الفهرس 
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Abstract
Summary
ICU delirium is a common medical problem in patients admitted to intensive care units (ICUs). Delirium is an acute condition, usually reversible, resulting directly from a disease, intoxication or withdrawal of psychoactive substances, use of drugs, effects of toxins and stress or combined action of all the factors mentioned above (Kotfis et al., 2020).
Postoperative delirium was categorized according to the time point at which delirium is diagnosed related to the surgical intervention. Emergence delirium is defined as psychomotor agitation that occurs as the patient rises from general anaesthesia. Post-anesthesia care unit (PACU) delirium refers to a disturbance in mental status occurring after waking but prior to discharge from a PACU. When the patient is discharged from the PACU to the hospital ward or ICU, mental status changes that meet delirium diagnosis criteria are defined as postoperative delirium (Rangel et al., 2018).
Delirium has many costs to the health system and, importantly, to patients after elective surgery. Patients who experience an episode of delirium are at an increased risk of extended mechanical ventilation, prolonged ICU stay, increased hospital financial costs, with a higher risk of readmission, increased hospital mortality and are more likely to develop long-term cognitive impairment (Krewulak et al., 2020).
Postoperative delirium (POD) increases morbidity rates through impairment of cognitive functions, by supporting the loss of functional self-rule, or by increasing the risk for falls and other complications associated with prolonged bed rest. In addition, POD is an independent predicting factor for postoperative mortality after other types of surgery (LaHue et al., 2019).
Aim of the study:
The present study aimed to identify the relation between delirium symptoms and patients’ outcomes during the postoperative period in the intensive care unit through:
1. Identifye the delirium symptoms of patients during the postoperative period in the intensive care unit.
2. Identifye the outcomes of patients with delirium during the postoperative period in the intensive care unit.
3. Identifye the incidence of delirium among patients during the postoperative period in the intensive care unit.
4. Assesse the risk factors of delirium among patients during the postoperative period in the intensive care unit.
5. Assesse the relation between delirium symptoms and patients’ outcomes during the postoperative period in the intensive care unit.
Research questions:
1. What are the symptoms of delirium among patients during the postoperative period in the intensive care unit?
2. What are the outcomes of postoperative patients with delirium in the intensive care unit?
3. What is the incidence of delirium among patients during the postoperative period in the intensive care unit?
4. What are the risk factors of delirium during the postoperative period for patients in the intensive care unit?
5. Is there a relation between delirium symptoms and patients’ outcomes during postoperative period in the intensive care unit?
Research design:
The descriptive correlational research design was utilized to achieve the aim of this study.
Study setting:
This study was conducted in the surgical intensive care unit (ICUs) at El-demerdash Hospital affiliated to Ain Shams University Hospitals. It consists of five (5) sections containing forty-two (42) beds. Classified as following; two (2) clean postoperative surgical incision sections containing twenty-two (22) beds, two (2) sections for patients with postoperative septic surgical incision including fourteen (14) beds, and an isolation section for patients with highly infectious diseases containing six (6) beds. The researcher selected this setting because she is a nursing supervisor in the selected previously mentioned setting, and she observed that there is several patients who have delirium postoperatively and want to search in this topic.
Subjects:
The subjects of the present study included a purposive sample of 325 patients, with an inclusion criterion: all adult patients >18 years old, patients who developed delirium symptoms postoperatively in the intensive care unit post 24 hours after admission, from both genders and conscious patients with 15 points according to Glasgow coma scale upon admission to the ICU.
While the exclusion criteria include patients who are diagnosed with delirium at the time of admission to the intensive care unit, comatose throughout their stay in the ICU and severely aphasic which interfering with the assessment.
Tool of data collection:
Data was collected through the following three main tools:
1. Patient assessment questionnaire:
This tool is concerned with assessing the demographic characteristics and clinical data of the postoperative patients with delirium in the intensive care unit who are included in the study. This tool was developed by the researcher in English language based on the related literatures (Jayaswal et al., 2019). It consists of two parts:
Part I: Patients demographic characteristics: This part was used to assess patients’ demographic characteristics such as age, gender, occupation, marital status, educational level, and residence.
Part II: Patients clinical data: This part was used to assess past, present and family history of patients. The past history includes four questions regarding the presence of chronic disease, previous hospitalization, previous delirium symptoms and surgery.
2. The Richmond Agitation-Sedation Scale (RASS):
This tool was used to assess the first item in the Intensive Care Delirium Screening Checklist. The RASS was adopted from Sessler et al. (2002). It is a validated and reliable method to assess patient’s level of sedation in the intensive care unit. It consists of 10 points with discrete criteria, four levels of agitation (+1 to +4), one level for calm and alert state (0), and five levels of sedation (−1 to −5). It is administered in three steps sequence (observation, response to verbal stimulation and response to physical stimulation).
3. Intensive Care Delirium Screening Checklist (ICDS):
This tool used to assess delirium for patients on mechanical ventilator, and verbally communicating patients. The ICDSC was adopted from Bergeron et al. (2001). It is consisted of 8-items designed for the bedside caregiver. The 8 items include altered level of consciousness, inattention, disorientation, hallucinations, psychomotor agitation / retardation, inappropriate mood/speech, sleep/wake cycle disturbance, and symptom fluctuation.
4. Outcomes assessment questionnaire:
This tool was developed by the researcher based on the related literature (Jayaswal et al., 2019). It was developed in English language to assess the outcomes of patients with delirium during the postoperative period in the intensive care unit. It consisted of fourteen (14) questions.The outcomes of delirium was assessed by calculating the duration of delirium sign and symptoms, assessing the type of delieium, calculating the numbers of days on the mechanical ventilator, the need for re-intubation, the incidence rate of unplanned removal of tubes or catheters by the patient, length of stay (LOS) in the intensive care unit, patient`s discharge from ICU, in-hospital mortality, permanent or temporary cognitive dysfunction, occurrence of acute kidney injury, stroke, limb ischemia, spinal cord ischemia and intensive care unit readmission.
Results:-
The results of the study showed that:
The current study revealed that, less than three quarters of studied patients had age > 40 years with a mean age 52.86 ± 16.22.
More than three quarters of studied patients were suffered from chronic disorders, and more than half of studied patients had diabetes mellitus and less than half of them had hypertension.
Only 4% of studied patient had history of delirium.
Less than one tenth of studied patients had a family history of mental disorder, and Alzheimer constiutes less than two thirds from theses disorder.
More than one third of studied patients had diabetic foot and performed amputation surgery, and more than one fifth of studied patients had cerebrovascular disorder as a preoperative diagnosis and performed craniotomy surgery.
More than one tenth of studied patients had a history of smoking, as well; only 0.6% of studied patients had a history of alcohol intake.
More than two fifths of studied patients administered with propofol, as well, more than one third of studied patients administered with thiopental (barbiturate) as anesthetic drugs.
More than one quarter of studied patients took nalufin (opioids), and more than one sixth of studied patients took midazolam (benzodiazepines) as analgesic drugs.
More than one quarter of studied patients had a major surgery, as well, more than one quarter of the studied patients had electrolyte imbalance as a risk factor of delirium.
More than one half of the studied patients were anxious from separation from their family, and more than two fifth had lack of privacy as environmental stressors that could lead to delirium.
More than one half of the studied patients had a mild pain and more than one quarter had no pain.
Less than three quarters of the studied patient were alert and calm and more than one quarter of the studied patient were restless, agitated, and light sedated.
Less than one quarter of the studied patients had delirium and one fifth of them had a delirium’s of < 10 days and only 2.5% of them had a delirium’s duration of ≥10 days.
More than one half of patients with delirium in the study had hypoactive delirium; more than one fifth of patients with delirium in the study had hyperactive delirium. In addition to, more than one fifth of patients with delirium in the study had a mixed type of delirium.
More than one fifth of patients with delirium in the study stayed on mechanical ventilator for duration of ≥ 5 days.
Two fifths of patients with delirium in the study removed intravenous lines (cannulas) and less than two fifths of patients with delirium in the study were reintubated after self-extubation.
Less than three quarters of patients with delirium in the study had duration of hospital stay from 5-10 days.
More than two thirds of patients with delirium were discharged from ICU and more than one third of patients with delirium died in the ICU, while only 8.5% of them were re-admitted to ICU.
One third of patients with delirium in the study had cognitive impairment, as well, about tenth of patients with delirium in the study had stroke as delirium complications.
There was no statistical relation between occurrence of delirium and the studied patients’ gender, residence, marital status, educational level, and occupation p- value >0.05 for all variables.
There was statistical relation between occurrence of delirium and increased the studied patient’s age p- value < 0.05.
There was no statistical relation between duration of surgery and occurrence of delirium p- value > 0.05.
There was highly statistically relation between occurrence of delirium and hypertension/hypotension and electrolyte imbalance with P < 0.01 for both. And there was statistically relation between occurrence of delirium and sepsis as well with the use of sedatives/muscle relaxants with p- value < 0.05.
There was highly statistically significant relation between occurrence of delirium and sensory deficits with p- value < 0.01. There was statistically significant relation between the occurrence of delirium and separation from family and lack of privacy with p- value < 0.05.
There was no statistical relation between type of delirium and the ICU studied patients’ mortality rate, acute kidney injury, stroke, and re-admission to ICU with p- value > 0.05 for all variables.
There was a statistical relation between type of delirium and the studied patients’ cognitive impairment p- value < 0.05.
Conclusion
Delirium symptoms altered patients’ level of consciousness, attention, orientation and developed hallucinations, psychomotor agitation / retardation, sleep/wake cycle disturbance, inappropriate mood/speech, and symptom fluctuation. As well, the results illustrated that the outcomes associated with delirium among patients in the intensive care unit including increase period of stay on the mechanical ventilator, re-intubation, readmission, unplanned removal of tubes or catheters by the patient, increase length of stay in the intensive care unit, increase duration of delirium sign and symptoms and cognitive. As regard to incidence of delirium among the studied patients during the postoperative period in the ICU was 23.4%. The results illustrated that the risk factors associated with delirium development among patients in the intensive care unit includes advanced age, sepsis, cognitive impairment, electrolyte imbalance, chronic diseases, sensory deprivation, and sedation. There was statistical relation between occurrence of delirium and increased the studied patient’s age, hypertension/hypotension and electrolyte, sepsis as well with the use of sedatives/muscle relaxants, separation from family and lack of privacy. There was a statistical relation between type of delirium and the studied patients’ cognitive impairment.
Recommendations:
The results of this study projected the following recommendations: -
For patients:
Avoid the stressors in the ICU environmental as these stressors increase the incidence of delirium.
A simplified and comprehensive booklet should be available for postoperative patients who suffered from delirium after discharge including information regarding delirium, therapeutic regime, and self-care.
Encourage long term multidisciplinary care and follow up visits for postoperative patients who suffered from delirium (during the postoperative period) after discharge to avoid readmission to hospital and prevent long term outcomes of delirium.
In services:
Patients’ assessment for delirium during the postoperative period should be started from the first day of their admission to the intensive care unit.
Establishing training programs in hospitals, focusing on the short and long-term care for patients with delirium during postoperative period.
Further Nursing research:
The study should be replicated using a large sample in different hospital settings to generalize the results and evaluate the appropriate frequency of delirium and the relation between the delirium symptoms and patients’ outcomes during the postoperative period in the intensive care unit.
As well further research are recommended to study the risk factors and outcomes of delirium, as well as more research with intervention action is needed to develop a comprehensive body of evidence upon which the base nursing care of delirium is applied to improve patients’ outcomes.