INTRODUCTION: Post-anaesthesia care unit (PACU) delirium affects 5%-45% of patients after surgery and is associated with postoperative delirium and increased mortality. Up to 40% of PACU delirium is preventable, but it remains under-recognised due to a lack of awareness of its diagnosis. The nursing delirium screening scale (Nu-DESC) has been validated for diagnosing PACU delirium, but is not routinely used locally. This study aimed to use Nu-DESC to establish the incidence and risk factors of PACU delirium in patients undergoing non-cardiac surgery in the surgical population. METHODS: We conducted an audit of eligible patients undergoing major surgery in three public hospitals in Singapore over 1 week. Patients were assessed for delirium 30-60 min following their arrival in PACU using Nu-DESC, with a total score of ≥2 indicative of delirium. RESULTS: A total of 478 patients were assessed. The overall incidence rate of PACU delirium was 18/478 (3.8%), and the incidence was 9/146 (6.2%) in patients aged > 65 years. Post-anaesthesia care unit delirium was more common in females, patients with malignancy and those who underwent longer operations. Logistic regression analysis showed that the use of bispectral index (P < 0.001) and the presence of malignancy (P < 0.001) were significantly associated with a higher incidence of PACU delirium. CONCLUSION In this first local study, the incidence of PACU delirium was 3.8%, increasing to 6.2% in those aged > 65 years. Understanding these risk factors will form the basis for which protocols can be established to optimise resource management and prevent long-term morbidities and mortality in PACU delirium.
Female ; Humans ; Delirium/epidemiology* ; Postoperative Complications/etiology* ; Singapore/epidemiology* ; Prospective Studies ; Anesthesia/adverse effects* ; Risk Factors ; Neoplasms

OBJECTIVE: To investigate the relationship between malnutrition and delirium and its effect on prognosis in elderly patients with severe pneumonia undergoing invasive mechanical ventilation. METHODS: A prospective observational study was conducted. Patients with severe pneumonia aged ≥ 60 years old who underwent invasive mechanical ventilation admitted to department of critical care medicine of the Second People's Hospital of Lianyungang from January 2021 to December 2022 were enrolled. The confusion assessment method (CAM) was used to evaluate the delirium of the patients in intensive care unit (ICU). The score of CAM ≥ 1 was defined as delirium. Mini nutritional assessment short-form (MNA-SF) was used to assess the nutritional status of patients, and MNA-SF score ≤ 7 was defined as malnutrition. Patients were divided into delirium group and non-delirium group according to whether delirium occurred. The differences in clinical indicators, length of ICU stay, duration of mechanical ventilation and wake-up time after drug withdrawal were compared between the two groups. After 28 days of short-term follow-up, the patients were divided into death group and survival group, and the differences in the incidence of delirium and malnutrition between the two groups were compared. Binary multivariate Logistic regression analysis was used to screen the risk factors for delirium in elderly patients with severe pneumonia undergoing invasive mechanical ventilation. Kaplan-Meier survival curve was used to analyze the effect of delirium on prognosis. RESULTS: A total of 132 elderly patients with severe pneumonia undergoing invasive mechanical ventilation were enrolled, of whom 98 survived and 34 died within 28 days, with a mortality of 25.76%. The incidence of malnutrition and delirium in the death group was significantly higher than that in the survival group (61.76% vs. 37.76%, 64.71% vs. 26.53%, both P < 0.05), and the MNA-SF score was significantly lower than that in the survival group (6.32±1.80 vs. 8.72±2.23, P < 0.01). Procalcitonin (PCT), interleukin-6 (IL-6) and blood lactic acid (Lac) in the death group were significantly higher than those in the survival group [PCT (μg/L): 4.47 (2.69, 10.39) vs. 2.77 (1.28, 5.94), IL-6 (ng/L): 204.08 (126.12, 509.85) vs. 120.46 (60.67, 290.99), Lac (mmol/L): 5.14 (2.75, 8.60) vs. 3.13 (2.16, 4.30), all P < 0.05], and the wake-up time after drug withdrawal was significantly longer than that in the survival group (minutes: 33.94±8.51 vs. 28.92±7.03, P < 0.01). Among 132 elderly patients with severe pneumonia undergoing invasive mechanical ventilation, 48 patients had delirium during ICU stay, and 84 patients did not have delirium. The incidence of delirium was 36.36%. The 28-day mortality in the delirium group was significantly higher than that in the non-delirium group (45.83% vs. 14.29%, P < 0.01), and the MNA-SF score was significantly lower than that in the non-delirium group (6.46±1.77 vs. 9.05±2.15, P < 0.01), the length of ICU stay, duration of mechanical ventilation, and wake-up time after drug withdrawal were also significantly longer than those in the non-delirium group [length of ICU stay (days): 13.40±9.59 vs. 10.06±7.81, duration of mechanical ventilation (hours): 197.06±89.80 vs. 138.81±82.30, wake-up time after drug withdrawal (minutes): 35.85±7.01 vs. 26.99±6.12, all P < 0.05]. Binary multivariate Logistic regression analysis showed that malnutrition [odds ratio (OR) = 7.527, 95% confidence interval (95%CI) was 2.585-21.917], Lac (OR = 5.345, 95%CI was 1.733-16.483), wake-up time after drug withdrawal (OR = 6.653, 95%CI was 2.021-21.904) were independent risk factors for delirium during ICU stay in elderly patients with severe pneumonia undergoing invasive mechanical ventilation (all P < 0.01). Kaplan-Meier survival analysis showed that the 28-day cumulative survival rate of patients in the delirium group was significantly lower than that in the non-delirium group (54.17% vs. 85.71%), and the difference was statistically significant (Log-Rank test: χ² = 16.780, P < 0.001). CONCLUSIONS The risk factors for delirium in elderly patients with severe pneumonia undergoing invasive mechanical ventilation during ICU stay include malnutrition, Lac, and wake-up time after drug withdrawal. The occurrence of delirium is closely related to poor prognosis.
Aged ; Humans ; Middle Aged ; Respiration, Artificial ; Interleukin-6 ; Pneumonia ; Intensive Care Units ; Delirium/etiology* ; Procalcitonin ; Prognosis ; Malnutrition ; Retrospective Studies

OBJECTIVES: To investigate the risk factors for delirium after sedation in children with convulsion, and to establish a nomogram model for predicting the risk of delirium. METHODS: A total of 373 children with convulsion who were hospitalized in the pediatric ward of the Second Affiliated Hospital of Air Force Medical University from August 2020 to January 2022 were prospectively enrolled. There were 245 children in the modeling group and 128 children in the validation group. A multivariate logistic regression analysis was used to identify independent predictive factors for delirium after sedation and establish a nomogram model for predicting the risk of this disorder based on these factors. The calibration curve, the receiver operating characteristic curve, and the decision curve analysis were used to evaluate the accuracy, discriminatory ability, and clinical application value of this model, respectively. RESULTS: The incidence of delirium after sedation was 22.3% (83/373) in the children with convulsion. The multivariate logistic regression analysis showed that age>5 years (OR=0.401, P<0.05) was a protective factor against delirium after sedation in these children, while presence of infection (OR=3.020, P<0.05), admission to the pediatric intensive care unit (OR=3.126, P<0.05), use of benzodiazepines (OR=5.219, P<0.05), history of status convulsion (OR=2.623, P<0.05), and history of delirium episodes (OR=3.119, P<0.05) were risk factors for delirium. The H-L deviation test of the nomogram prediction model showed a good degree of fit (χ²=9.494, P=0.302). Internal and external validation showed that the mean absolute errors between the actual and predicted values of the calibration curve were 0.030 and 0.018, respectively, and the areas under the receiver operating characteristic curve were 0.777 and 0.775, respectively. The decision curve analysis showed that the model provided significant net clinical benefit when the predicted risk threshold was >0.01. CONCLUSIONS Age, presence of infection, admission to the pediatric intensive care unit, use of benzodiazepines, history of status convulsion, and history of delirium episodes are closely associated with the development of delirium after sedation in children with convulsion. The nomogram model for predicting this disorder that is established based on these factors has relatively high accuracy, discriminatory ability, and clinical application value.
Humans ; Child ; Child, Preschool ; Nomograms ; Risk Factors ; Delirium/etiology* ; Seizures ; Benzodiazepines

Anesthesia, General/adverse effects* ; Delirium/etiology* ; Humans ; Postoperative Complications/etiology*

INTRODUCTION: Post-anaesthesia care unit (PACU) delirium is a potentially preventable condition that results in a significant long-term effect. In a multicentre prospective cohort study, we investigate the incidence and risk factors of postoperative delirium in elderly patients undergoing major non-cardiac surgery. METHODS: Patients were consented and recruited from 4 major hospitals in Singapore. Research ethics approval was obtained. Patients older than 65 years undergoing non-cardiac surgery >2 hours were recruited. Baseline perioperative data were collected. Preoperative baseline cognition was obtained. Patients were assessed in the post-anaesthesia care unit for delirium 30-60 minutes after arrival using the Nursing Delirium Screening Scale (Nu-DESC). RESULTS Ninety-eight patients completed the study. Eleven patients (11.2%) had postoperative delirium. Patients who had PACU delirium were older (74.6±3.2 versus 70.6±4.4 years, P=0.005). Univariate analysis showed those who had PACU delirium are more likely to be ASA 3 (63.6% vs 31.0%, P=0.019), had estimated glomerular filtration rate (eGFR) of >60mL/min/1.73m2 (36.4% vs 10.6%, P=0.013), higher HbA1C value (7.8±1.2 vs 6.6±0.9, P=0.011), raised random blood glucose (10.0±5.0mmol/L vs 6.5±2.4mmol/L, P=0.0066), and moderate-severe depression (18.2% vs 1.1%, P=0.033). They are more likely to stay longer in hospital (median 8 days [range 4-18] vs 4 days [range 2-8], P=0.049). Raised random blood glucose is independently associated with increased PACU delirium on multivariate analysis.
Aged ; Anesthesia ; Anesthesia Recovery Period ; Delirium/etiology* ; Humans ; Incidence ; Postoperative Complications/etiology* ; Prospective Studies ; Risk Factors

OBJECTIVES: To study the risk factors for postoperative delirium (POD) in children with congenital heart disease. METHODS: A prospective nested case-control study was performed on children with congenital heart disease who underwent surgery in Fuwai Hospital, Chinese Academy of Medical Sciences, from December 2020 to June 2021. The clinical data were compared between the POD group (n=114) and non-POD group (n=102). A multivariate unconditional logistic regression analysis was used to investigate the risk factors for POD in children with congenital heart disease. RESULTS: The multivariate logistic regression analysis showed that age (OR=0.951, P<0.001), gender (OR=2.127, P=0.049), number of invasive catheters per day (OR=1.490, P=0.017), degree of postoperative pain (OR=5.856, P<0.001), and preoperative parental anxiety level (OR=1.025, P=0.010) were independent risk factors for POD in children with congenital heart disease. CONCLUSIONS The risk of POD increases in children with congenital heart disease who are younger, male, have higher number of invasive catheters per day, higher degree of postoperative pain, or higher preoperative parental anxiety level.
Case-Control Studies ; Child ; Delirium/complications* ; Heart Defects, Congenital/surgery* ; Humans ; Male ; Postoperative Complications/etiology* ; Prospective Studies ; Risk Factors

PURPOSETo evaluate midazolam sequential with dexmedetomidine for agitated patients undergoing weaning to implement light sedation in ICU.

METHODSThis randomized, prospective study was conducted in Tianjin Third Central Hospital, China. Using a sealed-envelope method, the patients were randomly divided into 2 groups (40 patients per group). Each patient of group A received an initial loading dose of midazolam at 0.3-3mg/kg·h 24 h before extubation, followed by an infusion of dexmedetomidine at a rate of 0.2-1 μg/kg·h until extubation. Each patient of group B received midazolam at a dose of 0.3-3 mg/kg·h until extubation. The dose of sedation was regulated according to RASS sedative scores maintaining in the range of -2-1. All patients were continuously monitored for 60 min after extubation. During the course, heart rate (HR), mean artery pressure (MAP), extubation time, adverse reactions, ICU stay, and hospital stay were observed and recorded continuously at the following time points: 24 h before extubation (T1), 12 h before extubation (T2), extubation (T3), 30 min after extubation (T4), 60 min after extubation (T5).

RESULTSBoth groups reached the goal of sedation needed for ICU patients. Dexmedetomidine was associated with a significant increase in extubation quality compared with midazolam, reflected in the prevalence of delirium after extubation (20% (8/40) vs 45% (18/40)), respectively (p= 0.017). There were no clinically significant decreases in HR and MAP after infusing dexmedetomidine or midazolam. In the group A, HR was not significantly increased after extubation; however, in the group B, HR was significantly increased compared with the preextubation values (p < 0.05). HR was significantly higher in the group B compared with the group A at 30 and 60 min after extubation (both, p <0.05). Compared with preextubation values, MAP was significantly increased at extubation in the group B (p < 0.05) and MAP was significantly higher at T3, T4, T5 in the group B than group A (p < 0.05). There was a significant difference in extubation time ((3.0 ± 1.5) d vs (4.3 ± 2.2) d, p < 0.05), ICU stay ((5.4 ± 2.1) d vs (8.0 ± 1.4) d, p < 0.05), hospital stay ((10.1 ± 3.0) d vs (15.3 ± 2.6) d, p <0.05) between group A and B.

CONCLUSIONMidazolam sequential with dexmedetomidine can reach the goal of sedation for ICU agitated patients, meanwhile it can maintain the respiratory and circulation parameters and reduce adverse reactions.

Adult ; Aged ; Critical Care ; methods ; Delirium ; drug therapy ; etiology ; Dexmedetomidine ; administration & dosage ; Female ; Humans ; Hypnotics and Sedatives ; administration & dosage ; Intensive Care Units ; Length of Stay ; Male ; Midazolam ; administration & dosage ; Middle Aged ; Prognosis ; Prospective Studies ; Respiration, Artificial ; adverse effects ; methods ; Risk Assessment ; Statistics, Nonparametric ; Treatment Outcome ; Ventilator Weaning ; adverse effects ; psychology

BACKGROUNDThe relationship between inflammation and delirium remains to be determined. The purposes of this study were to investigate the association between serum interleukin-6 levels and the occurrence of delirium in elderly patients after major noncardiac surgery.

METHODSA total of 338 elderly patients (60 years of age and over) undergoing major noncardiac surgery were enrolled. Blood samples were obtained before anesthesia and in the first postoperative morning and serum interleukin-6 concentrations were measured. Delirium was assessed twice daily by the confusion assessment method for the Intensive Care Unit during the first three postoperative days. Survival analyses were performed to assess the relationship between the serum IL-6 level and the occurrence of postoperative delirium.

RESULTSPostoperative delirium occurred in 14.8% (50 of 338) of patients. High serum interleukin-6 levelsafter surgery were significantly associated with increased risk of the occurrence of postoperative delirium (hazard ratio 1.514, 95% confidence interval 1.155-1.985, P = 0.003). Other independent predictors of delirium included increasing age, poor preoperative New York Heart Association classification, low preoperative Mini-Mental State Examination score, and high total postoperative Visual Analogue Scale pain score. Patients who developed delirium had a prolonged hospital stay after surgery.

CONCLUSIONSDelirium is a frequent complication in elderly patients after noncardiac surgery. High serum interleukin-6 level after surgery is associated with increased risk of the occurrence of postoperative delirium.

Aged ; Cohort Studies ; Delirium ; etiology ; immunology ; Female ; Humans ; Interleukin-6 ; blood ; Male ; Middle Aged ; Postoperative Complications ; blood ; etiology ; Prospective Studies ; Risk

INTRODUCTIONExtensively drug-resistant tuberculosis (XDR-TB) is an emerging global health risk. We present the first case report of XDR-TB in Singapore.

CLINICAL PICTUREA 41-year-old Indonesian lady with previously treated pulmonary tuberculosis presented with chronic cough. Her sputum was strongly acid-fast bacilli positive and grew Mycobacterium tuberculosis complex resistant to first and second-line TB medications.

TREATMENTShe received 5 months of intensive multidrug treatment without sputum smear conversion. She then underwent resection of the diseased lung. The total cost incurred amounted to over S$100,000.

OUTCOMEShe achieved sputum smear/culture conversion post-surgery, but will require further medical therapy for at least 18 months.

CONCLUSIONXDRTB is poorly responsive to therapy and extremely expensive to manage. Its prevention by strict compliance to therapy is paramount.

Adult ; Antitubercular Agents ; therapeutic use ; Delirium ; drug therapy ; etiology ; Directly Observed Therapy ; Drug Resistance, Multiple, Bacterial ; drug effects ; Drug Therapy, Combination ; Extensively Drug-Resistant Tuberculosis ; drug therapy ; Female ; Humans ; Microbial Sensitivity Tests ; Mycobacterium tuberculosis ; drug effects ; isolation & purification ; Singapore ; Sputum ; microbiology ; Tuberculosis, Pulmonary ; drug therapy

BACKGROUNDDelirium is a common and deleterious complication in critically ill patients after surgery. The purpose of this study was to determine the incidence and risk factors of delirium in critically ill patients after non-cardiac surgery, and to investigate the relationship between the serum cortisol level and the occurrence of postoperative delirium.

METHODSIn a prospective cohort study, 164 consecutive patients who were admitted to the surgical intensive care unit after non-cardiac surgery were enrolled. Baseline characteristics and perioperative variables were collected. Blood samples were obtained on the first postoperative day and serum cortisol concentrations were measured. Delirium was assessed using the Nursing Delirium Screening Scale until the seventh postoperative day or the disappearance of delirious symptoms.

RESULTSPostoperative delirium occurred in 44.5% of patients (73 of 164). The median time to first onset of delirium is 0 (range 0 to 5 days) and the median duration of delirium is 3 (1 to 13) days. Independent risk factors of postoperative delirium included increasing age (odds ratio (OR) 2.646, 95% confidence interval (CI) 1.431 to 4.890, P = 0.002), a history of previous stroke (OR 4.499, 95%CI 1.228 to 16.481, P = 0.023), high Acute Physiology and Chronic Health Evaluation II score on surgical intensive care unite admission (OR 1.391, 95%CI 1.201 to 1.612, P < 0.001), and high serum cortisol level on the 1st postoperative day (OR 3.381, 95%CI 1.690 to 6.765, P = 0.001). The development of delirium was linked to higher incidence of postoperative complications (28.8% vs. 7.7%, P < 0.001), and longer duration of hospitalization (18 (7 to 74) days vs. 13 (3 to 48) days, P < 0.001).

CONCLUSIONSDelirium was a frequent complication in critically ill patients after non-cardiac surgery. High serum cortisol level was associated with increased incidence of postoperative delirium.

Aged ; Critical Illness ; Delirium ; epidemiology ; etiology ; Female ; Humans ; Incidence ; Male ; Middle Aged ; Postoperative Complications ; Prospective Studies ; Risk Factors