<i>Delirium</i> severity and outcomes of critically ill COVID-19 patients

Rego, Luciana Leal do; Salluh, Jorge Ibrain Figueira; Souza-Dantas, Vicente Cés de; Silva, José Roberto Lapa e; Póvoa, Pedro; Serafim, Rodrigo Bernardo

doi:10.5935/2965-2774.20230170-en

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ORIGINAL ARTICLE • Crit. Care Sci. 35 (4) • Oct-Dec 2023 • https://doi.org/10.5935/2965-2774.20230170-en copy

Delirium severity and outcomes of critically ill COVID-19 patients

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

To investigate the impact of delirium severity in critically ill COVID-19 patients and its association with outcomes.

Methods:

This prospective cohort study was performed in two tertiary intensive care units in Rio de Janeiro, Brazil. COVID-19 patients were evaluated daily during the first 7 days of intensive care unit stay using the Richmond Agitation Sedation Scale, Confusion Assessment Method for Intensive Care Unit (CAM-ICU) and Confusion Method Assessment for Intensive Care Unit-7 (CAM-ICU-7). Delirium severity was correlated with outcomes and one-year mortality.

Results:

Among the 277 COVID-19 patients included, delirium occurred in 101 (36.5%) during the first 7 days of intensive care unit stay, and it was associated with a higher length of intensive care unit stay in days (IQR 13 [7 - 25] versus 6 [4 - 12]; p < 0.001), higher hospital mortality (25.74% versus 5.11%; p < 0.001) and additional higher one-year mortality (5.3% versus 0.6%, p < 0.001). Delirium was classified by CAM-ICU-7 in terms of severity, and higher scores were associated with higher in-hospital mortality (17.86% versus 34.38% versus 38.46%, 95%CI, p value < 0.001). Severe delirium was associated with a higher risk of progression to coma (OR 7.1; 95%CI 1.9 - 31.0; p = 0.005) and to mechanical ventilation (OR 11.09; 95%CI 2.8 - 58.5; p = 0.002) in the multivariate analysis, adjusted by severity and frailty.

Conclusion:

In patients admitted with COVID-19 in the intensive care unit, delirium was an independent risk factor for the worst prognosis, including mortality. The delirium severity assessed by the CAM-ICU-7 during the first week in the intensive care unit was associated with poor outcomes, including progression to coma and to mechanical ventilation.

Keywords:
Delirium; COVID-19; Coronavirus infections; Critical illness; Psychiatric status rating scales; Surveys and questionnaires; Risk factors; Prognosis; Critical care outcomes; Intensive care units

Clinical characteristics	Non delirium (n = 176)	Delirium (n = 101)	p value
Age	64.5 (52.8 - 72.0)	80.0 (67.0 - 87.0)	< 0.001
Sex (male)	128 (72.7)	67 (66.3)	0.3248
Body mass index	27.69 (24.9 - 31.4)	26.5 (23.8 - 30.5)	0.0848
Alcoholism	4 (2.3)	5 (4.9)	0.2939
Dementia/cognitive impairment	4 (2.3)	22 (21.8)	0.001
Chronic kidney disease	6 (3.4)	4 (3.9)	1.000
Corticosteroid use	56 (31.8)	25 (24.8)	0.2682
Acute respiratory failure	43 (24.4)	59 (58.4)	< 0.001
Hypertension	83 (47.2)	70 (69.3)	< 0.001
Obesity	58 (32.9)	32 (31.7)	0.9329
Imunossupression/cancer	23 (13.1)	24 (23.8)	0.0343
CAM-ICU-7	0 (0.0 - 0.0)	2.50 (1.3 - 4.3)	< 0.001
SAPS 3	44.0 (41.0 - 50.0)	54.0 (49.0 - 57.0)	0.001
Frailty (m-FI)	48 (27.3)	56 (55.6)	0.001
Charlson Comorbidities Index	0 (0.0 - 2.0)	3.0 (1.0 - 6.0)	0.001
E-predeliric	19.0 (14.0 - 26.0)	33.0 (25.0 - 43.0)	0.001
CRP mean Day 1	6.90 (3.7 - 13.9)	9.72 (5.3 - 17.2)	0.0478
Midazolam use	27 (15.0)	38 (37.6)	0.001
Fentanyl use	39 (22)	43 (42.5)	0.001
Neuromuscular blockade use	14 (7.9)	10 (9.9)	0.29
Propofol use	11 (6.2)	19 (18.8)	0.48
Dexmedetomedine use	26 (14.8)	48 (47.5)	0.001
Invasive mechanical ventilation	36 (20.4)	48 (47.5)	0.001

Outcomes	Non delirium	Delirium	p value
Length of ICU stay	6 (4 - 12)	13 (7 - 25)	< 0.001
Length of hospital stay	8 (5 - 14)	17 (9 - 37)	< 0.001
Invasive mechanical ventilation days	0 (0 - 0)	2 (0 - 10)	< 0.001
Progression to mechanical ventilation	2 (1.1)	38 (37.6)	< 0.001
Coma	30 (17.0)	44 (43.6)	< 0.001
In-hospital mortality	9 (5.1)	26 (25.7)	< 0.001
One-year (additional) mortality	1 (0.6)	4 (5.3)	< 0.001

Outcomes	Measures of effect (95%CI)	p value
Chance of hospital discharge	HR 0.5 (0.4 - 0.7)	< 0.001
Chance of ICU discharge	HR 0.53 (0.4 - 0.7)	< 0.001
Progression to mechanical ventilation	OR 51.35 (11.7 - 226.4)	< 0.001
In-hospital mortality	OR 3.04 (1.26 - 7.36)	< 0.014
One year (additional) mortality	OR 1.96 (0.25 - 15.39)	0.521

	CAM-ICU-7			p value
	Median (< 3)	Median (3 - 5.99)	Median (6 - 7)	p value
Total of patients	56	32	13
Mean SAPS 3	52.0 (44.0 - 57.0)	56.0 (49.0 - 58.5)	54.0 (50.0 - 63.0)	< 0.001
Frailty-m-FI	23 (41.07)	23 (71.88)	10 (76.92)	< 0.001
Mean CAM-ICU-7	1.4 (0.96 - 2.0)	4.0 (3.65 - 5.0)	6.5 (6.0 - 7.0)	< 0.001
ICU length of stay	12.00 (6.00 - 24.25)	16.50 (8.00 - 26.50)	13.00 (5.00 - 25.00)	< 0.001
Hospital length of stay	16.00 (8.00 - 40.00)	17.00 (9.75 - 28.50)	20.00 (13.00 - 44.00)	< 0.001
Evolution to MV	15 (26.79)	13 (40.62)	10 (76.92)	< 0.001
Mortality	10 (17.85)	11 (34.38)	5 (38.46)	< 0.001

Outcomes	CAM-ICU-7
	Mean (3 - 5.99)		Mean (6 - 7)
	Measures of effect (95%CI)	p value	Measures of effect (95%CI)	p value
Chance of hospital discharge	HR 0.6 (0.4 - 1.1)	0.084	HR 0.6 (0.3 - 1.2)	0.144
Chance of ICU discharge	HR 0.7 (0.4 - 1.1)	0.120	HR 0.59 (0.3 - 1.4)	0.220
Evolution to coma	OR 2.2 (0.8 - 5.9)	0.126	OR 7.1 (1.9 - 31.0)	0.005
Evolution to mechanical ventilation	OR 2.2 (0.8 - 6.0)	0.119	OR 11.09 (2.8 - 58.5)	0.002
Mortality	OR 1.46 (0.4 - 4.8)	0.534	OR 1.77 (0.4 - 7.6)	0.447
Late mortality	OR 1.61 (0.5 - 5.0)	0.410	OR1.62 (0.4 - 6.7)	0.514

Associação de Medicina Intensiva Brasileira - AMIB Rua Arminda, 93 - 7º andar - Vila Olímpia, CEP: 04545-100, Tel.: +55 (11) 5089-2642 - São Paulo - SP - Brazil
E-mail: ccs@amib.org.br

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[1] Conflicts of interest: None.