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Purpose The AID-ICU trial was a randomised, blinded, placebo-controlled trial investigating effects of haloperidol versus placebo in acutely admitted, adult patients admitted in intensive care unit (ICU) with delirium. This pre-planned Bayesian analysis facilitates probabilistic interpretation of the AID-ICU trial results. Methods We used adjusted Bayesian linear and logistic regression models with weakly informative priors to analyse all primary and secondary outcomes reported up to day 90, and with sensitivity analyses using other priors. The probabilities for any benefit/harm, clinically important benefit/harm, and no clinically important differences with haloperidol treatment according to pre-defined thresholds are presented for all outcomes. Results The mean difference for days alive and out of hospital to day 90 (primary outcome) was 2.9 days (95% credible interval (CrI) - 1.1 to 6.9) with probabilities of 92% for any benefit and 82% for clinically important benefit. The risk difference for mortality was - 6.8 percentage points (95% CrI - 12.8 to - 0.8) with probabilities of 99% for any benefit and 94% for clinically important benefit. The adjusted risk difference for serious adverse reactions was 0.3 percentage points (95% CrI - 1.3 to 1.9) with 98% probability of no clinically important difference. Results were consistent across sensitivity analyses using different priors, with more than 83% probability of benefit and less than 17% probability of harm with haloperidol treatment. Conclusions We found high probabilities of benefits and low probabilities of harm with haloperidol treatment compared with placebo in acutely admitted, adult ICU patients with delirium for the primary and most secondary outcomes., Author(s): Nina C. Andersen-Ranberg [sup.1] [sup.2], Lone Musaeus Poulsen [sup.1] [sup.2], Anders Perner [sup.2] [sup.3], Johanna Hästbacka [sup.4], Matthew Morgan [sup.5], Giuseppe Citerio [sup.6] [sup.7], Marie Oxenbøll Collet [sup.2] [sup.3], [...]

Purpose Haloperidol and clonidine are commonly used to treat agitation in delirious intensive care unit (ICU) patients, but it is unclear whether these agents may shorten the duration of delirium. The objective of this study was to determine whether haloperidol, clonidine, or their combined administration to delirious ICU patients results in delirium resolution. Methods This was a cohort study on a mixed ICU, excluding patients with a primary neurological disorder. The main outcome was the probability of delirium resolution, using propensity score matching and Markov multinomial logistic regression models for daily transitions. Secondary outcomes were delirium duration, number of delirium days, ventilation days, length of stay in the ICU and hospital, and ICU mortality. Results A total of 3614 patients were included (1165 delirious [32%]; 2449 non-delirious [68%]). Delirium occurred on 4708 (18.9%) of 24,906 days. The probability of delirium resolution was lower in delirious patients who received haloperidol (OR 0.47, 95% CI 0.39-0.57), clonidine (OR 0.78, 95% CI 0.63-0.97), or both (OR 0.45, 95% CI 0.36-0.56) compared to untreated delirious patients. Delirious patients who received haloperidol, clonidine, or both had generally longer delirium duration, more delirium and ventilation days, and spent more time in the ICU and in hospital than untreated delirious patients. These agents had no effect on ICU mortality. Conclusion Haloperidol and clonidine use in delirious ICU patients may be associated with reduced probability of delirium resolution. This finding, however, merits further investigation given inherent limitations of this observational analysis., Author(s): Lisa Smit [sup.1], Sandra M. A. Dijkstra-Kersten [sup.2], Irene J. Zaal [sup.2], Mathieu van der Jagt [sup.1], Arjen J. C. Slooter [sup.2] Author Affiliations: (1) grid.5645.2, 000000040459992X, Department of [...]

Over the past 2 decades in psychiatry, interest in ketamine has grown based Upon the potential therapeutic benefit of subanesthetic doses to rapidly Improve symptoms of otherwise treatment-resistant depression. During [...]

Author(s): Jorge I. F. Salluh [sup.1] [sup.2], Nicola Latronico [sup.3] [sup.4] Author Affiliations: (1) grid.472984.4, D'Or Institute for Research and Education, , Rua Diniz Cordeiro, 30, Botafogo, 22281-100, Rio de [...]

Delirium, a prevalent organ dysfunction in critically ill patients, is independently associated with increased morbidity. This last decade has witnessed an exponential growth in delirium research in hospitalized patients, including those critically ill, and this research has highlighted that delirium needs to be better understood mechanistically to help foster research that will ultimately lead to its prevention and treatment. In this invited, evidence-based paper, a multinational and interprofessional group of clinicians and researchers from within the fields of critical care medicine, psychiatry, pediatrics, anesthesiology, geriatrics, surgery, neurology, nursing, pharmacy, and the neurosciences sought to address five questions: (1) What is the current standard of care in managing ICU delirium? (2) What have been the major recent advances in delirium research and care? (3) What are the common delirium beliefs that have been challenged by recent trials? (4) What are the remaining areas of uncertainty in delirium research? (5) What are some of the top study areas/trials to be done in the next 10 years? Herein, we briefly review the epidemiology of delirium, the current best practices for management of critically ill patients at risk for delirium or experiencing delirium, identify recent advances in our understanding of delirium as well as gaps in knowledge, and discuss research opportunities and barriers to implementation, with the goal of promoting an integrated research agenda., Author(s): Pratik P. Pandharipande [sup.1], E. Wesley Ely [sup.2], Rakesh C. Arora [sup.3], Michele C. Balas [sup.4], Malaz A. Boustani [sup.5], Gabriel Heras La Calle [sup.6], Colm Cunningham [sup.7], John [...]

Background. Patients with delirium, compared with those without, are at increased risk for loss of function, longer hospital stays, and increased mortality. We studied the effect that an Acute Care of the Elderly Unit, which includes a delirium room, has on patients with delirium. Methods. Retrospective observational study. Charts of 148 patients ([greater than or equal to] 65 years) admitted to an Acute Care of the Elderly Unit with a delirium room during a 4-month period were reviewed. Delirium on admission (prevalence) was based on physician-performed Confusion Assessment Method; delirium during hospital stay (incidence) was based on nurse- performed Confusion Assessment Method. Patients with delirium were compared with those without delirium regarding change in function between admission and discharge (activities of daily living), hospital length of stay, and mortality. Results. The prevalence of delirium was 16.2% (24/148), and the incidence was 16.1% (20/124). There were no significant differences between delirious and non-delirious patients in demographics or comorbidity scores. A significant interaction effect (p < .001) indicated improved activities of daily living (mean [+ or -] SD; scale 0-12) between admission and discharge among delirious patients (4.1 [+ or -] 4.6 and 6.1 [+ or -] 3.9) compared with non-delirious patients (7.4 [+ or -] 4.7 and 6.9 [+ or -] 4.5). There were no differences between delirious and non-delirious patients with reference to mean length of stay (6.4 [+ or -] 3.1 vs 5.9 [+ or -] 3.6 days, respectively; p = .461) and mortality (2 [4.5%] versus 2 [1.9%], respectively; p = .582). Conclusions. Although this study sample was small, the results suggest that an Acute Care of the Elderly Unit with a delirium room may improve function among delirious patients and may equalize other outcomes compared with nondelirious patients. Key Words: Delirium--ACE Unit--Delirium Room. doi: 10.1093/gerona/glq136

A study was conducted to evaluate the evidence available on the efficacy and safety of bedside instruments in diagnosing delirium in adults. Results indicated that the best evidence supported the Confusion Assessment Method (CAM), which takes 5 minutes to administer and the choice of instrument depends on the time available and the discipline of the administrator.

Author(s): Yanfei Shen [sup.1], Jing Yan [sup.1], Guolong Cai [sup.1] Author Affiliations: (1) 0000 0004 1799 0055, grid.417400.6, Department of Intensive Care, Zhejiang Hospital, , No. 12, Linyin Road, 310000, [...]

Byline: Gerald Chanques (1), Jean-Francois Payen (2), Gregoire Mercier (3), Sylvie Lattre (1), Eric Viel (4), Boris Jung (1), Moussa Cisse (1), Jean-Yves Lefrant (4), Samir Jaber (1) Keywords: Pain; Pain measurement; Analgesia; Delirium; Psychomotor agitation; Intensive care; Critical care Abstract: Purpose To validate an adaptation of the Behavioral Pain Scale (BPS) for its use in non-intubated intensive care unit (ICU) patients unable to self-report their pain because of the occurrence of delirium. The 'vocalization' domain was inserted to construct the BPS-non intubated (BPS-NI) scale, ranging from 3 (no pain) to 12 (most pain). Design Prospective psychometric study in a medical-surgical ICU. Methods The same physician and one bedside nurse rated pain in non-intubated patients unable to self-report their pain during four conditions: before and after a catheter dressing change (non-nociceptive procedure) and before and after turning the patient (nociceptive procedure). Delirium was assessed by the Confusion Assessment Method for the ICU (CAM-ICU). Results A total of 120 paired evaluations were performed in 30 consecutive adult patients, 84% with delirium (CAM-ICU positive). BPS-NI scores were higher during painful procedures than at rest [6.0 (5.0--8.0) vs. 3.0 (3.0--3.8) P < 0.001], while no changes in BPS-NI scores were found during non-nociceptive procedures (discriminative validity). The BPS-NI had good internal consistency (standardized Cronbach [alpha] = 0.79), and each domain reflected the pain expression factor in a balanced way (coefficients between 0.57 and 0.59). The BPS-NI had a good inter-rater reliability (weighted kappa coefficient = 0.89 for the four conditions and 0.82 during nociceptive procedures) and a good responsiveness, with an effect size ranging from 1.5 to 3.6. Conclusions Pain during procedures is perceived even in non-intubated ICU patients with delirium. In those patients, pain level can be assessed with the BPS-NI scale since this instrument exhibited good psychometric properties. Author Affiliation: (1) Service d'Anesthesie et de Reanimation 'B' (SAR B), Intensive Care and Anesthesiology Department, Saint Eloi Hospital-CHU de Montpellier, Montpellier University Hospital, 80, Avenue Augustin Fliche, 34295, Montpellier cedex 5, France (2) Intensive Care and Anesthesiology Department, Albert Michallon Hospital, Grenoble University Hospital, BP 217, 38043, Grenoble, France (3) Department of Medical Statistics, Arnaud de Villeneuve Hospital, Montpellier University Hospital, Route de Ganges, 34295, Montpellier cedex 5, France (4) Intensive Care and Anesthesiology Department, Pain Clinic, Caremeau Hospital, Nimes University Hospital, Place Professeur Robert Debre, 30029, Nimes cedex 9, France Article History: Registration Date: 14/07/2009 Received Date: 29/04/2009 Accepted Date: 07/07/2009 Online Date: 21/08/2009 Article note: Electronic supplementary material The online version of this article (doi: 10.1007/s00134-009-1590-5) contains supplementary material, which is available to authorized users.

Byline: Jan N. M. Schieveld (1), Judith A. Valk (2), Inge Smeets (1), Eline Berghmans (1), Renske Wassenberg (1), Piet L. M. N. Leroy (3), Gijs D. Vos (3), Jim Os (4,5) Keywords: Delirium; Critical illness; Sickness behavior; Pediatric intensive care unit (PICU); Diagnosis; Children; DSM-IV; RASS; PAED; CAM-ICU Abstract: Context If delirium is not diagnosed, it is unlikely that any effort will be made to reverse it. Given evidence for under-diagnosis, tools that aid recognition are required. Objective Relating three presentations of pediatric delirium (PD) to standard criteria and developing a diagnostic algorithm. Results Delirium-inducing factors, disturbance of consciousness and inattention are common in PICU patients: a pre-delirious state is present in most. An algorithm is introduced, containing (1) evaluation of the sedation-agitation level, (2) psychometric assessment of behavior and (3) opinion of the caregivers. Discussion It may be argued that the behavioral focus of the algorithm would benefit from the inclusion of neurocognitive measures. Limitations No sufficiently validated diagnostic instrument covering the entire algorithm is available yet. Conclusion This is the first proposal for a PD diagnostic algorithm. Given the high prevalence of pre-delirious states at the PICU, daily evaluation is mandatory. Future algorithmic refinement is urgently required. Author Affiliation: (1) Division of Child and Adolescent Psychiatry, Department of Psychiatry and Psychology, European Graduate School of Neuroscience, SEARCH, Maastricht University Medical Centre, PO Box 5800, 6202 AZ, Maastricht, The Netherlands (2) Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands (3) Division of Pediatric Intensive Care Medicine, Department of Pediatrics, Maastricht University Medical Centre, PO Box 5800, 6202 AZ, Maastricht, The Netherlands (4) Department of Psychiatry and Psychology, European Graduate School of Neuroscience, SEARCH, Maastricht University Medical Centre, PO Box 616, 6202 AZ, Maastricht, The Netherlands (5) Division of Psychological Medicine, Institute of Psychiatry, London, SE5 8AF, UK Article History: Registration Date: 28/08/2009 Received Date: 05/03/2009 Accepted Date: 27/07/2009 Online Date: 22/09/2009