Delirium in intensive care unit patients
Delirio en pacientes en la unidad de cuidados intensivos
Geomaira Estefanía Vicente-Flores
pg.geomairaevf84@uniandes.edu.ec
Universidad Regional Autónoma de Los Andes. UNIANDES,
Ambato - Ecuador.
https://orcid.org/0000-0003-4074-2108
ABSTRACT
The
aim of this study was to analyze the prevalence of delirium in mechanically
ventilated patients admitted to the Intensive Care Unit. We proceeded
methodologically from a descriptive documentary type of research with
bibliographic design, in a population of 15 scientific articles. The prevalence
of delirium in critically ill patients is not completely understood, but it is
known that its presence is an independent predictor of mortality, hospital
stay, duration of mechanical ventilation, cognitive deterioration after
hospital discharge, that is why the medical-nursing health personnel play a
fundamental role in these patients, since they must assess the CAM-ICU, in a
reliable way, in order to provide immediate follow-up and treatment, reducing
the number of cases in the ICU.
Descriptors: living
conditions; patients; clinical
medicine. (Source: UNESCO Thesaurus).
RESUMEN
La
investigación tiene como objetivo analizar la prevalencia del delirio en
pacientes con ventilación mecánica ingresados en la Unidad de Cuidados
Intensivos. Se procedió metodológicamente desde un tipo de investigación
descriptiva documental con diseño bibliográfico, en una población de 15
articulos científicos. La prevalencia del delirio en pacientes en
estado crítico no se comprende por completo, pero se sabe que su
presencia es un predictor independiente de mortalidad, estancia hospitalaria,
duración de la ventilación mecánica, deterioro cognitivo tras el alta
hospitalaria, por eso el personal de salud médico - enfermera cumple un rol
fundamental en estos pacientes, ya que debe valorar el CAM-ICU, de una manera
confiable, así poder dar un seguimiento y tratamiento de manera inmediata,
disminuyendo los casos en la UCI.
Descriptores: condiciones de vida; paciente; medicina
clínica. (Fuente: Tesauro UNESCO).
Research articles
section
INTRODUCTION
Delirium is a state caused by severe and reversible
brain dysfunction that is detectable on admission and persists after hospital
discharge. It is caused by the patient's clinical or surgical condition, the
effects of medications, exposure to toxins or a combination of all factors, is
characterized by cognitive impairment in level of consciousness and attention,
changes in behavior and mood, increased or decreased psychomotor activity,
changes in the sleep-wake cycle. Early detection and prevention are the best
way to reduce and treat delirium (Bastos, et al. 2020).
It usually occurs in critically ill patients
hospitalized in the intensive care unit (ICU), there are several predisposing
factors that influence the presence of delirium such as advanced age, sex more
frequent in men, severe illness, dementia, surgery, alcoholism, renal failure,
depression, visual or hearing impairment were also found. Stimuli such as
physical paralysis of a critically ill patient and somatic limitations,
hypoxia, painful phenomena, bladder catheterization, multiple procedures,
infectious process, drugs such as benzodiazepines, anticholinergics, among
others (Casault, et al. 2021), (Stollings, et
al. 2021).
It is classified as acute, i.e., lasting several
hours and lasting several weeks or months. Clinically, it can be hyperactive or
hypoactive. It can manifest as hyperactive (agitation, hallucinations),
hypoactive (psychomotor retardation, lethargy, lethargy) or mixed (fluctuation
of symptoms between the above forms), the inactive type being the most common
condition. The prevalence of delirium is close to 70% and the incidence can be
as high as 89%. In addition, patients who develop this disorder have worse clinical
outcomes, contributing to longer hospital stays and increased likelihood of
adverse events such as respiratory and neurological complications (Mori, et
al. 2016), (Bento, et al. 2018).
The health care team is often the first to identify
behavioral changes in intensive care patients. This reinforces the importance
and need for early identification of delirium by the nurse using valid tools.
The use of assessment tools should be encouraged to facilitate the
identification of delirium, among them are: the RASS scale (Richmond Agitation-
Sedation Scale), for its use we must also take into account the degree of
sedation and agitation of the patient and the method of assessment of delirium in
the ICU (CAM-ICU) (Mart, et al. 2021).
The research aims to analyze the prevalence of
delirium in mechanically ventilated patients admitted to the Intensive Care
Unit.
METHOD
We proceeded methodologically from a descriptive
documentary type of research with bibliographic design, in a population of 15
scientific articles, with the intention of analyzing the study variable from an
analytical-synthetic context to structure a theoretical corpus from the
application of the content analysis technique in order to scrutinize the
situation of greater preponderance present in the analyzed research works.
ANALYSIS OF RESULTS
Delirium is associated with high mortality and
long hospital stay. Given this epidemiological picture, rapid and accurate
treatment of delirium becomes a priority in the intensive care unit. The
evaluation of delirium as a clinical problem is broad and complex, from
diagnosis to treatment and rehabilitation. A systematic approach should guide
the care of these patients, so that timely and quality care is provided for
immediate improvement (Ormaza-Shiguango, et al. 2020), (Herrera, et
al. 2020).
One of the main accidents to be addressed in
the ICU is referred to traumatic brain injury (Olmos, et al. 2019),
intracranial tumors (Herrera, et al. 2020), hemorrhagic stroke (Herrera,
et al. 2020), ischemic stroke (Bento, et al. 2018). However; there are cases when these the
non-pharmacological treatments are not sufficient and
the patient becomes restless and present psychomotor agitation requires
pharmacological intervention.
In this sense; delirium has long been
considered a risk factor for death in the intensive care unit and after
hospital discharge, leading to increased patient dependency and long-term
cognitive impairment (Rojas, et al. 2017). Due to delirium: mechanical ventilation
cannot be withdrawn in the rapid manner and there are extubation
failures, re-intubation; prolonged ICU stay, hospital stay (and thus hospital
care costs), anxiety and depression after an ICU stay. In addition, in the long
term, there is also a decrease in cognitive and executive functions, causing a
lack of autonomy and independence in daily activities (Fuentes-Covian, 2017).
As well pointed out by several authors
delirium is an acute and fluctuating clinical presentation characterized by
inattention, accompanied by disorganized thinking or altered levels of
consciousness. It can appear as hyperactive, hypoactive (most commonly) or
mixed. The prevalence of delirium in the intensive care unit (ICU) is highly
variable: it affects 30-80% of critically ill patients and its presence is
independently associated with higher mortality rates, higher costs and longer
hospital stays (Giménez-Esparza, et al. 2022).
In addition, these patients have a higher risk
of developing long-term cognitive impairment and higher rates of mental status
changes, such as anxiety and depression. Risk factors for delirium include
advanced age, high risk scale scores, prolonged mechanical ventilation,
especially in patients with acute respiratory distress syndrome (ARDS), secure
depression, and benzodiazepine use. COVID-19, an epidemic caused by SARS-CoV-2,
is associated with extremely high rates of delirium, particularly in ventilated
ARDS patients who are affected in 80% of cases (Garcia-Sanchez, et al.
2019).
In the reviewed studies delirium, occurs in
all existing pathologies, as well as it was in the outbreak of SARS-CoV-2,
since there were predisposing factors such as: advanced age, social isolation
measures, without physical contact with their relatives can cause symptoms of
depression, anxiety, fear and hostility. In patients with Covid-19 there was an
increase of delirium events, it was possible to verify that there are two
theories to explain this fact; the first virus infection directly in the nervous
system and the second through the inflammatory reaction system, either of these
two theories causes neuronal damage, altering consciousness to vascular events.
Therefore, it is necessary to determine the first symptoms of delirium and use
diagnostic tests, such as CAM-ICU, to start with drugs or non-pharmacological
measures, and thus shorten the time and severity of delirium (Palacio-Jiménez, et
al. 2021).
In another article he comments that mixed
delirium is the most frequent, followed by hypoactive and hyperactive delirium,
with a much lower incidence than the previous forms. Despite its severe
morbidity, hypoactive delirium often goes undiagnosed and untreated because its
manifestations are often confused with the effects of anesthesia. Delirium in
the ICU is closely related to higher mortality at 6 months, the related factors
in most articles mention that they are: a long ICU hospital stay and longer duration
of MV (mechanical ventilation), having greater short-term adverse events such
as extubation and reintubation, MV failure,
hospital-acquired pneumonia, pressure ulcers, ICU immobilization or cardiac
arrhythmia. Delirium is associated with cognitive impairment by failing to
perform daily activities (Garcia-Montalvo, et al. 2020).
CONCLUSION
The prevalence of delirium in critically ill
patients is not completely understood, but it is known that its presence is an
independent predictor of mortality, hospital stay, duration of mechanical
ventilation, cognitive impairment after hospital discharge, that is why the
medical health personnel - nurse plays a fundamental role in these patients,
since they must assess the CAM-ICU, in a reliable manner, thus being able to
provide immediate follow-up and treatment, decreasing the cases in the ICU.
FINANCING
Non-monetary
CONFLICT
OF INTEREST
There is no conflict of
interest with persons or institutions linked to the research.
ACKNOWLEDGMENTS
Universidad Regional Autónoma de Los Andes.
UNIANDES, Ambato - Ecuador.
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