Challenges of Delirium Management in Patients with Traumatic Brain Injury: From Pathophysiology to Clinical Practice.
Challenges of Delirium Management in Patients with Traumatic Brain Injury: From Pathophysiology to Clinical Practice.
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DOI：
10.2174/1570159x19666210119153839
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发表时间：
2021
影响因子：
5.3
通讯作者：
Kotfis K
中科院分区：
文献类型：
--
作者：
Roberson SW;Patel MB;Dabrowski W;Ely EW;Pakulski C;Kotfis K
创伤性脑损伤（TBI）可引发非常复杂的中枢神经系统（CNS）疾病，其起始于引发创伤的原发病理学以及随后的炎症和CNS组织反应。谵妄长期以来被认为是中度至重度TBI的几乎不可避免的后果，但最近被认为是一种器官功能障碍综合征，具有潜在的缓解干预措施。谵妄的诊断与危重患者住院时间延长、死亡率增加和认知结果恶化独立相关。需要调查TBI患者的独特问题和管理挑战，以减少这一人群的谵妄负担。在这篇叙述性综述中，讨论了创伤后谵妄背后可能的病因机制，包括对介导唤醒和注意力的结构的原发性损伤以及由于脑实质进行性炎症破坏而引起的继发性损伤。其他潜在的病因学因素包括静脉镇静剂引起的神经传递失调、癫痫发作、器官衰竭、睡眠周期中断或其他谵妄风险因素。谵妄筛查可以在TBI患者中完成，谵妄的存在预示着更糟糕的结果。有证据表明，多组分护理包，包括昏迷优先镇静算法，定期自发觉醒和呼吸试验，协议谵妄评估，早期活动和家庭参与可以减少ICU谵妄的负担。本文旨在总结创伤性脑损伤患者谵妄的发病机制和治疗方法。强调了在临床前研究中显示出希望的新兴CNS活性药物疗法。
Traumatic brain injury (TBI) can initiate a very complex disease of the central nervous system (CNS), starting with the primary pathology of the inciting trauma and subsequent inflammatory and CNS tissue response. Delirium has long been regarded as an almost inevitable consequence of moderate to severe TBI, but more recently has been recognized as an organ dysfunction syndrome with potentially mitigating interventions. The diagnosis of delirium is independently associated with prolonged hospitalization, increased mortality and worse cognitive outcome across critically ill populations. Investigation of the unique problems and management challenges of TBI patients is needed to reduce the burden of delirium in this population. In this narrative review, possible etiologic mechanisms behind post-traumatic delirium are discussed, including primary injury to structures mediating arousal and attention and secondary injury due to progressive inflammatory destruction of the brain parenchyma. Other potential etiologic contributors include dysregulation of neurotransmission due to intravenous sedatives, seizures, organ failure, sleep cycle disruption or other delirium risk factors. Delirium screening can be accomplished in TBI patients and the presence of delirium portends worse outcomes. There is evidence that multi-component care bundles including an analgesia-prioritized sedation algorithm, regular spontaneous awakening and breathing trials, protocolized delirium assessment, early mobility and family engagement can reduce the burden of ICU delirium. The aim of this review is to summarize the approach to delirium in TBI patients with an emphasis on pathogenesis and management. Emerging CNS-active drug therapies that show promise in preclinical studies are highlighted.