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Multimodal delirium

Helmar Bornemann-Cimenti, Mischa Wejbora, Kristina Michaeli, Alexander Edler, Andreas Sandner-Kiesling
BACKGROUND: Evidence confirms that perioperative ketamine administration decreases opioid usage. To reduce the risk for potential psychodysleptic side effects, however, ketamine dosing tends to be limited to low-dose regimens. We hypothesized that even lower doses of ketamine would be sufficient, with minimal side effects, when used as a component of multimodal perioperative pain management. METHODS: In this triple-blinded, randomized, active- and placebo-controlled clinical trial, patients undergoing elective major abdominal surgery were randomized to one of three treatment groups: low-dose S-ketamine (a 0...
June 21, 2016: Minerva Anestesiologica
Deepali Dixit, Jeffrey Endicott, Lisa Burry, Liz Ramos, Siu Yan Amy Yeung, Sandeep Devabhakthuni, Claire Chan, Anthony Tobia, Marilyn N Bulloch
Approximately 16-31% of patients in the intensive care unit (ICU) have an alcohol use disorder and are at risk for developing alcohol withdrawal syndrome (AWS). Patients admitted to the ICU with AWS have an increased hospital and ICU length of stay, longer duration of mechanical ventilation, higher costs, and increased mortality compared with those admitted without an alcohol-related disorder. Despite the high prevalence of AWS among ICU patients, no guidelines for the recognition or management of AWS or delirium tremens in the critically ill currently exist, leading to tremendous variability in clinical practice...
July 2016: Pharmacotherapy
Matthew Kohler, Felicia Chiu, Katherine M Gelber, Christopher Aj Webb, Paul D Weyker
Pain management for critically ill patients provides physicians with the challenge of maximizing patient comfort while avoiding the risks that arise with oversedation. Preventing oversedation has become increasingly important as we better understand the negative impact it has on patients' experiences and outcomes. Current research suggests that oversedation can result in complications such as thromboembolism, pulmonary compromise, immunosuppression and delirium. Fortunately, the analgesic options available for physicians to limit these complications are growing as more treatment modalities are being researched and implemented in the intensive care unit...
May 18, 2016: Pain Management
Roland Nau, Marija Djukic, Manfred Wappler
The care of elderly patients will continue to challenge the healthcare system over the next decades. As a rule geriatric patients suffer from multimorbidities with complex disease patterns, and the ability to cope with everyday life is severely reduced. Treatment is provided by a multiprofessional geriatric team, and the primary goal is improvement of functional status, quality of life in the social environment and autonomy by employing a holistic approach. In Germany geriatric care is provided by physicians from various medical specialties (e...
June 2016: Der Nervenarzt
Jean-Louis Vincent, Yahya Shehabi, Timothy S Walsh, Pratik P Pandharipande, Jonathan A Ball, Peter Spronk, Dan Longrois, Thomas Strøm, Giorgio Conti, Georg-Christian Funk, Rafael Badenes, Jean Mantz, Claudia Spies, Jukka Takala
We propose an integrated and adaptable approach to improve patient care and clinical outcomes through analgesia and light sedation, initiated early during an episode of critical illness and as a priority of care. This strategy, which may be regarded as an evolution of the Pain, Agitation and Delirium guidelines, is conveyed in the mnemonic eCASH-early Comfort using Analgesia, minimal Sedatives and maximal Humane care. eCASH aims to establish optimal patient comfort with minimal sedation as the default presumption for intensive care unit (ICU) patients in the absence of recognised medical requirements for deeper sedation...
June 2016: Intensive Care Medicine
Calin Stefan Moucha, Mitchell C Weiser, Emily J Levin
Total knee arthroplasty is associated with substantial postoperative pain that may impair mobility, reduce the ability to participate in rehabilitation, lead to chronic pain, and reduce patient satisfaction. Traditional general anesthesia with postoperative epidural and patient-controlled opioid analgesia is associated with an undesirable adverse-effect profile, including postoperative nausea and vomiting, hypotension, urinary retention, respiratory depression, delirium, and an increased infection rate. Multimodal anesthesia--incorporating elements of preemptive analgesia, neuraxial perioperative anesthesia, peripheral nerve blockade, periarticular injections, and multimodal oral opioid and nonopioid medications during the perioperative and postoperative periods--can provide superior pain control while minimizing opioid-related adverse effects, improving patient satisfaction, and reducing the risk of postoperative complications...
February 2016: Journal of the American Academy of Orthopaedic Surgeons
Hubert A Benzon, Ravi D Shah, Jennifer Hansen, John Hajduk, Kathleen R Billings, Gildasio S De Oliveira, Santhanam Suresh
BACKGROUND: Tonsillectomy is a frequently performed surgical procedure in children; however, few multimodal analgesic strategies have been shown to improve postsurgical pain in this patient population. Systemic magnesium infusions have been shown to reliably improve postoperative pain in adults, but their effects in pediatric surgical patients remain to be determined. In the current investigation, our main objective was to evaluate the use of systemic magnesium to improve postoperative pain in pediatric patients undergoing tonsillectomy...
December 2015: Anesthesia and Analgesia
Mavis Afriyie-Boateng, Carla Loftus, Mary Ann Hamelin
This column shares the best evidence-based strategies and innovative ideas on how to facilitate the learning of EBP principles and processes by clinicians as well as nursing and interprofessional students. Guidelines for submission are available at
December 2015: Worldviews on Evidence-based Nursing
Dushad Ram, Najla Eiman, Basavana Gowdappa
We are reporting a case of zolpidem induced multimodal hallucinations in a 22 year old female without any history of psychiatric disorders. Zolpidem, by acting on gamma-amino butyric acid type A receptor has a potential to cause a paradoxical reaction and there also exists a possibility of an induced delirium with its use. This case reports evaluates its potential to cause multimodal hallucinations. Zolpidem needs to be prescribed judiciously with the caution of potential side effects particularly in females...
August 31, 2015: Clinical Psychopharmacology and Neuroscience: the Official Scientific Journal of the Korean College of Neuropsychopharmacology
Kathy J Horvath, Theressa Burns, Carmen Fernandez, J W Terri Huh, Julie Moorer, Stephen Thielke, Emily Trittschuh, Susan Cooley
There is a perennial need to extend geriatrics knowledge and expertise to primary care providers to meet the unique needs of older patients. Reaching the target population of providers in an effective manner presents challenges for educators and evaluation of education programs. Gaps in a previous dissemination of an Assessment Guide for delirium, dementia, and depression were addressed through a multimodal strategy to reach a greater proportion of the intended audience, primary care clinicians, and to further evaluate the clinical impact of this learning resource...
November 11, 2014: Gerontology & Geriatrics Education
Richard R Riker, Jennifer E Fugate
Serial clinical examination represents the most fundamental and basic form of neurological monitoring, and is often the first and only form of such monitoring in patients. Even in patients subjected to physiological monitoring using a range of technologies, the clinical examination remains an essential tool to follow neurological progress. Key aspects of the clinical examination have now been systematized into scoring schemes, and address consciousness, pain, agitation, and delirium (PAD). The Glasgow Coma Scale has been the traditional tool to measure consciousness, but the full outline of unresponsiveness (FOUR) score has recently been validated in a variety of settings, and at present, both represent clinically useful tools...
December 2014: Neurocritical Care
Nada S Al-Qadheeb, Ethan M Balk, Gilles L Fraser, Yoanna Skrobik, Richard R Riker, John P Kress, Shawn Whitehead, John W Devlin
OBJECTIVES: We reviewed randomized trials of adult ICU patients of interventions hypothesized to reduce delirium burden to determine whether interventions that are more effective at reducing delirium duration are associated with a reduction in short-term mortality. DATA SOURCES: We searched CINHAHL, EMBASE, MEDLINE, and the Cochrane databases from 2001 to 2012. STUDY SELECTION: Citations were screened for randomized trials that enrolled critically ill adults, evaluated delirium at least daily, compared a drug or nondrug intervention hypothesized to reduce delirium burden with standard care (or control), and reported delirium duration and/or short-term mortality (≤ 45 d)...
June 2014: Critical Care Medicine
R Griffiths, F Beech, A Brown, J Dhesi, I Foo, J Goodall, W Harrop-Griffiths, J Jameson, N Love, K Pappenheim, S White
Increasing numbers of elderly patients are undergoing an increasing variety of surgical procedures. There is an age-related decline in physiological reserve, which may be compounded by illness, cognitive decline, frailty and polypharmacy. Compared with younger surgical patients, the elderly are at relatively higher risk of mortality and morbidity after elective and (especially) emergency surgery. Multidisciplinary care improves outcomes for elderly surgical patients. Protocol-driven integrated pathways guide care effectively, but must be individualised to suit each patient...
January 2014: Anaesthesia
Pookala S Bhat, Vssr Ryali, Kalpana Srivastava, Shashi R Kumar, Jyoti Prakash, Ankit Singal
Alcoholic hallucinosis is a rare complication of chronic alcohol abuse characterized by predominantly auditory hallucinations that occur either during or after a period of heavy alcohol consumption. Bleuler (1916) termed the condition as alcohol hallucinosis and differentiated it from Delirium Tremens. Usually it presents with acoustic verbal hallucinations, delusions and mood disturbances arising in clear consciousness and sometimes may progress to a chronic form mimicking schizophrenia. One such case with multimodal hallucinations in a Defence Service Corps soldier is presented here...
July 2012: Industrial Psychiatry Journal
Tia R M Kostas, Kristin M Zimmerman, James L Rudolph
Delirium is an acute change in awareness and attention and is common, morbid, and costly for patients and health care systems. While hyperactive delirium is easily identifiable, the hypoactive form is more common and carries a higher mortality. Hospital systems to address delirium should consist of 3 critical steps. First, hospitals must identify patients who develop or are at intermediate or high risk for delirium. Delirium risk may be assessed using known patient-based and illness-based risk factors, including preexisting cognitive impairment...
October 2013: Neurohospitalist
Michael G Zywiel, Atul Prabhu, Anthony V Perruccio, Rajiv Gandhi
BACKGROUND: Despite the overall success of total joint arthroplasty, patients undergoing this procedure remain susceptible to cognitive decline and/or delirium, collectively termed postoperative cognitive dysfunction. However, no consensus exists as to whether general or regional anesthesia results in a lower likelihood that a patient may experience this complication, and controversy surrounds the role of pain management strategies to minimize the incidence of postoperative cognitive dysfunction...
May 2014: Clinical Orthopaedics and related Research
Michele C Balas, William J Burke, David Gannon, Marlene Z Cohen, Lois Colburn, Catherine Bevil, Doug Franz, Keith M Olsen, E Wesley Ely, Eduard E Vasilevskis
OBJECTIVE: The awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle is an evidence-based interprofessional multicomponent strategy for minimizing sedative exposure, reducing duration of mechanical ventilation, and managing ICU-acquired delirium and weakness. The purpose of this study was to identify facilitators and barriers to awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle adoption and to evaluate the extent to which bundle implementation was effective, sustainable, and conducive to dissemination...
September 2013: Critical Care Medicine
E Celis-Rodríguez, C Birchenall, M Á de la Cal, G Castorena Arellano, A Hernández, D Ceraso, J C Díaz Cortés, C Dueñas Castell, E J Jimenez, J C Meza, T Muñoz Martínez, J O Sosa García, C Pacheco Tovar, F Pálizas, J M Pardo Oviedo, D I Pinilla, F Raffán-Sanabria, N Raimondi, C Righy Shinotsuka, M Suárez, S Ugarte, S Rubiano
INTRODUCTION: Optimal management of sedation, analgesia and delirium offers comfort and security for the critical care patient, allows support measures to be applied more easily and enables an integral approach of medical care, at the same time that lowers the incidence of complications, wich translates in better patient outcomes. OBJECTIVE: To update the Guía de práctica clínica basada en la evidencia para el manejo de la sedoanalgesia en el paciente adulto críticamente enfermo published in Medicina Intensiva in 2007, and give recommendations for the management of sedation, analgesia, and delirium...
November 2013: Medicina Intensiva
David P Reardon, Kevin E Anger, Christopher D Adams, Paul M Szumita
PURPOSE: The role of dexmedetomidine for the management of pain, agitation, and delirium in adult patients in the intensive care unit (ICU) is reviewed and updated. SUMMARY: Searches of MEDLINE (July 2006-March 2012) and an extensive manual review of journals were performed. Relevant literature with a focus on data published since our last review in 2007 was evaluated for topic relevance and clinical applicability. Optimal management of pain, agitation, and delirium in ICUs requires a systematic and multimodal approach aimed at providing comfort while maximizing outcomes...
May 1, 2013: American Journal of Health-system Pharmacy: AJHP
R Ryan Field, Michael H Wall
Delirium was described by Hippocrates over 2500 years ago and it remains an important clinical problem today. Work continues to improve definition, prevention, diagnosis, and treatment, but relatively young science remains. Delirium affects 12,500,000 patients and costs $152,000,000,000 every year. Up to 80% of mechanically ventilated patients experience delirium, which exists as a spectrum of acute brain organ dysfunction. Multiple theories exist, including contribution from baseline pathology, medications, surgical inflammation, and environment...
September 2013: Seminars in Cardiothoracic and Vascular Anesthesia
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