive research of ED, precise pathophysiology remains uknown. PAED score is only validated tool for ED diagnosis. This review summarizes the risk factors of ED development and provide current options of pharmacologic and non-pharmacologic prevention and treatment.
- MeSH
- anestetika intravenózní aplikace a dávkování MeSH
- celková anestezie * škodlivé účinky MeSH
- dítě MeSH
- hypnotika a sedativa aplikace a dávkování MeSH
- lidé MeSH
- pooperační delirium * diagnóza farmakoterapie patofyziologie prevence a kontrola MeSH
- rizikové faktory MeSH
- Check Tag
- dítě MeSH
- lidé MeSH
- Publikační typ
- přehledy MeSH
OBJECTIVE: Emergence delirium (ED) is a postoperative complication in pediatric anesthesia characterized by a perception and psychomotor disorder, with a negative impact on postoperative recovery. As the use of inhalation anesthesia is associated with a higher incidence of ED, we investigated whether titrating the depth of general anesthesia with BIS monitor can reduce the incidence of ED. DESIGN: Randomized, prospective, and double-blind. SETTING: Patients undergoing endoscopic adenoidectomy under general anesthesia according to a uniform protocol. PATIENTS: A total of 163 patients of both sexes aged 3-8 years were enrolled over 18 months. INTERVENTIONS: Immediately after the induction of general anesthesia, a bispectral index (BIS) electrode was placed on the patient's forehead. In the study group, the depth of general anesthesia was monitored with the aim of achieving BIS values of 40-60. In the control group, the dose of sevoflurane was determined by the anaesthesiologist based on MAC (minimum alveolar concentration) and the end-tidal concentration. MEASUREMENTS: The primary objective was to compare the occurrence of ED during the PACU (post-anesthesia care unit) stay in both arms of the study. The secondary objective was to determine the PAED score at 10 and 30 min in the PACU and the need for rescue treatment of ED. MAIN RESULTS: 86 children were randomized in the intervention group and 77 children in the control group. During the entire PACU stay, 23.3% (38/163) of patients developed ED with PAED score >10: 35.1% (27/77) in the control group and 12.8% (11/86) in the intervention group (p = 0.001). Lower PAED scores were also found in the intervention group at 10 (p < 0.001) and 30 (p < 0.001) minutes compared to the control group. The need for rescue treatment did not differ between groups (p = 0.067). CONCLUSION: Individualization of the depth of general anesthesia with BIS monitoring is an effective method of preventing ED in children. CLINICAL TRIAL REGISTRATION: NCT04466579.
- MeSH
- celková anestezie * škodlivé účinky MeSH
- dítě MeSH
- inhalační anestezie * škodlivé účinky MeSH
- lidé MeSH
- pooperační delirium * epidemiologie prevence a kontrola etiologie MeSH
- předškolní dítě MeSH
- probouzení z anestezie MeSH
- prospektivní studie MeSH
- sevofluran MeSH
- Check Tag
- dítě MeSH
- lidé MeSH
- mužské pohlaví MeSH
- předškolní dítě MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- randomizované kontrolované studie MeSH
PURPOSE: Incident delirium is a frequent complication among hospitalized older people with COVID-19, associated with increased length of hospital stay, higher morbidity and mortality rates. Although delirium is preventable with early detection, systematic assessment methods and predictive models are not universally defined, thus delirium is often underrated. In this study, we tested the role of the Multidimensional Prognostic Index (MPI), a prognostic tool based on Comprehensive Geriatric Assessment, to predict the risk of incident delirium. METHODS: Hospitalized older patients (≥ 65 years) with COVID-19 infection were enrolled (n = 502) from ten centers across Europe. At hospital admission, the MPI was administered to all the patients and two already validated delirium prediction models were computed (AWOL delirium risk-stratification score and Martinez model). Delirium occurrence during hospitalization was ascertained using the 4A's Test (4AT). Accuracy of the MPI and the other delirium predictive models was assessed through logistic regression models and the area under the curve (AUC). RESULTS: We analyzed 293 patients without delirium at hospital admission. Of them 33 (11.3%) developed delirium during hospitalization. Higher MPI score at admission (higher multidimensional frailty) was associated with higher risk of incident delirium also adjusting for the other delirium predictive models and COVID-19 severity (OR = 12.72, 95% CI = 2.11-76.86 for MPI-2 vs MPI-1, and OR = 33.44, 95% CI = 4.55-146.61 for MPI-3 vs MPI-1). The MPI showed good accuracy in predicting incident delirium (AUC = 0.71) also superior to AWOL tool, (AUC = 0.63) and Martinez model (AUC = 0.61) (p < 0.0001 for both comparisons). CONCLUSIONS: The MPI is a sensitive tool for early identification of older patients with incident delirium.
- MeSH
- COVID-19 * komplikace epidemiologie diagnóza MeSH
- delirium * diagnóza epidemiologie MeSH
- geriatrické hodnocení * metody MeSH
- hodnocení rizik MeSH
- hospitalizace * statistika a číselné údaje MeSH
- incidence MeSH
- lidé MeSH
- prognóza MeSH
- prospektivní studie MeSH
- rizikové faktory MeSH
- SARS-CoV-2 MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- Check Tag
- lidé MeSH
- mužské pohlaví MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- multicentrická studie MeSH
- Geografické názvy
- Evropa MeSH
Delírium je univerzálna patologická reakcia mozgu na rôzne nepriaznivé činitele, pričom u kriticky chorých pacientov existuje vysoké riziko vzniku delíria. Nemusí to byť iba prechodný a očakávaný stav s minimálnymi následkami, ale môže viesť k predĺženiu pobytu v nemocnici a kognitívnemu deficitu po prepustení z pracoviska intenzívnej starostlivosti. Vyžaduje multimodálnu stratégiu, komplexný ošetrovateľský, lekársky prístup. Dôležitá je diagnostika delíria, nefarmakologické opatrenia, farmakologická prevencia a v prípade ich zlyhania farmakologická liečba. Správnymi liečebno – preventívnymi opatreniami môžeme znížiť výskyt delíria o jednu tretinu.
Delirium is a universal pathological response of the brain to various adverse factors. The risk of developing delirium is high in critically ill patients. It may not only be a transient and predicted condition with minimal consequences, but may lead to prolonged hospital stay and to cognitive deficit after discharge from intensive care unit. The condition requires multimodal strategy, complex nursing and medical approach. Imperative interventions involve the diagnosis of delirium, non-pharmacological measures, pharmacological prevention and, them failing, pharmacological treatment. Correct treatment and preventive measures can help reduce the incidence of delirium by one third.
OBJECTIVES: Delirium is common during acute infection in older patients and is associated with functional decline. Geriatric rehabilitation (GR) can help older patients to return to their premorbid functional level. It is unknown whether delirium affects GR outcomes in patients with acute infection. We evaluated whether delirium affects trajectories of activities of daily living (ADL) and quality of life (QoL) recovery in GR after COVID-19 infection. DESIGN: This study was part of the EU-COGER study, a multicenter cohort study conducted between October 2020 and October 2021. SETTING AND PARTICIPANTS: Participants were recruited after COVID-19 infection from 59 GR centers in 10 European countries. METHODS: Data were collected at GR admission, discharge, and at the 6-week and 6-month follow-ups. Trajectories of ADL [using the Barthel index (BI)] and QoL [using the EuroQol-5 Dimensions-5 Level (EQ-5D-5L)] recovery were examined using linear mixed models. RESULTS: Of the 723 patients included (mean age 75.5 ± 9.9 years; 52.4% male), 28.9% had delirium before or during GR admission. Participants with delirium recovered in ADL at approximately the same rate as those without (linear slope effect = -0.13, SE 0.16, P = .427) up to an estimated BI score of 16.1 at 6 months. Similarly, participants with delirium recovered in QoL at approximately the same rate as those without (linear slope effect = -0.017, SE 0.015, P = .248), up to an estimated EQ-5D-5L score of 0.8 at 6 months. CONCLUSIONS AND IMPLICATIONS: Presence of delirium during the acute phase of infection or subsequent GR did not influence the recovery trajectory of ADL functioning and QoL.
- MeSH
- činnosti denního života * MeSH
- COVID-19 * MeSH
- delirium * MeSH
- geriatrické hodnocení MeSH
- kohortové studie MeSH
- kvalita života * MeSH
- lidé MeSH
- obnova funkce * MeSH
- SARS-CoV-2 MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- Check Tag
- lidé MeSH
- mužské pohlaví MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- multicentrická studie MeSH
- Geografické názvy
- Evropa MeSH
- MeSH
- antikoagulancia terapeutické užití MeSH
- dehydratace ošetřování terapie MeSH
- delirium ošetřování terapie MeSH
- geriatrické ošetřovatelství MeSH
- imobilizace MeSH
- nádorová bolest ošetřování terapie MeSH
- nádory MeSH
- ošetřovatelská péče o pacienty v kritickém stavu MeSH
- oxygenoterapie MeSH
- podvýživa ošetřování terapie MeSH
- polohování pacienta MeSH
- poruchy močení MeSH
- rehabilitace MeSH
- senioři MeSH
- Check Tag
- senioři MeSH
OBJECTIVES: The aim of this project was to improve compliance with evidence-based criteria regarding risk of delirium and the assessment of delirium among older patients in the general hospitalization wards and the emergency department. INTRODUCTION: More than 50% of older hospitalized patients experience delirium. Some studies have highlighted the need to implement an orientation protocol in the emergency department and to continue this in the general wards, with the aim of decreasing the delirium rate among older patients admitted to hospital. METHODS: The project followed the JBI evidence implementation framework. We conducted a baseline audit, a half-way audit, and final audit of 50 patients at risk of delirium admitted to the emergency department and the general wards, respectively. The audits measured compliance with eight criteria informed by the available evidence. RESULTS: In the final audit, three of the eight criteria achieved more than 50% compliance in the general wards: pressure injury screening (96%); monitoring changes (74%); and performing interventions (76%). In the emergency department, worse results were reported because of the service conditions. The exception was the criterion on the training of nurses on the topic, with 98%. The integration of a tool to screen for delirium in older patients in the hospital's electronic clinical history records increased the percentage of compliance with audit criteria regarding the use of the scale and delirium detection (rising from 0% to 32% in the final audit in the general wards). CONCLUSION: Through the implementation of this project, validated and evidence-based evaluation will ensure that nurses are supported through appropriate measures to reduce patient confusion and aggression resulting from delirium.
- MeSH
- delirium * diagnóza prevence a kontrola MeSH
- hospitalizace MeSH
- lidé MeSH
- nemocnice MeSH
- pokoje pro pacienty * MeSH
- senioři MeSH
- urgentní služby nemocnice MeSH
- Check Tag
- lidé MeSH
- senioři MeSH
- Publikační typ
- časopisecké články MeSH
Monitorace kvality spánku a deliria jsou naprosto zásadní pro poskytování moderní intenzivní péče. Představují však přístrojovou a personální výzvu. Nejen proto, že určité metody monitorace, např. polysomnografie, monitorovaný spánek samy ovlivňují. Ačkoliv existují nové alternativy, polysomnografie zůstává zlatým standardem v diagnostice a výzkumu poruch spánku pro nejlepší validitu získaných dat. Bez monitorace a screeningových metod nelze spolehlivě diagnostikovat delirium a poruchy spánku v intenzivní péči a bez jasně stanovené diagnózy nelze zkoumat dopady deliria a snížené kvality spánku. Tento článek shrnuje jednotlivé možnosti monitorace spánku i deliria, jejich výhody a limitace v prostředí intenzivní péče.
Monitoring sleep quality and delirium are essential in providing modern intensive care. They present both equipment and personnel challenges. Not only because certain monitoring methods, such as polysomnography, affect monitored sleep themselves. Although new alternatives exist, polysomnography remains the gold standard in diagnosing and researching sleep disorders for the validity of the data obtained. Without monitoring and screening methods, delirium and sleep disorders cannot be reliably diagnosed in intensive care. Without a clearly established diagnosis, the outcomes of delirium and reduced sleep quality cannot be investigated. This article summarizes various options for monitoring both sleep and delirium, their advantages and limitations in the critical care setting.
- MeSH
- delirium * diagnóza prevence a kontrola MeSH
- kvalita spánku MeSH
- lidé MeSH
- monitorování fyziologických funkcí klasifikace metody MeSH
- monitory vědomí MeSH
- péče o pacienty v kritickém stavu MeSH
- polysomnografie metody MeSH
- sběr dat metody MeSH
- spánek * MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- práce podpořená grantem MeSH
- přehledy MeSH
Špatná kvalita spánku a rozvoj deliria jsou časté komplikace v intenzivní péči. Incidence obou komplikací je vysoká a pohledem medicíny založené na důkazech jsou v obou případech signifikantně prokázané závažné konsekvence. Stran deliria je k dispozici více dat, zatímco u zhoršené kvality spánku je i vzhledem k technickým limitacím monitorace a diagnostiky významný prostor k dalšímu výzkumu. Tento článek shrnuje data, která jsou k dispozici stran epidemiologie a rizikových faktorů snížené kvality spánku i deliria v prostředí intenzivní péče.
Poor quality of sleep and delirium are frequent complications of intensive care. The incidence of both complications is high, and evidence-based medicine has significantly demonstrated serious consequences in both cases. More data are available on delirium. While there is significant room for further research on sleep quality impairment, there are also technical limitations of monitoring and diagnosis. This article summarises known data on the epidemiology and risk factors of decreased quality of sleep and delirium in the intensive care setting.
Pooperační delirium je jednou z nejčastějších pooperačních komplikací u pacientů nad 65 let. Prevence vzniku deliria by měla začít už v anesteziologické ambulanci, identifikací rizikových pacientů a snahou optimalizovat stav před výkonem. Během operačního zákroku by měla být monitorována hloubka anestezie, minimalizovány dávky opioidů a využívány kombinované metody anestezie. Po výkonu je stěžejní automatická implementace nefarmakologických preventivních a léčebných postupů. Farmakologické postupy se používají jako metoda poslední volby u agitovaných a agresivních pacientů s hyperaktivní formou deliria. V současné době nejsou doporučené postupy v diagnostice, prevenci a léčbě deliria v klinické praxi rutinně využívány. Cílem článku je popsat aktuální možnosti prevence a léčby pooperačního deliria.
Postoperative delirium is one of the most common postoperative complications in patients over 65 years of age. The prevention of delirium should start already in the anesthesiology clinic, with the identification of patients at risk and efforts to optimize the condition before the procedure. During surgery, the depth of anesthesia should be monitored, opioid doses should be minimized, and combined methods of anesthesia should be used. After the surgery the automatic implementation of non-pharmacological preventive and treatment measures is crucial. Pharmacological approaches are used as a last option method in agitated and aggressive patients with hyperactive delirium. Currently, the recommended procedures in the diagnosis, prevention and treatment of delirium are not routinely used in clinical practice. The aim of the article is to describe the current possibilities of prevention and treatment of postoperative delirium.
