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  1. Ng KT, Shubash CJ, Chong JS
    Anaesthesia, 2019 Mar;74(3):380-392.
    PMID: 30367689 DOI: 10.1111/anae.14472
    Delirium is common in intensive care patients. Dexmedetomidine is increasingly used for sedation in this setting, but its effect on delirium remains unclear. The primary aim of this review was to examine whether dexmedetomidine reduces the incidence of delirium and agitation in intensive care patients. We sought randomised clinical trials in MEDLINE, EMBASE, PubMed and CENTRAL from their inception until June 2018. Observational studies, case reports, case series and non-systematic reviews were excluded. Twenty-five trials including 3240 patients were eligible for inclusion in the data synthesis. In the patients who received dexmedetomidine (eight trials, 1425 patients), delirium was reduced, odds ratio (95%CI) 0.36 (0.26-0.51), p delirium, bradycardia and hypotension was conclusive but not for the incidence of agitation and mortality. In summary, this meta-analysis suggests that dexmedetomidine reduces the incidence of delirium and agitation in intensive care patients. The general quality of evidence ranged from moderate to high.
    Matched MeSH terms: Delirium/epidemiology; Delirium/prevention & control*
  2. Khoo SB
    Malays Fam Physician, 2011;6(2-3):51-7.
    PMID: 25606223 MyJurnal
    Delirium in the elderly is a challenging and under-recognized problem in the community. Early detection and management improves outcomes and quality of life for the elders with delirium at home.1 Family physicians (FP) play a key role in the assessments, early identification, and management of delirium and in the support and education of patients and their family caregivers.1 Clinical analysis of this case illustrates the bio-psychosocial spiritual model of approach to management of delirium in an elderly patient in the home setting.
    Matched MeSH terms: Delirium*
  3. Chew PH, Leong LC, Yao SK
    Med J Malaysia, 1982 Dec;37(4):370-2.
    PMID: 7167091
    Matched MeSH terms: Delirium/diagnosis*
  4. Francis B, Petrus CF, Wong HH
    Asian J Psychiatr, 2020 Apr;50:101986.
    PMID: 32135484 DOI: 10.1016/j.ajp.2020.101986
    BACKGROUND: Electroconvulsive therapy (ECT) is safe and efficacious in the elderly population. However, clinicians are still weary to use it among the old-old population, citing safety concerns. Our case report highlights the use of ECT in a 91 year old lady with late onset Bipolar Mania.

    CASE REPORT: A 91 year old lady presented with an acute manic relapse for the past 2 weeks. She was previously on oral Sodium Valproate, and during this current admission was augmented with oral Quetiapine IR 100 mg bd. She remained unwell and was planned for right unilateral ECT with age-based dosing stimuli. After only 4 sessions, she showed complete resolution of her manic symptoms.

    RESULT: In our case study, the patient showed rapid response to right unilateral ECT. Even though the Post Suppression Index (PSI) was not significant, there is some evidence that in elderly patients, burst suppression (not measured in this case) may be more accurate measure of ECT efficacy. The transient treatment emergent delirium was short lived and ECT was very tolerated in this patient.

    CONCLUSION: Clinicians should not delay ECT in old-old patients who do not respond to pharmacologic treatment, as early switch to ECT results in rapid response with good safety profile.

    Matched MeSH terms: Delirium/etiology
  5. Seed, H.F., Thong, K.S., Siti-Nor Aizah, A.
    MyJurnal
    Although disturbance of consciousness in delirium patients have been well
    established, but sudden drop of Glasgow Coma Scale (GCS) level to three is
    frightening and mysterious. We are reporting a case of a delirious elderly
    man with multiple medical illnesses presented with acute precipitous
    decrement of GCS with pin point pupils bilaterally after given a course of
    benzodiazepines and regained full consciousness spontaneously 32 hours
    later. We discussed the use of deliriogenic medications in the context of
    delirious elderly gentleman with multiple medical illnesses. We also looked
    into the possible differentials of sudden drop of conscious level with bilateral
    pin point pupils.
    Matched MeSH terms: Delirium
  6. Ramoo V, Abu H, Rai V, Surat Singh SK, Baharudin AA, Danaee M, et al.
    J Clin Nurs, 2018 Nov;27(21-22):4028-4039.
    PMID: 29775510 DOI: 10.1111/jocn.14525
    AIMS AND OBJECTIVES: To assess intensive care unit nurses' knowledge of intensive care unit delirium and delirium assessment before and after an educational intervention. In addition, nurses' perception on the usefulness of a delirium assessment tool and barriers against delirium assessment were assessed as secondary objectives.

    BACKGROUND: Early identification of delirium in intensive care units is crucial for patient care. Hence, nurses require adequate knowledge to enable appropriate evaluation of delirium using standardised practice and assessment tools.

    DESIGN: This study, performed in Malaysia, used a single-group pretest-posttest study design to assess the effect of educational interventions and hands-on practices on nurses' knowledge of intensive care unit delirium and delirium assessment.

    METHODS: Sixty-one nurses participated in educational intervention sessions, including classroom learning, demonstrations and hands-on practices on the Confusion Assessment Method-Intensive Care Unit. Data were collected using self-administered questionnaires for the pre- and postintervention assessments. Analysis to determine the effect of the educational intervention consisted of the repeated-measures analysis of covariance.

    RESULTS: There were significant differences in the knowledge scores pre- and postintervention, after controlling for demographic characteristics. The two most common perceived barriers to the adoption of the intensive care unit delirium assessment tool were "physicians did not use nurses' delirium assessment in decision-making" and "difficult to interpret delirium in intubated patients".

    CONCLUSIONS: Educational intervention and hands-on practices increased nurses' knowledge of delirium assessment. Teaching and interprofessional involvements are essential for a successful implementation of intensive care unit delirium assessment practice.

    RELEVANCE TO CLINICAL PRACTICE: This study supports existing evidences, indicating that education and training could increase nurses' knowledge of delirium and delirium assessment. Improving nurses' knowledge could potentially lead to better delirium management practice and improve ICU patient care. Thus, continuous efforts to improve and sustain nurses' knowledge become relevant in ICU settings.

    Matched MeSH terms: Delirium/diagnosis*; Delirium/nursing
  7. Chandrasekaran, Prem Kumar, Jambunathan, Stephen Thevanathan, Nor Zuraida Zainal
    MyJurnal
    This is a cross-sectional, two-year follow up study. The authors determined the varied presentations of delirium, dementia and other organic disorders to assess their mortality and outcome. They described the diagnosis of patients suffering from the psychiatric effects of those organic states and compared their symptom resolution and mortality between those with the acute and chronic varieties during their index hospitalization and again, 24 months later. Although mortality rates did not differ, patients with the acute syndrome had significantly better outcomes in terms of symptom resolution as compared to those with the chronic syndrome (p=0.001). Patients with symptom resolution upon discharge did not show statistically significant lower mortality rates.
    Matched MeSH terms: Delirium
  8. Cheng V, Abdul-Aziz MH, Roberts JA, Shekar K
    J Thorac Dis, 2018 Mar;10(Suppl 5):S629-S641.
    PMID: 29732181 DOI: 10.21037/jtd.2017.09.154
    Optimal pharmacological management during extracorporeal membrane oxygenation (ECMO) involves more than administering drugs to reverse underlying disease. ECMO is a complex therapy that should be administered in a goal-directed manner to achieve therapeutic endpoints that allow reversal of disease and ECMO wean, minimisation of complications (treatment of complications when they do occur), early interruption of sedation and rehabilitation, maximising patient comfort and minimising risks of delirium. ECMO can alter both the pharmacokinetics (PK) and pharmacodynamics (PD) of administered drugs and our understanding of these alterations is still evolving. Based on available data it appears that modern ECMO circuitry probably has a less significant impact on PK when compared with critical illness itself. However, these findings need further confirmation in clinical population PK studies and such studies are underway. The altered PD associated with ECMO is less understood and more research is indicated. Until robust dosing guidelines become available, clinicians will have to rely on the principles of drug dosing in critically ill and known PK alterations induced by ECMO itself. This article summarises the PK alterations and makes preliminary recommendations on possible dosing approaches.
    Matched MeSH terms: Delirium
  9. Tengku Mohd Saifuddin, Chong Wei Wei, Aida Farina Ismail, Noorul Amilin Harun
    MyJurnal
    Alcohol-induced psychotic disorder (AIPD) is a rare complication of alcohol
    abuse which is characterized by an acute onset of auditory or visual
    hallucinations that occur either during or after a period of heavy alcohol
    consumption. Other symptoms include delusions, thought disorder,
    psychomotor disturbances, and abnormal affect. To establish the diagnosis,
    one must rule out other disorders such as alcohol withdrawal delirium or
    other psychotic disorders. Although it is well recognised, relatively little is
    known about the condition. Moreover, the pathogenesis and treatment of
    AIPD are still unclear despite high co-morbidity with other psychiatric
    disorders, high re-hospitalization as well as mortality rates and suicidal
    behaviour. Therefore, the prognosis appears less favourable. We present a
    case of young man with AIPD with suicidal attempt secondary to auditory
    hallucination.
    Matched MeSH terms: Alcohol Withdrawal Delirium
  10. Masiran R, Abdul Aziz MF
    BMJ Case Rep, 2017 Aug 28;2017.
    PMID: 28847993 DOI: 10.1136/bcr-2017-220631
    A patient with bipolar I disorder has been treated with lithium and haloperidol for the last 20 years and received an ACE inhibitor for his hypertension since 9 years ago. Despite regular clinic follow-ups and blood monitoring, he recently developed tremors and delirium. On hospital admission, serum level of lithium was far above toxic level. Mental state examination revealed an anxious and disorientated man with irrelevant speech. Immediate discontinuation of lithium resulted in slow reduction of serum lithium levels and gradual resolution of tremor but his delirium persisted for 2 weeks. His condition took a turn for the worse when he developed acute renal failure and arm abscess. We discussed about lithium toxicity and the vulnerability factors which have induced delirium and renal failure in this patient.
    Matched MeSH terms: Delirium/chemically induced*; Delirium/complications
  11. Sivarooban, V., Yogitagavari, Y., Che, C.K., Lee, C.W.
    MyJurnal
    Neuropsychiatric symptoms are symptoms that caused by organic brain
    disorders. Multiple neuropsychiatric symptoms can occur concurrently in the
    course of brain related organic disorders. Two main components of
    neuropsychiatric symptoms are cognitive impairment and disturbance of
    consciousness while other neuropsychiatric symptoms, such as hallucinations,
    delusions, mood disorders, anxiety, apathy, behavioural and personality
    changes also commonly occur. Some of the mild neuropsychiatric symptoms
    could possibly be the earliest manifestations of brain related organic
    disorders. Clinicians should carefully evaluate organic factors in the
    treatment of psychosis, especially in patients of very young age or older age.
    They should have enough knowledge and experience in the integrating
    neuroscience, that is, neuropsychiatry. The present report illustrates a case of
    organic disorder with neuropsychiatric manifestations. It is about a young
    male patient who was diagnosed with anti-NMDA receptor encephalitis and
    subsequently developed acute delirium secondary to the illness.
    Matched MeSH terms: Delirium
  12. Shehabi Y, Chan L, Kadiman S, Alias A, Ismail WN, Tan MA, et al.
    Intensive Care Med, 2013 May;39(5):910-8.
    PMID: 23344834 DOI: 10.1007/s00134-013-2830-2
    To ascertain the relationship among early (first 48 h) deep sedation, time to extubation, delirium and long-term mortality.
    Matched MeSH terms: Delirium/diagnosis
  13. Ng KT, Sarode D, Lai YS, Teoh WY, Wang CY
    Paediatr Anaesth, 2019 12;29(12):1163-1172.
    PMID: 31587414 DOI: 10.1111/pan.13752
    BACKGROUND: Ketamine is believed to reduce the incidence of emergence agitation in children undergoing surgery or procedure. However, recent randomized controlled trials reported conflicting findings.

    AIMS: To investigate the effect of ketamine on emergence agitation in children.

    METHODS: Databases of MEDLINE, EMBASE, and CENTRAL were systematically searched from their start date until February 2019. Randomized controlled trials comparing intravenous ketamine and placebo in children were sought. The primary outcome was the incidence of emergence agitation. Secondary outcomes included postoperative pain score, duration of discharge time, and the adverse effects associated with the use of ketamine, namely postoperative nausea and vomiting, desaturation, and laryngospasm.

    RESULTS: Thirteen studies (1125 patients) were included in the quantitative meta-analysis. The incidence of emergence agitation was 14.7% in the ketamine group and 33.3% in the placebo group. Children receiving ketamine had a lower incidence of emergence agitation, with an odds ratio being 0.23 (95% confidence interval: 0.11 to 0.46), certainty of evidence: low. In comparison with the placebo, ketamine group achieved a lower postoperative pain score (odds ratio: -2.42, 95% confidence interval: -4.23 to -0.62, certainty of evidence: very low) and lower pediatric anesthesia emergence delirium scale at 5 minutes after operation (odds ratio: -3.99, 95% confidence interval: -5.03 to -2.95; certainty of evidence: moderate). However, no evidence was observed in terms of incidence of postoperative nausea and vomiting, desaturation, and laryngospasm.

    CONCLUSION: In this meta-analysis of 13 randomized controlled trials, high degree of heterogeneity and low certainty of evidence limit the recommendations of ketamine for the prevention of emergence agitation in children undergoing surgery or imaging procedures. However, the use of ketamine is well-tolerated without any notable adverse effects across all the included trials.

    PROSPERO REGISTRATION: CRD42019131865.

    Matched MeSH terms: Emergence Delirium/drug therapy*
  14. Shehabi Y, Bellomo R, Kadiman S, Ti LK, Howe B, Reade MC, et al.
    Crit. Care Med., 2018 06;46(6):850-859.
    PMID: 29498938 DOI: 10.1097/CCM.0000000000003071
    OBJECTIVES: In the absence of a universal definition of light or deep sedation, the level of sedation that conveys favorable outcomes is unknown. We quantified the relationship between escalating intensity of sedation in the first 48 hours of mechanical ventilation and 180-day survival, time to extubation, and delirium.

    DESIGN: Harmonized data from prospective multicenter international longitudinal cohort studies SETTING:: Diverse mix of ICUs.

    PATIENTS: Critically ill patients expected to be ventilated for longer than 24 hours.

    INTERVENTIONS: Richmond Agitation Sedation Scale and pain were assessed every 4 hours. Delirium and mobilization were assessed daily using the Confusion Assessment Method of ICU and a standardized mobility assessment, respectively.

    MEASUREMENTS AND MAIN RESULTS: Sedation intensity was assessed using a Sedation Index, calculated as the sum of negative Richmond Agitation Sedation Scale measurements divided by the total number of assessments. We used multivariable Cox proportional hazard models to adjust for relevant covariates. We performed subgroup and sensitivity analysis accounting for immortal time bias using the same variables within 120 and 168 hours. The main outcome was 180-day survival. We assessed 703 patients in 42 ICUs with a mean (SD) Acute Physiology and Chronic Health Evaluation II score of 22.2 (8.5) with 180-day mortality of 32.3% (227). The median (interquartile range) ventilation time was 4.54 days (2.47-8.43 d). Delirium occurred in 273 (38.8%) of patients. Sedation intensity, in an escalating dose-dependent relationship, independently predicted increased risk of death (hazard ratio [95% CI], 1.29 [1.15-1.46]; p < 0.001, delirium hazard ratio [95% CI], 1.25 [1.10-1.43]), p value equals to 0.001 and reduced chance of early extubation hazard ratio (95% CI) 0.80 (0.73-0.87), p value of less than 0.001. Agitation level independently predicted subsequent delirium hazard ratio [95% CI], of 1.25 (1.04-1.49), p value equals to 0.02. Delirium or mobilization episodes within 168 hours, adjusted for sedation intensity, were not associated with survival.

    CONCLUSIONS: Sedation intensity independently, in an ascending relationship, predicted increased risk of death, delirium, and delayed time to extubation. These observations suggest that keeping sedation level equivalent to a Richmond Agitation Sedation Scale 0 is a clinically desirable goal.

    Matched MeSH terms: Delirium/etiology
  15. Patricia Sator, Noorhafizah Ag Riun
    MyJurnal
    Introduction: Ventilator-associated pneumonia (VAP) is defined as pneumonia that occurs 48-72 hours or there-after following endotracheal intubation. VAP increased health care costs due to hospital length of stay. Since VAP can be prevented, this study underscores the importance of identifying the current knowledge and practice on the prevention of VAP among the ICU nurses in Queen Elizabeth Hospital 2 (QEH2). The objective of this study is to determine the nurse’s knowledge and practice towards VAP prevention. Methods: The methodology used for this study is a cross-sectional study to evaluate nurses’ knowledge and practice in the ICU, QEH2. 82 ICU QEH2 nurs-es participated. Data were collected using a modified structured questionnaire based on the checklist of VAP data elements. The elements covered in the questionnaire consist of three parts, which are Part A on socio-demographic information, Part B on knowledge ventilator-associated pneumonia events and Part C on nurse’s prevention practice on ventilator-associated events. The data was analyzed using SPSS version 20. Results: The overall results of this study are 45.1% of the nurses were less knowledgeable on VAP prevention and this could lead to a prevalence of VAP in the unit. VAP is a new concept implemented in 2013, meaning that 48.53% (n=33) nurses who trained 2-5 years ago may have not covered VAP in their infection prevention and control training. Most of the ICU nurses did not profoundly practices on subglottic suction (35/82), hand hygiene prior suctioning (40/82), hand hygiene after ETT suction (16/82) and delirium risk assessment (1/82). As a discussion, this could mean the ICU nurses do not have adequate knowledge and practice awareness on VAP prevention. Conclusion: For the conclusion of this study, the nurses working in ICU, QEH2 practiced most of the recommended VAP prevention but not all. Continuous training on prevention for VAP in ICU needs to be review. The hospital management to ensure the availability of the facilities needed and the adoption of guidelines based on evidence-based practice.
    Matched MeSH terms: Delirium
  16. Yap MT, Yubbu P, Yong SW, Hing WV, Ong YS, Devaraj NK, et al.
    Med J Malaysia, 2020 09;75(5):494-501.
    PMID: 32918416
    BACKGROUND: The long waiting time for Tetralogy of Fallot (TOF) operation may potentially increase the risk of hypoxic insult. Therefore, the objective of this study is to determine the frequency of acute neurological complications following primary TOF repair and to identify the peri-operative risk factors and predictors for the neurological sequelae.

    METHODS: A retrospective review of the medical and surgical notes of 68 patients who underwent TOF repair in Hospital Serdang, from January 2013 to December 2017 was done. Univariate and multivariate analyses of demographics and perioperative clinical data were performed to determine the risk for the development of acute neurological complications (ANC) among these patients.

    RESULTS: ANC was reported in 13 cases (19.1%) with delirium being the most common manifestation (10/68, 14.7%), followed by seizures in 4 (5.9%) and abnormal movements in two patients (2.9%). Univariate analyses showed that the presence of right ventricular (RV) dysfunction, prolonged duration of inotropic support (≥7 days), prolonged duration of mechanical ventilation (≥7 days), longer length of ICU stays (≥7 days), and longer length of hospital stay (≥14 days), were significantly associated with the presence of ANCs (p<0.05). However, multivariate analyses did not show any significant association between these variables and the development of ANC (p>0.05). The predictors for the development of postoperative delirium were pre-operative oxygen saturation less than 75% (Odds Ratio, OR=16.90, 95% Confidence Interval, 95%CI:1.36, 209.71) and duration of ventilation of more than 7 days (OR=13.20, 95%CI: 1.20, 144.98).

    CONCLUSION: ANC following TOF repair were significantly higher in patients with RV dysfunction, in those who required a longer duration of inotropic support, mechanical ventilation, ICU and hospital stay. Low pre-operative oxygen saturation and prolonged mechanical ventilation requirement were predictors for delirium which was the commonest neurological complications observed in this study. Hence, routine screening for delirium using an objective assessment tool should be performed on these high-risk patients to enable accurate diagnosis and early intervention to improve the overall outcome of TOF surgery in this country.

    Matched MeSH terms: Delirium
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