Video

Brief Oral Papers

Session: Oral Presentation Session 08: Neurocognitive Disorders, Delirium and Neuropsychiatry

Delirium During Intubation in Traumatic Brain Injury (TBI) Compared to Non-TBI Patients in Neuro Critical Care

Friday, November 11, 2022

2:15 PM – 3:45 PM

Location: Room 204-205

Presenting Author(s)

Thomas Arikian, MD candidate

Medical Student
Stritch School of Medicine
Chicago, Illinois

PDF

Co-Author(s)

BS

Brenda Swartz, PsyD.

Assistant Professor: Psychiatry and Behavioral Neurosciences
Loyola University Chicago: Stritch School of Medicine
Maywood, Illinois
Muhammad Nouman

Medical Student
Stritch School of Medicine
Lombard, IL
RC

Renzo Costa

Fourth Year Medical Student
Loyola University Chicago Stritch School of Medicine
Chicago, Illinois
Conrad Stasieluk, MD (he/him/his)

Resident-Physician
Loyola University Medical Center
Maywood, Illinois
EM

Edwin Meresh, MD, MPH, FACLP

Professor of Psychiatry
Loyola University Medical Center
Maywood, Illinois

Abstract:

Background: Mechanical ventilation (MV) leads to higher delirium rates; costs associated with delirium in MV patients in the US alone are 4–16 billion dollars per year and delirium in ICU patients is associated with increased duration of MV and risk of mortality^1,2,3. Delirium in TBI patients leads to poor outcomes⁴.

Objective: Dexmedetomidine and propofol are commonly used sedatives in neurocritical care. The purpose of this research is to assess the impact of delirium on intubated TBI versus non-TBI patients.

Methods: In this retrospective chart review, intubated TBI and non-TBI patients (Neurosurgery, Substance related, Seizures, Brain Hemorrhage) in the neuro ICU from 2015-2020 were identified. The following data were collected: intubation and extubation date, propofol and dexmedetomidine administration, length of ICU stay, evidence of delirium, and Glasgow Coma Scale. Preliminary analyses examined characteristics and distributions of all variables of interest. T-test analysis examined length of intubation difference by medication group.

Results: TBI n=100, mean age of 42.9, administration of propofol n=55, propofol and dexmedetomidine n=26, dexmedetomidine n=3, midazolam and fentanyl n=16.

Delirium: TBI 37/100 (37%), delirium in propofol group n=10 (18%), propofol and dexmedetomidine n=12 (46%), midazolam and fentanyl n=14 (87%).

Non-TBI n=155, mean age: 62.9

Propofol n=87, propofol and dexmedetomidine n=56, dexmedetomidine n=12.

Delirium: 51/155 (33%), delirium in propofol group n=25 (28%), propofol and dexmedetomidine n=23 (41%).

Length of intubation time (days): TBI 4.67, non-TBI 2.37.

T-test showed a significant difference between TBI and non-TBI group intubation times: average (p< 0.0001), propofol only (p=0.0002), dexmedetomidine only (p=0.0007), combination therapy (p=0.0068). Combination therapy intubation time was longer compared to the propofol group (p=0.0415 TBI; p=0.0008 non-TBI). Patients who received precedex >24 hours after propofol: 39.1% non-TBI, 58% TBI.

Discussion: As dexmedetomidine is commonly given for agitation control, it is likely that more patients in TBI group required dexmedetomidine after 24 hours compared to non-TBI as intubation time is prolonged in TBI. Delirium and prolonged intubation time in TBI compared to non-TBI could be related to diffuse brain injury, co-morbid substance use, and underlying mental illness (younger age group).

Conclusion: Prospective studies are required to determine whether delirium prolongs intubation time in TBI and if early initiation of dexmedetomidine could prevent delirium.

References:

1.Arumugam, S., et al. (2017). Delirium in the Intensive Care Unit. Journal of emergencies, trauma, and shock, 10(1), 37–46.

2.Ely EW et al. The impact of delirium in the Intensive Care Unit on hospital length of stay. Intensive Care Med. 2001;27:1892–900.

3.Ely EW et al. Delirium as a predictor of mortality in mechanically ventilated patients in the Intensive Care Unit. JAMA. 2004;291:1753–62.

4.Roberson SW et al. Challenges of Delirium Management in Patients with Traumatic Brain Injury: From Pathophysiology to Clinical Practice. Curr Neuropharmacol. PMID: 33463474.