PubMed Health⌕ Search

Biomedical subjects

E Wesley Ely

Publications and source records attributed to E Wesley Ely.

At least 19 recordsLinked to original sources
PubMed2007

Apolipoprotein E4 polymorphism as a genetic predisposition to delirium in critically ill patients.

OBJECTIVE: To test for an association between apolipoprotein E (APOE) genotypes and duration of intensive care unit delirium. DESIGN: Prospective, observational cohort study. SETTING: A 541-bed, community-based teaching hospital. PATIENTS: Fifty-three mechanically ventilated intensive care unit patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: All patients were managed with standardized sedation and ventilator weaning protocols as part of an ongoing clinical trial and were evaluated prospectively for delirium with the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). DNA was extracted from whole blood samples obtained on enrollment, and APOE genotype was determined using polymerase chain reaction followed by restriction enzyme digestion by investigators blinded to the clinical information. Delirium occurred in 47 (89%) patients at some point during the intensive care unit stay. Of the 53 patients, 12 (23%) had an APOE4 allele (APOE4+) and 41 (77%) had only APOE2 or APOE3 alleles (APOE4-). APOE4+ patients were younger (53.2 +/- 21.9 vs. 65.4 +/- 13.4, p = .08) and less often admitted for pneumonia (0% vs. 29.3%, p = .05) compared with APOE4- patients, yet they had a duration of delirium that was twice as long: median (interquartile range), 4 (3, 4.5) vs. 2 (1, 4) days (p = .05). No other clinical outcomes were significantly different between the APOE4+ and APOE4- patients. Using multivariable regression analysis to adjust for age, admission diagnosis of sepsis or acute respiratory distress syndrome or pneumonia, severity of illness, and duration of coma, the presence of APOE4 allele was the strongest predictor of delirium duration (odds ratio, 7.32; 95% confidence interval, 1.82-29.51, p = .005). CONCLUSIONS: APOE4 allele represents the first demonstrated genetic predisposition to longer duration of delirium in humans.

Aged↗
PubMed2007

Long-term cognitive, emotional, and functional outcomes in trauma intensive care unit survivors without intracranial hemorrhage.

BACKGROUND: Trauma patients without intracranial hemorrhage or focal neurologic deficits are typically considered low risk for lasting neuropsychological and emotional deficits, and such sequela may be overlooked, especially in those with skull fractures and concussions. We undertook this study to determine the prevalence of and risk factors for persistent cognitive impairment and emotional and functional difficulties in a sample of adult trauma intensive care unit survivors without intracranial hemorrhage. METHODS: We queried the Vanderbilt University Trauma Registry for all patients admitted during 2003 with an Injury Severity Score >25 and a head computed tomography scan showing no intracranial hemorrhage. Of the 97 patients identified, 58 were evaluated, in person between 12 to 24 months after hospital discharge, with a comprehensive battery of cognitive, emotional, and functional instruments. The Informant Questionnaire of Cognitive Decline in the Elderly-Short Form (IQCODE-SF) was used to evaluate for pre-existing cognitive deficits in patients suspected of having cognitive impairment before their trauma. RESULTS: A total of 33 (57%) patients were determined to have cognitive impairment, which was most pronounced in the domains of attention and executive functioning/verbal fluency. Of these patients, one (3%) was determined by the IQCODE-SF to be cognitively impaired before trauma intensive care unit hospitalization. Of the 58 patients studied, 21 (36.2%) had a concussion or skull fracture and 37 (63.8%) had neither. Cognitive impairment was significantly more likely to occur in patients who sustained a concussion or skull fracture than in trauma patients who did not (81% versus 43%; p = 0.006). Patients reported significant depressive symptoms (56%), significant symptoms of posttraumatic stress disorder (38%), and significant symptoms of anxiety (29%). Quality of life scores were lower than in the general United States population and employment difficulties were widespread. A total of 34% of patients reported being unemployed at follow-up, and cognitive impairment was more common among these patients compared with patients in the workforce (p = 0.03). Neither cognitive impairment nor emotional dysfunction was associated with age, sex, race, Injury Severity Score, blood loss, ventilatory days, or intramedullary nailing of long-bone fractures. CONCLUSIONS: The majority of trauma survivors without intracranial hemorrhage display persistent cognitive impairment, which is nearly twice as likely in those with skull fractures or concussions. This cognitive impairment was associated with functional defects, poor quality of life, and an inability to return to work. Future research must delineate modifiable risk factors for these poor outcomes, especially in patients with skull fractures and concussions, to help improve long-term cognitive and functional status.

Activities of Daily Living↗
PubMed2006

Brain dysfunction: another burden for the chronically critically ill.

BACKGROUND: Chronic critical illness is a devastating syndrome of prolonged respiratory failure and other derangements. To our knowledge, no previous research has addressed brain dysfunction in the chronically critically ill, although this topic is important for medical decision making. METHODS: We studied a prospective cohort of 203 consecutive, chronically critically ill adults transferred to our hospital's respiratory care unit (RCU) after tracheotomy for failure to wean. We measured prevalence and duration of coma and delirium during RCU treatment using the Confusion Assessment Method for the Intensive Care Unit with the Richmond Agitation-Sedation Scale. To assess survivors (at 3 and 6 months after RCU discharge), we used a validated telephone Confusion Assessment Method. RESULTS: Before hospitalization, most (153 [75.4%]) of the 203 patients in the study were at home, completely independent (115 [56.7%]), and cognitively intact (116 [82.0%]). In the RCU, 61 (30.0%) were comatose throughout the stay. Approximately half of patients (66 of 142) who were not in coma were delirious. Patients spent an average of 17.9 days (range, 1-153 days) in coma or delirium (average RCU stay, 25.6 days). Half of survivors (79 of 160) had one of these disturbances at RCU discharge. At 6 months, three fourths (151) of the study patients were dead or institutionalized; of 85 survivors, 58 (68.2%) were too profoundly impaired to respond to telephone cognitive assessment, and 53 (62.4%) were dependent in all activities of daily living. CONCLUSIONS: Severe, prolonged, and permanent brain dysfunction is a prominent feature of chronic critical illness. These data, together with previous reports of symptom distress and rates of mortality and institutionalization, describe burdens for chronically critically ill patients receiving continued life-prolonging treatment and for their families.

Adult↗
PubMed2006

Sedative and analgesic medications: risk factors for delirium and sleep disturbances in the critically ill.

Sedatives and analgesics are routinely used in critically ill patients, although they have the potential for side effects, such as delirium and sleep architecture disruption. Although it should be emphasized that these medications are extremely important in providing patient comfort, health care professionals must also strive to achieve the right balance of sedative and analgesic administration through greater focus on reducing unnecessary or overzealous use. Ongoing clinical trials should help us to understand whether altering the delivery strategy, via daily sedation interruption, or protocolized target-based sedation or changing sedation paradigms to target different central nervous system receptors can affect cognitive outcomes and sleep preservation in our critically ill patients.

Aged↗
PubMed2006

Delirium and cognitive dysfunction in the intensive care unit.

Delirium remains a non recognized, but highly prevalent, form of organ dysfunction in the intensive care unit (ICU). Intensive care physicians have begun to benefit from elucidation of risk factors for delirium in the ICU, some of which are modifiable, whereas others are not. In the last 5 years, a new tool for use in detecting delirium among critically ill patients has been adapted, validated, and found objectively reliable for use at the bedside by nonpsychiatrists. Moreover, that tool-the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU)-has enabled determination of the serious sequelae of delirium, including increased mortality, higher cost, longer length of hospital stay, failure of extubation, and burdensome long-term cognitive impairment. Although prevention and treatment options exist, little data guide current pharmacological approaches to delirium, and nonpharmacological approaches have yet to be fully adopted by ICUs. Ongoing trials will address some of these limitations, but large cohort studies within the ICU are needed to further clarify risk factors and to identify targets to modify the occurrence and course of delirium. Furthermore, consideration of a continuum may better elucidate the true magnitude of acute brain dysfunction in the ICU.

Aged↗
PubMed2006

Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients.

BACKGROUND: Delirium has recently been shown as a predictor of death, increased cost, and longer duration of stay in ventilated patients. Sedative and analgesic medications relieve anxiety and pain but may contribute to patients' transitioning into delirium. METHODS: In this cohort study, the authors designed a priori an investigation to determine whether sedative and analgesic medications independently increased the probability of daily transition to delirium. Markov regression modeling (adjusting for 11 covariates) was used in the evaluation of 198 mechanically ventilated patients to determine the probability of daily transition to delirium as a function of sedative and analgesic dose administration during the previous 24 h. RESULTS: Lorazepam was an independent risk factor for daily transition to delirium (odds ratio, 1.2 [95% confidence interval, 1.1-1.4]; P = 0.003), whereas fentanyl, morphine, and propofol were associated with higher but not statistically significant odds ratios. Increasing age and Acute Physiology and Chronic Health Evaluation II scores were also independent predictors of transitioning to delirium (multivariable P values < 0.05). CONCLUSIONS: Lorazepam administration is an important and potentially modifiable risk factor for transitioning into delirium even after adjusting for relevant covariates.

APACHE↗
PubMed2006

Radiographic measures of intravascular volume status: the role of vascular pedicle width.

PURPOSE OF REVIEW: A valid, low-cost, high-yield instrument to assess intravascular volume status in critically ill patients does not exist. The portable chest X-ray is a common part of any intensivist's or chest clinician's daily rounds. RECENT FINDINGS: A simple, objective, valid measure of intravascular volume status, the vascular pedicle width, remains underappreciated in the medical literature. While more invasive, more expensive, and less common technologies are looked upon to assist in the clinical evaluation of volume status among critically ill patients, the vascular pedicle width stands alone in its low-cost, nearly risk-free potential to impact clinical practice. Even as the daily chest X-ray has become less common in practice, the role of measuring vascular pedicle width is potentially significant, particularly among mechanically ventilated patients. A standardized approach to reading the portable chest X-ray (supine or erect) is needed to facilitate interpretation of complex medical problems among the critically ill. Prospective evaluation of its appropriate use, particularly as compared with other, typically more invasive measures of intravascular volume, is warranted. SUMMARY: Vascular pedicle width measurement using a standardized approach to daily chest X-ray interpretation represents untapped potential for improving the non-invasive assessment of volume status in critically ill patients.

Blood Vessels↗
PubMed2006

Delirium and its motoric subtypes: a study of 614 critically ill patients.

OBJECTIVES: To describe the motoric subtypes of delirium in critically ill patients and compare patients aged 65 and older with a younger cohort. DESIGN: Prospective cohort study. SETTING: The medical intensive care unit (MICU) of a tertiary care academic medical center. PARTICIPANTS: Six hundred fourteen MICU patients admitted during a process improvement initiative to monitor levels of sedation and delirium. MEASUREMENTS: MICU nursing staff assessed delirium and level of consciousness in all MICU patients at least once per 12-hour shift using the Confusion Assessment Method for the Intensive Care Unit and the Richmond Agitation-Sedation Scale. Delirium episodes were categorized as hypoactive, hyperactive, and mixed type. RESULTS: Delirium was detected in 112 of 156 (71.8%) subjects aged 65 and older and 263 of 458 (57.4%) subjects younger than 65. Mixed type was most common (54.9%), followed by hypoactive delirium (43.5%) and purely hyperactive delirium (1.6%). Patients aged 65 and older experienced hypoactive delirium at a greater rate than younger patients (41.0% vs 21.6%, P<.001) and never experienced hyperactive delirium. Older age was strongly and independently associated with hypoactive delirium (adjusted odds ratio=3.0, 95% confidence interval=1.7-5.3), compared with no delirium in a model that adjusted for other important determinants of delirium including severity of illness, sedative medication use, and ventilation status. CONCLUSION: Older age is a strong predictor of hypoactive delirium in MICU patients, and this motoric subtype of delirium may be missed in the absence of active monitoring.

Age Factors↗
PubMed2005

The immunopathogenesis of sepsis in elderly patients.

Prominent among the numerous events that contribute to the enhanced susceptibility of elderly patients to infection is the decline of immune function that accompanies aging. Elderly patients experience a marked decline in cell-mediated immune function and reduced humoral immune function. Age-dependent defects in T and B cell function are readily demonstrable in elderly patients, yet the essential elements of innate immunity are remarkably well preserved. The cytokine and chemokine signaling networks are altered in elderly patients and tends to favor a type 2 cytokine response over type 1 cytokine responses. The induction of proinflammatory cytokines after septic stimuli is not adequately controlled by anti-inflammatory mechanisms in elderly persons. This immune dysregulation is accompanied by a more pronounced procoagulant state in older patients. These molecular events function in concert to render elderly patients at excess risk for mortality from severe sepsis and septic shock.

Aged↗
PubMed2005

Intensive care unit delirium is an independent predictor of longer hospital stay: a prospective analysis of 261 non-ventilated patients.

INTRODUCTION: Delirium occurs in most ventilated patients and is independently associated with more deaths, longer stay, and higher cost. Guidelines recommend monitoring of delirium in all intensive care unit (ICU) patients, though few data exist in non-ventilated patients. The study objective was to determine the relationship between delirium and outcomes among non-ventilated ICU patients. METHOD: A prospective cohort investigation of 261 consecutively admitted medical ICU patients not requiring invasive mechanical ventilation during hospitalization at a tertiary-care, university-based hospital between February 2002 and January 2003. ICU nursing staff assessed delirium and level of consciousness at least twice per day using the Confusion Assessment Method for the ICU (CAM-ICU) and Richmond Agitation-Sedation Scale (RASS). Cox regression with time-varying covariates was used to determine the independent relationship between delirium and clinical outcomes. RESULTS: Of 261 patients, 125 (48%) experienced at least one episode of delirium. Patients who experienced delirium were older (mean +/- SD: 56 +/- 18 versus 49 +/- 17 years; p = 0.002) and more severely ill as measured by Acute Physiology and Chronic Health Evaluation II (APACHE II) scores (median 15, interquartile range (IQR) 10-21 versus 11, IQR 6-16; p < 0.001) compared to their non-delirious counterparts. Patients who experienced delirium had a 29% greater risk of remaining in the ICU on any given day (compared to patients who never developed delirium) even after adjusting for age, gender, race, Charlson co-morbidity score, APACHE II score, and coma (hazard ratio (HR) 1.29; 95% confidence interval (CI) 0.98-1.69, p = 0.07). Similarly, patients who experienced delirium had a 41% greater risk of remaining in the hospital after adjusting for the same covariates (HR 1.41; 95% CI 1.05-1.89, p = 0.023). Hospital mortality was higher among patients who developed delirium (24/125, 19%) versus patients who never developed delirium (8/135, 6%), p = 0.002; however, time to in-hospital death was not significant the adjusted (HR 1.27; 95% CI 0.55-2.98, p = 0.58). CONCLUSION: Delirium occurred in nearly half of the non-ventilated ICU patients in this cohort. Even after adjustment for relevant covariates, delirium was found to be an independent predictor of longer hospital stay.

Cohort Studies↗
PubMed2005

Narcotic-based sedation regimens for critically ill mechanically ventilated patients.

Sedatives and analgesics are routinely used in the intensive care unit to relieve pain and anxiety. These agents have numerous side effects and may contribute to poor outcomes such as increased length of mechanical ventilation, longer ICU stays and acute and long-term cognitive dysfunction. Modifying sedation paradigms utilizing either narcotic-based regimens with remifentanil or fentanyl, or by using alpha2 agonists such as dexmedetomidine may help in improving these outcomes in critically ill patients.

Procedural Sedation↗
PubMed2005

Insights into severe sepsis in older patients: from epidemiology to evidence-based management.

Up to 60% of patients who develop severe sepsis in the United States are > or =65 years of age, and the incidence of sepsis in this population is steadily increasing. Elderly individuals have an increased risk of developing sepsis, compared with younger patients, because of frequent comorbidities, institutionalization, declining performance status, and altered immune function. The clinical presentation of older patients with sepsis is often atypical, leading to a difficult and delayed diagnosis. Although increasing age appears to confer a high risk of death due to severe sepsis, recent evidence shows that many older patients respond well to selected interventions when the interventions are initiated in a timely fashion. Newly published clinical practice guidelines outline key recommendations regarding the treatment of patients with severe sepsis. Clinicians must be aware of the level of evidence in support of various interventions and must keenly screen older survivors for ongoing deficits that will limit their functional recovery.

Adolescent↗
PubMed2005

Short-term outcomes in older intensive care unit patients with dementia.

OBJECTIVE: To determine the impact of dementia on the outcomes of intensive care unit (ICU) care and use of ICU interventions among older patients. DESIGN: Prospective observational cohort study. SETTING: Urban university teaching hospital. PATIENTS: Patients were 395 patients age >/=65 consecutively admitted to a medical ICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Dementia was determined by a previously validated proxy measure, the Modified Blessed Dementia Rating Scale. We chose cut points to focus on patients with moderate-severe dementia at baseline. Our primary outcomes included length of mechanical ventilation and ICU and hospital length of stay. Secondary outcomes included ICU readmission, changes in code status, discharge location, mortality, and use of ICU interventions. Medical record abstraction was performed to determine the rates of ICU outcomes, use of ICU interventions, and potential confounders. Our study documented a prevalence of moderate-severe dementia of 17% in patients age >/=65 admitted to the ICU. Patients with dementia were significantly older (80 vs. 76), more likely to be female (65% vs. 52%), and more likely to be admitted from a nursing home (46% vs. 11%). Patients with dementia had significantly higher Acute Physiology and Chronic Health Evaluation II scores on admission to the ICU (25 vs. 23). Patients with dementia were more likely to have their code status changed to less aggressive in the ICU (24% vs. 14%). There was no significant difference in readmission to the ICU, discharge location, ICU or hospital mortality rate, or use of ICU interventions between patients with and without dementia. CONCLUSIONS: Our study documents no difference in outcomes from ICU care in older patients with and without dementia. There was no increased short-term mortality rate in older patients with dementia compared with those without dementia after admission to the ICU. Presumptions that outcomes from critical care are less favorable in patients with dementia should not drive treatment decisions in the ICU.

Aged↗
PubMed2005

Large-scale implementation of sedation and delirium monitoring in the intensive care unit: a report from two medical centers.

OBJECTIVE: To implement sedation and delirium monitoring via a process-improvement project in accordance with Society of Critical Care Medicine guidelines and to evaluate the challenges of modifying intensive care unit (ICU) organizational practice styles. DESIGN: Prospective observational cohort study. SETTING: The medical ICUs at two institutions: the Vanderbilt University Medical Center (VUMC) and a community Veterans Affairs hospital (York-VA). SUBJECTS: Seven hundred eleven patients admitted to the medical ICUs for >24 hrs and followed over 4,163 days during a 21-month study period. INTERVENTIONS: Unit-wide nursing documentation was changed to accommodate a sedation scale (Richmond Agitation-Sedation Scale) and delirium instrument (Confusion Assessment Method for the ICU). A 20-min introductory in-service was performed for all ICU nurses, followed by graded, staged educational interventions at regular intervals. Data were collected daily for compliance, and randomly 40% of nurses each day were chosen for accuracy spot-checks by reference raters. An implementation survey questionnaire was distributed at 6 months. MEASUREMENTS AND MAIN RESULTS: The implementation project involved 64 nurses (40 at VUMC and 24 at York-VA). Sedation and delirium monitoring data were recorded for 711 patients (614 at VUMC and 97 at York-VA). Compliance with the Richmond Agitation-Sedation Scale was 94.4% (21,931 of 23,220) at VUMC and 99.7% (5,387 of 5,403) at York-VA. Compliance with the Confusion Assessment Method for the ICU was 90% (7,323 of 8,166) at VUMC and 84% (1,571 of 1,871) at York-VA. The Confusion Assessment Method for the ICU was performed more often than requested on 63% of shifts (5,146 of 8,166) at VUMC and on 8% (151 of 1871) of shifts at York-VA. Overall weighted-kappa between bedside nurses and references raters for the Richmond Agitation-Sedation Scale were 0.89 (95% confidence interval, 0.88 to 0.92) at VUMC and 0.77 (95% confidence interval, 0.72 to 0.83) at York-VA. Overall agreement (kappa) between bedside nurses and reference raters using the Confusion Assessment Method for the ICU was 0.92 (95% confidence interval, 0.90-0.94) at VUMC and 0.75 (95% confidence interval, 0.68-0.81) at York-VA. The two most-often-cited barriers to implementation were physician buy-in and time. CONCLUSIONS: With minimal training, the compliance of bedside nurses using sedation and delirium instruments was excellent. Agreement of data from bedside nurses and a reference-standard rater was very high for both the sedation scale and the delirium assessment over the duration of this process-improvement project.

Adult↗
PubMed2005

Delirium: acute cognitive dysfunction in the critically ill.

PURPOSE OF REVIEW: The management of sepsis and the multiple organ dysfunction syndrome has traditionally been centered on dysfunction of organs other than the brain (e.g., heart, lungs, or kidneys), although the brain is one of the most prevalent organs involved. Recent studies indicate that nonpulmonary acute organ dysfunction may contribute significantly to mortality and other important clinical outcomes. Acute confusional states (delirium) occur in 10 to 60% of the older hospitalized population and in 60 to 80% of patients in the intensive care unit, yet go unrecognized by the managing physicians and nurses in 32 to 66% of cases. Delirium is an important independent prognostic determinant of hospital outcomes, including duration of mechanical ventilation, nursing home placement, functional decline, and death. Recently, new monitoring instruments have been validated for monitoring of delirium in noncommunicative patients receiving mechanical ventilation. Hence, critical care physicians and nurses should routinely assess their patients for delirium and develop strategies for its prevention and treatment. RECENT FINDINGS: This state-of-the-art review discusses in depth the delirium monitoring instruments, the pathophysiology and risk factors of delirium, its prognostic implications, and strategies (including ongoing clinical trials) to prevent and treat delirium. SUMMARY: Delirium is extremely common and has significant prognostic implications in critically ill patients. Routine monitoring and a multimodal approach to prevent or reduce the prevalence of delirium are of paramount importance.

Aged↗
PubMed2005

Detection of delirium in the intensive care unit: comparison of confusion assessment method for the intensive care unit with confusion assessment method ratings.

OBJECTIVES: To compare the Confusion Assessment Method (CAM) and CAM for the Intensive Care Unit (CAM-ICU) methods for detecting delirium in alert, nonintubated older ICU patients. DESIGN: Comparison study. SETTING: Fourteen-bed medical ICU of an 800-bed university teaching hospital. PARTICIPANTS: Twenty-two patients aged 65 and older admitted to the ICU. MEASUREMENTS: Two blinded, trained clinician-researchers who had undergone interrater reliability testing interviewed patients separately, usually within 10 minutes of each other (up to 120 minutes). Each researcher examined patients for the four key CAM criteria: acuteness, inattention, disorganized thinking, and altered level of consciousness. One researcher used the CAM method with the Mini-Mental State Examination and Digit Span; the other researcher used the CAM-ICU method with nonverbal cognitive and attention tasks. RESULTS: Rates of delirium were 68% according to CAM and 50% according CAM-ICU. Comparing the two methods, agreement was 82%, with a kappa of 0.64. Using the CAM as the reference standard, the CAM-ICU had a sensitivity of 73% (95% confidence interval (CI)=60-86) and specificity of 100% (95% CI=56-100). There were four false-negative ratings using the CAM-ICU. Reasons for disparate results were that the CAM used more-detailed cognitive testing that detected more deficits (3 patients) and the time elapsed (90 minutes) between ratings in one patient with markedly fluctuating symptoms. CONCLUSION: CAM and CAM-ICU agreement was moderately high. Although the CAM-ICU is recommended for ICU patients because of its brevity and ease of use, the standard CAM method may detect more subtle cases of delirium in nonintubated, verbal ICU patients.

Aged↗