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Das Delir auf Intensivstationen

Ein Überblick für Pflegekräfte und Ärzte
  • A. Luetz
  • B. Weiss
  • H. Held
  • C.D. SpiesEmail author
CME Zertifizierte Fortbildung
  • 1.5k Downloads

Zusammenfassung

Das Delir ist eine der häufigsten akuten Organdysfunktionen während einer intensivmedizinischen Behandlung. Seine Inzidenz ist mit 50% bei nichtbeatmeten und bis zu 80% bei beatmeten Patienten sehr hoch. Im Rahmen der klinischen Routineversorgung von kritisch kranken Patienten bleibt es, insbesondere wegen der mangelhaften Implementierung valider Messinstrumente, häufig unerkannt. Ein Delir ist mit einer verlängerten Beatmungsdauer, einer verlängerten Krankenhausverweildauer, erhöhten Komplikationsraten, wie nosokomialen Infektionen, und einer erhöhten Mortalität assoziiert. Maßnahmen zur verbesserten Diagnostik und Behandlung können nur erfolgreich sein, wenn Ärzte, Pflegekräfte und medizinisches Personal eng zusammenarbeiten und Strategien gemeinsam umsetzen.

Schlüsselwörter

Delir Intensivstationen Analgosedierung Monitoring Delirprävention 

Delirium in the intensive care unit

Overview for nurses and physicians

Abstract

Delirium is a severe but frequent organ dysfunction in intensive care units (ICU) affecting nearly 80% of mechanically ventilated patients and up to 50% of non-ventilated patients. Although guidelines for diagnosis and treatment of delirium exist it often remains underdiagnosed due to the lack of implementation of these guidelines. Therefore, the chance of a positive outcome for patients can be significantly reduced. Delirium results in longer mechanical ventilation, extended hospital stay, more nosocomial infections and an increased mortality. Measures which improve the frequency of diagnosis and increase the quality of treatment will only be successful if physicians, nursing staff and other medical staff on ICUs realize strategies together and raise their awareness on delirium.

Keywords

Delirium Intensive care units Analgesia Monitoring Prevention 

Notes

Interessenkonflikt

Der korrespondierende Autor gibt für sich und seine Koautoren an, dass kein Interessenkonflikt besteht.

Literatur

  1. 1.
    Sass H, Wittchen HU, Zaudig M, Houben I (2003) Diagnostische Kriterien DSM-IV-TR. Hogrefe, GöttingenGoogle Scholar
  2. 2.
    WHO (1990) The ICD-10 classification of mental and behavioral disorder, diagnostic criteria for research. WHO, GenfGoogle Scholar
  3. 3.
    Laurila JV, Pitkala KH, Strandberg TE, Tilvis RS (2004) Impact of different diagnostic criteria on prognosis of delirium: a prospective study. Dement Geriatr Cogn Disord 18:240–244PubMedCrossRefGoogle Scholar
  4. 4.
    Pandharipande P, Cotton BA, Shintani A et al (2007) Motoric subtypes of delirium in mechanically ventilated surgical and trauma intensive care unit patients. Intensive Care Med 33:1726–1731PubMedCrossRefGoogle Scholar
  5. 5.
    Ouimet S, Riker R, Bergeron N et al (2007) Subsyndromal delirium in the ICU: evidence for a disease spectrum. Intensive Care Med 33:1007–1013PubMedCrossRefGoogle Scholar
  6. 6.
    Cole M, McCusker J, Dendukuri N, Han L (2003) The prognostic significance of subsyndromal delirium in elderly medical inpatients. J Am Geriatr Soc 51:754–760PubMedCrossRefGoogle Scholar
  7. 7.
    Cole MG, You Y, McCusker J et al (2008) The 6 and 12 month outcomes of older medical inpatients who recover from delirium. Int J Geriatr Psychiatry 23:301–307PubMedCrossRefGoogle Scholar
  8. 8.
    Sprung CL, Peduzzi PN, Shatney CH et al (1990) Impact of encephalopathy on mortality in the sepsis syndrome. The Veterans Administration Systemic Sepsis Cooperative Study Group. Crit Care Med 18:801–806PubMedCrossRefGoogle Scholar
  9. 9.
    Martin BJ, Buth KJ, Arora RC, Baskett RJ (2010) Delirium as a predictor of sepsis in post-coronary artery bypass grafting patients: a retrospective cohort study. Crit Care 14:R171PubMedCrossRefGoogle Scholar
  10. 10.
    Iacobone E, Bailly-Salin J, Polito A et al (2009) Sepsis-associated encephalopathy and its differential diagnosis. Crit Care Med 37:331–336CrossRefGoogle Scholar
  11. 11.
    Ely EW, Inouye SK, Bernard GR et al (2001) Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA 286:2703–2710PubMedCrossRefGoogle Scholar
  12. 12.
    Ely EW, Gautam S, Margolin R et al (2001) The impact of delirium in the intensive care unit on hospital length of stay. Intensive Care Med 27:1892–1900PubMedCrossRefGoogle Scholar
  13. 13.
    Ely EW, Shintani A, Truman B et al (2004) Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 291:1753–1762PubMedCrossRefGoogle Scholar
  14. 14.
    Lin SM, Huang CD, Liu CY et al (2008) Risk factors for the development of early-onset delirium and the subsequent clinical outcome in mechanically ventilated patients. J Crit Care 23:372–379PubMedCrossRefGoogle Scholar
  15. 15.
    Kat MG, Vreeswijk R, Jonghe JF de et al (2008) Long-term cognitive outcome of delirium in elderly hip surgery patients. A prospective matched controlled study over two and a half years. Dement Geriatr Cogn Disord 26:1–8PubMedCrossRefGoogle Scholar
  16. 16.
    Pisani MA, Kong SY, Kasl SV et al (2009) Days of delirium are associated with 1-year mortality in an older intensive care unit population. Am J Respir Crit Care Med 180:1092–1097PubMedCrossRefGoogle Scholar
  17. 17.
    Inouye SK, Charpentier PA (1996) Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability. JAMA 275:852–857PubMedCrossRefGoogle Scholar
  18. 18.
    Radtke FM, Franck M, MacGuill M et al (2010) Duration of fluid fasting and choice of analgesic are modifiable factors for early postoperative delirium. Eur J Anaesthesiol 27:411–416PubMedCrossRefGoogle Scholar
  19. 19.
    Ancelin ML, Artero S, Portet F et al (2006) Non-degenerative mild cognitive impairment in elderly people and use of anticholinergic drugs: longitudinal cohort study. BMJ 332:455–459PubMedCrossRefGoogle Scholar
  20. 20.
    Gool WA van, Beek D van de, Eikelenboom P (2010) Systemic infection and delirium: when cytokines and acetylcholine collide. Lancet 375:773–775PubMedCrossRefGoogle Scholar
  21. 21.
    Novaes MA, Aronovich A, Ferraz MB, Knobel E (1997) Stressors in ICU: patients‘ evaluation. Intensive Care Med 23:1282–1285PubMedCrossRefGoogle Scholar
  22. 22.
    Nie H, Zhao B, Zhang YQ et al (2011) Pain and cognitive dysfunction are the risk factors of delirium in elderly hip fracture Chinese patients. Arch Gerontol Geriatr 54(2):e172–e174PubMedCrossRefGoogle Scholar
  23. 23.
    Young J, Murthy L, Westby M et al (2010) Diagnosis, prevention, and management of delirium: summary of NICE guidance. BMJ 341:c3704PubMedCrossRefGoogle Scholar
  24. 24.
    Jacobi J, Fraser GL, Coursin DB et al (2002) Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med 30:119–141PubMedCrossRefGoogle Scholar
  25. 25.
    Martin J, Heymann A, Bäsell K et al (2010) Evidence and consensus-based German guidelines for the management of analgesia, sedation and delirium in intensive care – short version. Ger Med Sci 8:Doc02PubMedGoogle Scholar
  26. 26.
    Devlin JW, Marquis F, Riker RR et al (2008) Combined didactic and scenario-based education improves the ability of intensive care unit staff to recognize delirium at the bedside. Crit Care 12:R19PubMedCrossRefGoogle Scholar
  27. 27.
    Guenther U, Popp J, Koecher L et al (2010) Validity and reliability of the CAM-ICU flowsheet to diagnose delirium in surgical ICU patients. J Crit Care 25:144–151PubMedCrossRefGoogle Scholar
  28. 28.
    Radtke FM, Franck M, Oppermann S et al (2009) The intensive care delirium screening checklist (ICDSC) – translation and validation of intensive care delirium checklist in accordance with guidelines. Anasthesiol Intensivmed Notfallmed Schmerzther 44:80–86PubMedCrossRefGoogle Scholar
  29. 29.
    Lütz A, Radtke FM, Franck M et al (2008) The nursing delirium screening scale (NU-DESC). Anasthesiol Intensivmed Notfallmed Schmerzther 43:98–102PubMedCrossRefGoogle Scholar
  30. 30.
    Sander M, Neumann T, Dossow V von et al (2006) Alcohol use disorder: risks in anesthesia and intensive care medicine. Internist (Berl) 47:332, 334–336, 338 Google Scholar
  31. 31.
    Lütz A, Heymann A, Radtke FM, Spies CD (2010) If delirium is not monitored it will often be not detected. Anasthesiol Intensivmed Notfallmed Schmerzther 45:106–111PubMedCrossRefGoogle Scholar
  32. 32.
    Luetz A, Heymann A, Radtke FM et al (2010) Different assessment tools for intensive care unit delirium: which score to use? Crit Care Med 38:409–418PubMedCrossRefGoogle Scholar
  33. 33.
    Plaschke K, Haken R von, Scholz M et al (2008) Comparison of the confusion assessment method for the intensive care unit (CAM-ICU) with the intensive care delirium screening checklist (ICDSC) for delirium in critical care patients gives high agreement rate(s). Intensive Care Med 34:431–436PubMedCrossRefGoogle Scholar
  34. 34.
    Girard TD, Kress JP, Fuchs BD et al (2008) Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (awakening and breathing controlled trial): a randomised controlled trial. Lancet 371:126–134PubMedCrossRefGoogle Scholar
  35. 35.
    Ely EW, Truman B, Shintani A et al (2003) Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond agitation-sedation scale (RASS). JAMA 289:2983–2991PubMedCrossRefGoogle Scholar
  36. 36.
    Ouimet S, Kavanagh BP, Gottfried SB, Skrobik Y (2007) Incidence, risk factors and consequences of ICU delirium. Intensive Care Med 33:66–73PubMedCrossRefGoogle Scholar
  37. 37.
    Whipple JK, Lewis KS, Quebbeman EJ et al (1995) Analysis of pain management in critically ill patients. Pharmacotherapy 15:592–599PubMedGoogle Scholar
  38. 38.
    Payen JF, Chanques G, Mantz J et al (2007) Current practices in sedation and analgesia for mechanically ventilated critically ill patients: a prospective multicenter patient-based study. Anesthesiology 106:687–695, 891–892PubMedCrossRefGoogle Scholar
  39. 39.
    Chanques G, Viel E, Constantin JM et al (2010) The measurement of pain in intensive care unit: comparison of 5 self-report intensity scales. Pain 151:711–721PubMedCrossRefGoogle Scholar
  40. 40.
    Payen JF, Bru O, Bosson JL et al (2001) Assessing pain in critically ill sedated patients by using a behavioral pain scale. Crit Care Med 29:2258–2263PubMedCrossRefGoogle Scholar
  41. 41.
    Chanques G, Payen JF, Mercier G et al (2009) Assessing pain in non-intubated critically ill patients unable to self report: an adaptation of the behavioral pain scale. Intensive Care Med 35:2060–2067PubMedCrossRefGoogle Scholar
  42. 42.
    Mistarz R, Eliott S, Whitfield A, Ernest D (2011) Bedside nurse-patient interactions do not reliably detect delirium: an observational study. Aust Crit Care 24:126–132PubMedCrossRefGoogle Scholar
  43. 43.
    McCusker J, Cole MG, Voyer P et al (2011) Use of nurse-observed symptoms of delirium in long-term care: effects on prevalence and outcomes of delirium. Int Psychogeriatr 23:602–608PubMedCrossRefGoogle Scholar
  44. 44.
    Heymann A, Radtke F, Schiemann A et al (2010) Delayed treatment of delirium increases mortality rate in intensive care unit patients. J Int Med Res 38:1584–1595PubMedGoogle Scholar
  45. 45.
    Girard TD, Pandharipande PP, Carson SS et al (2010) Feasibility, efficacy, and safety of antipsychotics for intensive care unit delirium: the MIND randomized, placebo-controlled trial. Crit Care Med 38:428–437PubMedCrossRefGoogle Scholar
  46. 46.
    Kalisvaart KJ, Jonghe JF de, Bogaards MJ et al (2005) Haloperidol prophylaxis for elderly hip-surgery patients at risk for delirium: a randomized placebo-controlled study. J Am Geriatr Soc 53:1658–1666PubMedCrossRefGoogle Scholar
  47. 47.
    Meyer-Massetti C, Cheng CM, Sharpe BA et al (2010) The FDA extended warning for intravenous haloperidol and torsades de pointes: how should institutions respond? J Hosp Med 5:E8–16PubMedCrossRefGoogle Scholar
  48. 48.
    Spies CD, Rommelspacher H (1999) Alcohol withdrawal in the surgical patient: prevention and treatment. Anesth Analg 88:946–954PubMedGoogle Scholar
  49. 49.
    Spies CD, Otter HE, Hüske B et al (2003) Alcohol withdrawal severity is decreased by symptom-orientated adjusted bolus therapy in the ICU. Intensive Care Med 29:2230–2238PubMedCrossRefGoogle Scholar
  50. 50.
    Lonergan E, Luxenberg J, Areosa Sastre A, Wyller TB (2009) Benzodiazepines for delirium. Cochrane Database Syst Rev 4:CD006379PubMedGoogle Scholar
  51. 51.
    Pandharipande P, Shintani A, Peterson J et al (2006) Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients. Anesthesiology 104:21–26PubMedCrossRefGoogle Scholar
  52. 52.
    Pisani MA, Murphy TE, Araujo KL et al (2009) Benzodiazepine and opioid use and the duration of intensive care unit delirium in an older population. Crit Care Med 37:177–183PubMedCrossRefGoogle Scholar
  53. 53.
    Lütz A, Spies C (2011) ICU delirium – consequences for management of analgesia and sedation in the critically ill. Anasthesiol Intensivmed Notfallmed Schmerzther 46:568–572PubMedCrossRefGoogle Scholar
  54. 54.
    Pandharipande PP, Pun BT, Herr DL et al (2007) Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial. JAMA 298:2644–2653PubMedCrossRefGoogle Scholar
  55. 55.
    Reade MC, O’Sullivan K, Bates S et al (2009) Dexmedetomidine vs. haloperidol in delirious, agitated, intubated patients: a randomised open-label trial. Crit Care 13:R75PubMedCrossRefGoogle Scholar
  56. 56.
    American Psychiatric Association (1999) Practice guideline for the treatment of patients with delirium. Am J Psychiatry 156:1–20Google Scholar
  57. 57.
    Lundström M, Edlund A, Karlsson S et al (2005) A multifactorial intervention program reduces the duration of delirium, length of hospitalization, and mortality in delirious patients. J Am Geriatr Soc 53:622–628PubMedCrossRefGoogle Scholar
  58. 58.
    Morandi A, Brummel NE, Ely EW (2011) Sedation, delirium and mechanical ventilation: the ‚ABCDE‘ approach. Curr Opin Crit Care 17(1):43–49PubMedCrossRefGoogle Scholar
  59. 59.
    Luetz A, Goldmann A, Weber-Carstens S, Spies C (2012) Weaning from mechanical ventilation and sedation. Curr Opin Anaesthesiol 25(2):164–169PubMedCrossRefGoogle Scholar
  60. 60.
    Skrobik Y, Ahern S, Leblanc M et al (2010) Protocolized intensive care unit management of analgesia, sedation, and delirium improves analgesia and subsyndromal delirium rates. Anesth Analg 111:451–463PubMedCrossRefGoogle Scholar
  61. 61.
    King MS, Render ML, Ely EW, Watson PL (2010) Liberation and animation: strategies to minimize brain dysfunction in critically ill patients. Semin Respir Crit Care Med 31:87–96PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2012

Authors and Affiliations

  1. 1.Klinik für Anästhesiologie mit Schwerpunkt operative IntensivmedizinCharité-Universitaetsmedizin Berlin, Campus Virchow-Klinikum BerlinDeutschland
  2. 2.Klinik für Anästhesiologie mit Schwerpunkt operative IntensivmedizinCharité-Universitaetsmedizin Berlin, Campus MitteBerlinDeutschland

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