|Year : 2020 | Volume
| Issue : 1 | Page : 9-11
Point prevalence of delirium among critically ill patients in Saudi Arabia: A multicenter study
Nada S Al-Qadheeb1, Mai Hashhoush1, Khaled Maghrabi2, Asia Rugaan3, Faisal Eltatar3, Haifa Algethamy4, Abdullah Abudayah5, Nadia Ismail6, Almubarak6, Kasim Alkhatib7, Mohammed Amaani8, Alaa Ghabashi9, Mohammed Almaani10, Rashid Amin2, Abdulrahman M Alharthy11, Nasir Nasim11, Galal ElRakaiby9, Farhan Alonazi12, Israa Alnajdi13, Mariam Alansari14, Mohammed Al Ahmed13, Ahmed Alenazi15, Abdulrahman Alruwaili12, Osama Almuslim1
1 Adult Intensive Care Unit, King Fahad Specialist Hospital Dammam, Dammam, Saudi Arabia
2 King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
3 Department of Critical Care, King Abdullah Medical City, Makkah, Saudi Arabia
4 King Abdulaziz University Hospital, Jeddah, Saudi Arabia
5 Prince Sultan Military Medical City, Riyadh, Saudi Arabia
6 King Fahad University Hospital, Khobar, Saudi Arabia
7 Al Noor Specialist Hospital, Makkah, Saudi Arabia
8 King Fahad Medical City, Riyadh, Saudi Arabia
9 King Abdulaziz Medical City, Jeddah, Saudi Arabia
10 King Khaled University Hospital, Riyadh, Saudi Arabia
11 King Saud Medical City, Riyadh, Saudi Arabia
12 King Abdulaziz Medical City, Riyadh, Saudi Arabia
13 Johns Hopkins Aramco Health Care, Dhahran, Saudi Arabia
14 mam Abdulrahman Al Faisal Hospital, Dammam, Saudi Arabia
15 mam Abdulrahman Al Faisal Hospital, Dammam; Saudi Critical Care Society, Riyadh, Saudi Arabia
|Date of Submission||27-Jan-2020|
|Date of Decision||06-Feb-2020|
|Date of Acceptance||09-Feb-2020|
|Date of Web Publication||30-Apr-2020|
Nada S Al-Qadheeb
Research Center, King Khaled Medical City, Dammam and First Health Cluster in Eastern Province E1, King Fahad Specialist Hospital Dammam, P. O. Box 15215, Dammam 31444
Source of Support: None, Conflict of Interest: None
Delirium is commonly recognized among critically ill patients; previous work suggests that delirium prevalence is up to 80% in intensive care unit (ICU) patients and is associated with a variety of adverse outcomes. While several tools have been validated for the detection of ICU delirium, the confusion assessment method -ICU and the intensive care delirium screening checklist are the most widely studied and used. Several risk factors are known to influence delirium occurrence such as benzodiazepines use, drug-induced coma, sleep alterations, metabolic disturbances, and sepsis. In Saudi Arabia, few studies have discussed delirium burden and associated risk factors among critically ill patients. Therefore, the aim of this study is to determine the prevalence of ICU delirium and to study the risk factors associated with the development of delirium in patients in the intensive care setting in Saudi Arabia. This is a 1-day cross-sectional study performed on January 28, 2020, in the medical-surgical ICUs at 14 hospitals in Saudi Arabia. Patients are excluded from the study if they have traumatic brain injury, documented dementia in patient's medical chart, and the inability to conduct valid delirium assessment.
Keywords: Delirium, intensive care delirium screening checklist, intensive care unit, prevalence
|How to cite this article:|
Al-Qadheeb NS, Hashhoush M, Maghrabi K, Rugaan A, Eltatar F, Algethamy H, Abudayah A, Ismail N, Almubarak, Alkhatib K, Amaani M, Ghabashi A, Almaani M, Amin R, Alharthy AM, Nasim N, ElRakaiby G, Alonazi F, Alnajdi I, Alansari M, Al Ahmed M, Alenazi A, Alruwaili A, Almuslim O. Point prevalence of delirium among critically ill patients in Saudi Arabia: A multicenter study. Saudi Crit Care J 2020;4:9-11
|How to cite this URL:|
Al-Qadheeb NS, Hashhoush M, Maghrabi K, Rugaan A, Eltatar F, Algethamy H, Abudayah A, Ismail N, Almubarak, Alkhatib K, Amaani M, Ghabashi A, Almaani M, Amin R, Alharthy AM, Nasim N, ElRakaiby G, Alonazi F, Alnajdi I, Alansari M, Al Ahmed M, Alenazi A, Alruwaili A, Almuslim O. Point prevalence of delirium among critically ill patients in Saudi Arabia: A multicenter study. Saudi Crit Care J [serial online] 2020 [cited 2020 Aug 6];4:9-11. Available from: http://www.sccj-sa.org/text.asp?2020/4/1/9/283643
| Introduction|| |
Delirium, defined as a disturbance in attention and awareness, develops over a short period of time and accompanied by a fluctuating course of change in cognition. Rates of delirium range from 50% to 80% in mechanically ventilated patients and 20%–50% in patients with lower severity of illness. These results highly depend on the population studied, and the diagnostic tool was used. Underrecognition of delirium is an extensive problem and is estimated to occur in 30%–75% of cases. Common subtypes of delirium include mixed (54%), hypoactive delirium characterized by lethargy, reduced activity (44%), and hyperactive form (1.6%) characterized by restlessness and agitation.,,,,,,,,
Several studies suggest that delirium is an independent predictor of a longer time in the intensive care unit (ICU) and on mechanical ventilation, greater cost, and higher mortality. Furthermore, delirium is linked to worsening cognitive performance that persists for months to years after ICU discharge.,,, While numerous delirium risk factors have been reported in the literature, benzodiazepines use, drug-induced coma, sleep alterations, metabolic disturbances, and sepsis are modifiable risk factors that should be addressed in clinical practice.,,,,,,
Given the negative sequelae of delirium, the society of critical care medicine pain agitation and delirium guideline recommends routine delirium screening in the ICU with the validated confusion assessment method-ICU (CAM-ICU) or the intensive care delirium screening checklist (ICDSC).,,, Plaschke et al. compared the CAM-ICU and the ICDSC, a good agreement between both tools was found (kappa coefficient of 0.80; confidence interval [CI] 95%: 0.78–0.84; P < 0.001).
While the CAM-ICU evaluates four features (acute fluctuation in mental status, inattention, altered level of consciousness, and disorganized thinking) in a focused patient assessment approach, taking <2 min to complete, the 8-domain ICDSC assesses four symptoms of delirium (altered level of consciousness, inattention, disorientation, and psychosis) in a focused patient assessment method and four domains (changes in psychomotor activity, inappropriate speech/mood, sleep disturbances, and fluctuations of symptoms) over the prior and current nursing shift. An ICDSC score ≥4 has been shown to highly correlate with a formal psychiatric diagnosis of delirium. Both tools are validated in several languages including Arabic and English.,,, The Arabic CAM-ICU and ICDSC demonstrated a good reliability and validity to assess delirium in Arabic-speaking critically ill patients.
In Saudi Arabia, little is known about ICU delirium, its burden and associated risk factors among critically ill patients. In 2014, a survey related to delirium was conducted in one center in Saudi Arabia, 54% scored their performance related to delirium assessment and management in the ICU as fair to poor. Aljuaid et al. tested the validity and reliability of the Arabic CAM-ICU in a tertiary care hospital in Saudi Arabia, delirium was diagnosed in 63% of enrolled patients as per the psychiatrist clinical assessment. In 2019, the Arabic version of ICDSC was successfully developed by Al-Qadheeb et al. demonstrating an acceptable reliability and validity in detecting delirium among critically ill Arabic-speaking population. Incidence of delirium was 21% as per the psychiatrist evaluation and 17% using the Arabic version of ICDSC., In addition, Rasheed et al. reported an incidence of 17.3% in ICU patients from one center in Saudi Arabia using the CAM-ICU. Moreover, the authors investigated risk factors associated with delirium and found a strong association with sedation, mechanical ventilation, and a baseline Glasgow Coma Scale score of <15. Epidemiological data from a large number of ICUs may provide a more precise estimate of prevalence and may help design future observational studies.
In this study, we sought to determine, in a multicenter fashion, the point prevalence of ICU delirium and to study the risk factors associated with the development of delirium among critically ill patients in Saudi Arabia.
| Materials and Methods|| |
The study is a 1-day cross-sectional study performed on January 28, 2020, in the medical-surgical ICUs at 14 hospitals in Saudi Arabia. We submitted for approval from all the institutional review boards from all participating centers. All 14 ICUs are closed units integrating well-established pain and sedation protocols.
Critically ill patients expected to stay in the ICU for at least 24 h with a Richmond Agitation and Sedation Scale (RASS) score of ≥−3 are included in the study. Patients are excluded from the study if they have traumatic brain injury, documented dementia in patient's medical chart, and inability to conduct valid delirium assessment. Delirium is diagnosed by trained ICU physicians and/or critical care clinical pharmacists using the ICDSC [Figure 1]. Assessments are performed once to twice daily.
A multi-faceted approach is utilized to train clinicians. Each investigator is instructed and trained on how to use the ICDSC through online materials to educate about delirium. An independent delirium expert will be available for questions. All data entries are performed using Research Electronic Data Capture tools. Each investigator is provided an access to the tool where a comprehensive manual describing the process of data entry and data collection is available. A training manual for the RASS and ICDSC in Arabic and English is provided for the investigators. A conference call explaining the application and pitfalls of the ICDSC is scheduled with all investigators. Standard descriptive statistics are used. Prevalence is calculated with 95% CI, α =0.05, and 5% level of significance. Logistic regression is used for dependent correlation.
This present study represents the first attempt to report the prevalence of ICU delirium in Saudi Arabia in a multicenter fashion. The availability of such data enforces the routine use of validated tools to screen for delirium in critical care units in Saudi Arabia, an algorithm can then be developed to determine the cause and a management strategy.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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