Delirium in critical illness: clinical manifestations, outcomes, and management.
Delirium in critical illness: clinical manifestations, outcomes, and management.
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DOI：
10.1007/s00134-021-06503-1
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发表时间：
2021-10
影响因子：
38.9
通讯作者：
Ely EW
中科院分区：
文献类型：
--
作者：
Stollings JL;Kotfis K;Chanques G;Pun BT;Pandharipande PP;Ely EW
谵妄是危重患者脑功能障碍最常见的表现。在重症监护病房（ICU），谵妄持续时间是过度死亡、住院时间、护理费用和获得性痴呆的独立预测因素。有许多神经递质/功能和/或损伤引起的假设，而不是一个统一的机制谵妄。如果不使用经过验证的谵妄仪器，谵妄可能会被误诊（诊断不足，但也可能过度诊断和轻视），这支持了常规使用监测仪器的建议。最有效的ICU床边仪器是CAM-ICU和ICDSC，这两种仪器也能检测亚综合征谵妄。这两种工具在神经损伤患者中有一些固有的局限性，但一旦原发性损伤的后遗症进入新的损伤后基线，仍然提供有关谵妄的有价值的信息。现在人们知道，抗精神病药物和其他精神活性药物不能可靠地改善危重谵妄患者的脑功能。ICU团队应系统地筛查易感和促发因素。这些包括心脏/呼吸衰竭或败血症恶化、代谢紊乱（低血糖、血钠异常、尿毒症和氨血症）、接受精神活性药物、通过长时间固定导致的感觉剥夺、未矫正的视力和听力缺陷、睡眠卫生不良以及与亲人隔离，在COVID-19大流行期间非常常见。ABCDEF（A2 F）包是促进实施2018年ICU（PADIS）成人患者疼痛、躁动/镇静、谵妄、不动和睡眠中断指南的一种手段。在近100家机构的25，000多名患者中，A2 F束已显示出剂量反应方式（即，更大的束顺应性），以提高生存率、住院时间、昏迷和谵妄持续时间、成本，并减少ICU反弹和出院到疗养院。
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.
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通讯作者：
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DOI：
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