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Background:The incidence and risk factors for delirium vary among studies.Objective:We aimed to determine the incidence, risk factors, and impact on outcome of delirium in a medical Intensive Care Unit (ICU) in Tunisia using a prospective observational study.Patients:All consecutive patients admitted to the ICU between May 2012 and April 2013 were included if they were aged more than 18 years and had an ICU stay of more than 24 h. Patients who had a cardiac arrest or have a history of dementia or psychosis were excluded. Patients eligible for the study were evaluated by the medical staff to detect delirium using the CAM-ICU.Results:A total of 206 patients were included, 167 did not present delirium and 39 (19%) were analyzed for delirium. Delirious patients had a significantly longer duration of mechanical ventilation (10 days[6–20] vs. 2 days[0–7]) respectively and length of stay in ICU (21.5 days [10.5–32.5] vs. 8 days [5–13]), with no impact on mortality. Delirium was associated with high incidence of unintentional removal of catheters (39% vs. 9%; P < 0.0001), endotracheal tubes (18% vs. 1%; P < 0.0001), and urinary catheters (28% vs. 2%, P < 0.0001). In multivariable risk regression analysis, age (odds ratio [OR] = 4.1, 95% confidence interval [CI]: 1.39–12.21; P = 0.01), hypertension (OR = 3.3, 95% CI: 1.31–8.13; P = 0.011), COPD (OR = 3.5, 95% CI: 1.47–8.59; P = 0.005), steroids (OR = 2.8, 95% CI: 1.05–7.28; P = 0.038), and sedation (OR = 5.4, 95% CI: 2.08–13.9; P < 0.0001) were independent risk factors for delirium. We did not find a relationship between delirium and mortality.Conclusion:Delirium is frequent in the ICU and is associated with poor outcome. Several risk factors for delirium are linked to intensive care environment.

BACKGROUND: Patients with COPD are at a high risk for pulmonary embolism (PE) because of systemic inflammation and co-existing comorbidities. We aimed to determine the incidence, risk factors, and impact of PE during COPD exacerbation requiring mechanical ventilation. METHODS: This prospective cohort study was conducted between March 2013 and May 2017. Subjects with severe COPD exacerbation requiring mechanical ventilation were included. A lower-limb ultrasonography or a multidetector helical computed tomography scan (MDCT) was performed according to Wells score. Subjects with ultrasonographic signs of phlebitis underwent MDCT to confirm PE. RESULTS: During the study period, 131 COPD subjects were admitted to the ICU for severe COPD exacerbation. The incidence of PE was 13.7%. Factors independently associated with PE were increased sputum volume (odds ratio [OR] ‫؍‬ 0.106, 95% CI 0.029-0.385, P ‫؍‬ .001), recent immobilization > 7 d (OR ‫؍‬ 5.024, 95% CI 1.470-17.170, P ‫؍‬ .01), age > 70 y (OR ‫؍‬ 5.483, 95% CI 1.269-23.688, P ‫؍‬ .02), and invasive mechanical ventilation at ICU admission (OR ‫؍‬ 3.615, 95% CI 1.005-13.007, P ‫؍‬ .049). ICU mortality was higher in the PE group (44% vs 11%). Predictive factors of mortality were PE (OR ‫؍‬ 7.135, 95% CI 2.042-24.931, P ‫؍‬ .002), SAPS II score at admission OR ‫؍‬ 1.040, 95% CI 1.005-1.077, P ‫؍‬ .02), and duration of mechanical ventilation (OR ‫؍‬ 1.098, 95% CI 1.044-1.154, P < .001). CONCLUSION: PE was found to be a common etiology of severe exacerbation of COPD, leading to high mortality. Age, invasive mechanical ventilation, and immobilization were risk factors for PE.

Objectives: The best modality of administration of hydrocortisone during septic shock has been poorly evaluated and the guidelines remain unclear in this respect. This study aimed to compare bolus of hydrocortisone to a continuous infusion during septic shock. Design: Randomized controlled, open-label trial. Setting: Medical ICU of a university hospital. Patients: Adult patients with septic shock requiring more than 2 mg/h (approximately 33.3 μg/mn) of norepinephrine after adequate fluid administration were eligible. Patients already receiving corticosteroids or who have a contraindication to corticosteroids, patients who died within 24 h and those with a decision of not to resuscitate were excluded. Interventions: Patients were randomized either to receive hydrocortisone 200 mg/d by continuous infusion or by boluses of 50 mg every 6 h throughout the prescription of vasopressors with a maximum of 7 days. Results: Twenty-nine patients were included in each group. Shock reversal was significantly higher in the HC bolus group (66% vs. 35%, P = 0.008). The median time to shock reversal was 5 days (95% CI, 4.31–5.69) in the HC bolus group compared to 6 days (95% CI, 4.80–7.19) in the HC continuous infusion group (log Rank = 0.048). The number of hours spent with blood glucose ≥ 180 mg/dL was higher in the HC continuous infusion group with a median of 64 h [IQR (2–100)] versus 48 h [IQR (14–107)] in the HC bolus group, (P = 0.60), and daily insulin requirements were similar between the two groups (P = 0.63). The occurrence of other side effects, mortality, and ICU LOS were similar between the study groups. Conclusion: Hydrocortisone administered by intermittent bolus was associated with higher shock reversal at day 7 compared with a continuous infusion.

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