Focus on delirium, sedation and neuro critical care 2019: towards a more brain-friendly environment?

Excerpt

The brain is always ‘at risk’ in critically ill patients, regardless of the underlying condition that precipitated their admission to an intensive care unit (ICU) [1]. Clinically, this may manifest in many ways: reduced consciousness, coma, or delirium, are all prevalent symptoms in critically ill patients [2]. The pathophysiology can be conceptualized as a complex interplay between predisposing risk factors, disease-related processes, and issues related to the ICU environment or therapies (Fig. 1). Such a brain dysfunction is associated with worse outcomes and long-lasting cognitive and psychological consequences in ICU survivors [3]. The Improving Care of Acute lung injury Patients (ICAP) trial [4] was a prospective 5-year follow-up of 520 acute respiratory distress syndrome (ARDS) patients. Hospital Anxiety and Depression Scale and Impact of Event Scale-Revised were obtained in 186 of the 196 patients who survived to 3 months. More than half of these patients suffered from prolonged symptoms of anxiety (in 38%), depression (in 32%), and post-traumatic stress disorder (in 23%) with overlap between these symptoms and a median symptom duration of 33–39 months. Antecedents of mental health problems, especially recent anxiety and depression preceding the ARDS, and a lower level of education were the most important pre-ARDS risk factors for prolonged psychiatric morbidity. A similar association was found in a Dutch retrospective study of 1090 patients admitted to a mixed medical/surgical ICU [5] in which pre-ICU psychopathology increased the incidence of delirium by 30%. Perhaps screening for these risk factors might allow for more directed interventions in the recovery phase after critical illness?

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