Journal Article Annotations
2020, 1st Quarter
Kemuel Philbrick, MD, FACLP
March 30th, 2020
Using the CAM-ICU and CAM-ICU-7 to detect and grade delirium, respectively, plasma levels of biomarkers IL-6, 8, 10, TNF alpha, and S100B collected early in critical illness were associated with fewer delirium/coma-free days and predicted average delirium severity.
Strength and weaknesses:
The authors conducted a multisite trial with 321 critically ill patients using standard delirium measurements and proactively drew plasma levels of several inflammatory mediators and S100B, a marker of astrocyte and glial activation which becomes elevated in the blood stream when the blood brain barrier is disrupted. This relationship persisted even after subgroup analysis excluding neurologic injury. Given the study design, no causal relationship could be established. All patients in the study had delirium, so no comparison with non-delirious patients was done. Serum biomarkers were drawn at only one time point so no trend could be examined.
This study adds to the growing body of literature supporting a relationship between these markers and delirium. Serum inflammatory biomarkers and S100B may not only be predictive of delirium duration but also severity, though further studies are needed. As of now, these labs are not widely available and take time to process though would be more accessible/less invasive than CSF tests.
Type of study:
Prospective cohort study
In this thoughtful study, the authors addressed a common problem, how to assess for delirium in patients with gross neurologic deficits, in this case after a hemorrhagic stroke. An attending neurointensivist performed daily assessments in a Neuro Critical Care Unit or Stroke Unit, including the CAM-ICU and ICDSC, in 60 patients. The authors noted that some delirium symptoms were easy to assess, including symptom fluctuation, psychomotor changes, sleep-wake disturbances, and impaired arousal. Others were more difficult to assess, including inattention, disorientation, and disorganized thinking (e.g., in aphasic or abulic patients). The authors noted that the ICDSC was much more sensitive and more specific than the CAM-ICU in this context.
Strength and weaknesses:
The assessment methods were rigorous, and the framing of the problem quite thoughtful. Unfortunately, like with most psychiatric conditions, we do not have a “gold standard” for delirium diagnosis.
This article is very helpful to review when attempting to determine whether a given patient is delirious post-stroke.
Type of study: prospective observational cohort study