Hypotension and a positive fluid balance are associated with delirium in patients with shock
The pathogenesis of delirium in critically ill patients is multifactorial. How hypotension and hypoxemia affect brain function and whether they can promote delirium remains unclear. A high cumulative positive fluid balance may also have a negative effect on brain function and promote delirium. We hy...
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| description | The pathogenesis of delirium in critically ill patients is multifactorial. How hypotension and hypoxemia affect brain function and whether they can promote delirium remains unclear. A high cumulative positive fluid balance may also have a negative effect on brain function and promote delirium. We hypothesized that delirium would be more likely to develop in patients with low systemic arterial pressure, hypoxemia and a higher positive fluid balance, and investigated these associations in a prospective observational cohort study in patients with shock. After initial resuscitation, episodes of hypotension, defined as a mean arterial pressure (MAP) |
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How hypotension and hypoxemia affect brain function and whether they can promote delirium remains unclear. A high cumulative positive fluid balance may also have a negative effect on brain function and promote delirium. We hypothesized that delirium would be more likely to develop in patients with low systemic arterial pressure, hypoxemia and a higher positive fluid balance, and investigated these associations in a prospective observational cohort study in patients with shock. After initial resuscitation, episodes of hypotension, defined as a mean arterial pressure (MAP) <65 mmHg or diastolic pressure <60 mmHg, and hypoxemia, defined as peripheral oxygen saturation (SpO2) <90% for more than one minute or any arterial oxygen concentration (PaO2) <90 mmHg, were recorded during the first 5 days of the ICU stay. Fluid balance was evaluated daily and the 5-day cumulative fluid balance recorded. Delirium was assessed using the Confusion Assessment Method for the ICU. A total of 252 patients were admitted with shock during the study period; 185 (73%) developed delirium. Patients who developed delirium also had more episodes of hypotension with a low MAP (p = 0.013) or diastolic pressure (p = 0.018) during the first five days of the ICU stay than those who did not. Patients with a higher cumulative fluid balance during the same period were also more likely to develop delirium (p = 0.01); there was no significant difference in the occurrence of hypoxemia between groups. Joint modeling, combining a linear-mixed model and an adjusted Cox survival model showed that low diastolic pressure (alpha effect = -0.058±0.0013, p = 0.043) and a positive cumulative fluid balance (alpha effect = 0.04±0.003, p = 0.021) were independently associated with delirium. In conclusion, low diastolic pressure and a cumulative positive fluid balance but not hypoxemia were independently associated with development of delirium in patients with shock.</description><identifier>ISSN: 1932-6203</identifier><identifier>EISSN: 1932-6203</identifier><identifier>DOI: 10.1371/journal.pone.0200495</identifier><identifier>PMID: 30086136</identifier><language>eng</language><publisher>United States: Public Library of Science</publisher><subject>Aged ; Alcohol ; Blood pressure ; Brain ; Complications and side effects ; Critical care ; Delirium ; Delirium - diagnosis ; Delirium - etiology ; Diagnosis ; Diastolic pressure ; Edema ; Female ; Fluid-electrolyte balance ; Health aspects ; Humans ; Hypertension ; Hypotension ; Hypotension - complications ; Hypotension - physiopathology ; Hypoxemia ; Intensive care ; Laboratories ; Male ; Medicine and Health Sciences ; Mental disorders ; Middle Aged ; Monitoring, Physiologic ; Mortality ; Nosocomial infections ; Observational studies ; Oxygen ; Oxygen content ; Pathogenesis ; Patients ; Pressure effects ; Prospective Studies ; Resuscitation ; Risk Factors ; Saturation ; Sepsis ; Shock ; Shock - complications ; Shock - physiopathology ; Survival ; Trauma ; Traumatic brain injury ; Water-Electrolyte Balance</subject><ispartof>PloS one, 2018-08, Vol.13 (8), p.e0200495-e0200495</ispartof><rights>COPYRIGHT 2018 Public Library of Science</rights><rights>2018 Nguyen et al. This is an open access article distributed under the terms of the Creative Commons Attribution License: http://creativecommons.org/licenses/by/4.0/ (the “License”), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License.</rights><rights>2018 Nguyen et al 2018 Nguyen et al</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c692t-924fa8a3e58d1ecb445f3636cc47b0b2ee671a5c95eadee1e737f4e9647512af3</citedby><cites>FETCH-LOGICAL-c692t-924fa8a3e58d1ecb445f3636cc47b0b2ee671a5c95eadee1e737f4e9647512af3</cites><orcidid>0000-0002-1034-6289</orcidid></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC6080753/pdf/$$EPDF$$P50$$Gpubmedcentral$$Hfree_for_read</linktopdf><linktohtml>$$Uhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC6080753/$$EHTML$$P50$$Gpubmedcentral$$Hfree_for_read</linktohtml><link.rule.ids>230,314,723,776,780,860,881,2096,2915,23845,27901,27902,53766,53768,79342,79343</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/30086136$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Nguyen, Duc Nam</creatorcontrib><creatorcontrib>Huyghens, Luc</creatorcontrib><creatorcontrib>Parra, Jose</creatorcontrib><creatorcontrib>Schiettecatte, Johan</creatorcontrib><creatorcontrib>Smitz, Johan</creatorcontrib><creatorcontrib>Vincent, Jean-Louis</creatorcontrib><title>Hypotension and a positive fluid balance are associated with delirium in patients with shock</title><title>PloS one</title><addtitle>PLoS One</addtitle><description>The pathogenesis of delirium in critically ill patients is multifactorial. How hypotension and hypoxemia affect brain function and whether they can promote delirium remains unclear. A high cumulative positive fluid balance may also have a negative effect on brain function and promote delirium. We hypothesized that delirium would be more likely to develop in patients with low systemic arterial pressure, hypoxemia and a higher positive fluid balance, and investigated these associations in a prospective observational cohort study in patients with shock. After initial resuscitation, episodes of hypotension, defined as a mean arterial pressure (MAP) <65 mmHg or diastolic pressure <60 mmHg, and hypoxemia, defined as peripheral oxygen saturation (SpO2) <90% for more than one minute or any arterial oxygen concentration (PaO2) <90 mmHg, were recorded during the first 5 days of the ICU stay. Fluid balance was evaluated daily and the 5-day cumulative fluid balance recorded. Delirium was assessed using the Confusion Assessment Method for the ICU. A total of 252 patients were admitted with shock during the study period; 185 (73%) developed delirium. Patients who developed delirium also had more episodes of hypotension with a low MAP (p = 0.013) or diastolic pressure (p = 0.018) during the first five days of the ICU stay than those who did not. Patients with a higher cumulative fluid balance during the same period were also more likely to develop delirium (p = 0.01); there was no significant difference in the occurrence of hypoxemia between groups. Joint modeling, combining a linear-mixed model and an adjusted Cox survival model showed that low diastolic pressure (alpha effect = -0.058±0.0013, p = 0.043) and a positive cumulative fluid balance (alpha effect = 0.04±0.003, p = 0.021) were independently associated with delirium. In conclusion, low diastolic pressure and a cumulative positive fluid balance but not hypoxemia were independently associated with development of delirium in patients with shock.</description><subject>Aged</subject><subject>Alcohol</subject><subject>Blood pressure</subject><subject>Brain</subject><subject>Complications and side effects</subject><subject>Critical care</subject><subject>Delirium</subject><subject>Delirium - diagnosis</subject><subject>Delirium - etiology</subject><subject>Diagnosis</subject><subject>Diastolic pressure</subject><subject>Edema</subject><subject>Female</subject><subject>Fluid-electrolyte balance</subject><subject>Health aspects</subject><subject>Humans</subject><subject>Hypertension</subject><subject>Hypotension</subject><subject>Hypotension - complications</subject><subject>Hypotension - physiopathology</subject><subject>Hypoxemia</subject><subject>Intensive care</subject><subject>Laboratories</subject><subject>Male</subject><subject>Medicine and Health Sciences</subject><subject>Mental disorders</subject><subject>Middle Aged</subject><subject>Monitoring, Physiologic</subject><subject>Mortality</subject><subject>Nosocomial infections</subject><subject>Observational studies</subject><subject>Oxygen</subject><subject>Oxygen content</subject><subject>Pathogenesis</subject><subject>Patients</subject><subject>Pressure effects</subject><subject>Prospective Studies</subject><subject>Resuscitation</subject><subject>Risk Factors</subject><subject>Saturation</subject><subject>Sepsis</subject><subject>Shock</subject><subject>Shock - complications</subject><subject>Shock - physiopathology</subject><subject>Survival</subject><subject>Trauma</subject><subject>Traumatic brain injury</subject><subject>Water-Electrolyte Balance</subject><issn>1932-6203</issn><issn>1932-6203</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2018</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><sourceid>BENPR</sourceid><sourceid>DOA</sourceid><recordid>eNqNk12L1DAUhoso7rr6D0QLgujFjGnz0fRGWBZ1BxYW_LoSwml6Os3YaWqSru6_N7PTXaayFxJKSvKcNzlvzkmS5xlZZrTI3m3s6HroloPtcUlyQljJHyTHWUnzhcgJfXjwf5Q88X5DCKdSiMfJESVEioyK4-TH-fVgA_be2D6Fvk4hHaw3wVxh2nSjqdMKOug1puDi573VBgLW6W8T2rTGzjgzblPTpwMEg33w-x3fWv3zafKogc7js2k-Sb59_PD17HxxcflpdXZ6sdCizMOizFkDEihyWWeoK8Z4QwUVWrOiIlWOKIoMuC45Qo2YYUGLhmEpWMGzHBp6krzc6w6d9WoyxqucSCYjRYpIrPZEbWGjBme24K6VBaNuFqxbK3DB6A6VKKt4H14hk5rlXACNriGnLI4aJIta76fTxmqLtY5JO-hmovOd3rRqba-UIJIUnEaBN5OAs79G9EFtjdfYRZ_Rjjf35oIzSXfoq3_Q-7ObqDXEBEzf2Hiu3omqU87KXLKSyEgt76HiqHFrdKyixsT1WcDbWUBkAv4Jaxi9V6svn_-fvfw-Z18fsC1CF1pvuzHEGvRzkO1B7az3Dps7kzOidk1w64baNYGamiCGvTh8oLug26qnfwFujQHo</recordid><startdate>20180807</startdate><enddate>20180807</enddate><creator>Nguyen, Duc Nam</creator><creator>Huyghens, Luc</creator><creator>Parra, Jose</creator><creator>Schiettecatte, Johan</creator><creator>Smitz, Johan</creator><creator>Vincent, Jean-Louis</creator><general>Public Library of Science</general><general>Public Library of Science (PLoS)</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>IOV</scope><scope>ISR</scope><scope>3V.</scope><scope>7QG</scope><scope>7QL</scope><scope>7QO</scope><scope>7RV</scope><scope>7SN</scope><scope>7SS</scope><scope>7T5</scope><scope>7TG</scope><scope>7TM</scope><scope>7U9</scope><scope>7X2</scope><scope>7X7</scope><scope>7XB</scope><scope>88E</scope><scope>8AO</scope><scope>8C1</scope><scope>8FD</scope><scope>8FE</scope><scope>8FG</scope><scope>8FH</scope><scope>8FI</scope><scope>8FJ</scope><scope>8FK</scope><scope>ABJCF</scope><scope>ABUWG</scope><scope>AEUYN</scope><scope>AFKRA</scope><scope>ARAPS</scope><scope>ATCPS</scope><scope>AZQEC</scope><scope>BBNVY</scope><scope>BENPR</scope><scope>BGLVJ</scope><scope>BHPHI</scope><scope>C1K</scope><scope>CCPQU</scope><scope>D1I</scope><scope>DWQXO</scope><scope>FR3</scope><scope>FYUFA</scope><scope>GHDGH</scope><scope>GNUQQ</scope><scope>H94</scope><scope>HCIFZ</scope><scope>K9.</scope><scope>KB.</scope><scope>KB0</scope><scope>KL.</scope><scope>L6V</scope><scope>LK8</scope><scope>M0K</scope><scope>M0S</scope><scope>M1P</scope><scope>M7N</scope><scope>M7P</scope><scope>M7S</scope><scope>NAPCQ</scope><scope>P5Z</scope><scope>P62</scope><scope>P64</scope><scope>PATMY</scope><scope>PDBOC</scope><scope>PIMPY</scope><scope>PQEST</scope><scope>PQQKQ</scope><scope>PQUKI</scope><scope>PRINS</scope><scope>PTHSS</scope><scope>PYCSY</scope><scope>RC3</scope><scope>7X8</scope><scope>5PM</scope><scope>DOA</scope><orcidid>https://orcid.org/0000-0002-1034-6289</orcidid></search><sort><creationdate>20180807</creationdate><title>Hypotension and a positive fluid balance are associated with delirium in patients with shock</title><author>Nguyen, Duc Nam ; Huyghens, Luc ; Parra, Jose ; Schiettecatte, Johan ; Smitz, Johan ; Vincent, Jean-Louis</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c692t-924fa8a3e58d1ecb445f3636cc47b0b2ee671a5c95eadee1e737f4e9647512af3</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2018</creationdate><topic>Aged</topic><topic>Alcohol</topic><topic>Blood pressure</topic><topic>Brain</topic><topic>Complications and side effects</topic><topic>Critical care</topic><topic>Delirium</topic><topic>Delirium - 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Academic</collection><collection>PubMed Central (Full Participant titles)</collection><collection>Directory of Open Access Journals</collection><jtitle>PloS one</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Nguyen, Duc Nam</au><au>Huyghens, Luc</au><au>Parra, Jose</au><au>Schiettecatte, Johan</au><au>Smitz, Johan</au><au>Vincent, Jean-Louis</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Hypotension and a positive fluid balance are associated with delirium in patients with shock</atitle><jtitle>PloS one</jtitle><addtitle>PLoS One</addtitle><date>2018-08-07</date><risdate>2018</risdate><volume>13</volume><issue>8</issue><spage>e0200495</spage><epage>e0200495</epage><pages>e0200495-e0200495</pages><issn>1932-6203</issn><eissn>1932-6203</eissn><abstract>The pathogenesis of delirium in critically ill patients is multifactorial. How hypotension and hypoxemia affect brain function and whether they can promote delirium remains unclear. A high cumulative positive fluid balance may also have a negative effect on brain function and promote delirium. We hypothesized that delirium would be more likely to develop in patients with low systemic arterial pressure, hypoxemia and a higher positive fluid balance, and investigated these associations in a prospective observational cohort study in patients with shock. After initial resuscitation, episodes of hypotension, defined as a mean arterial pressure (MAP) <65 mmHg or diastolic pressure <60 mmHg, and hypoxemia, defined as peripheral oxygen saturation (SpO2) <90% for more than one minute or any arterial oxygen concentration (PaO2) <90 mmHg, were recorded during the first 5 days of the ICU stay. Fluid balance was evaluated daily and the 5-day cumulative fluid balance recorded. Delirium was assessed using the Confusion Assessment Method for the ICU. A total of 252 patients were admitted with shock during the study period; 185 (73%) developed delirium. Patients who developed delirium also had more episodes of hypotension with a low MAP (p = 0.013) or diastolic pressure (p = 0.018) during the first five days of the ICU stay than those who did not. Patients with a higher cumulative fluid balance during the same period were also more likely to develop delirium (p = 0.01); there was no significant difference in the occurrence of hypoxemia between groups. Joint modeling, combining a linear-mixed model and an adjusted Cox survival model showed that low diastolic pressure (alpha effect = -0.058±0.0013, p = 0.043) and a positive cumulative fluid balance (alpha effect = 0.04±0.003, p = 0.021) were independently associated with delirium. In conclusion, low diastolic pressure and a cumulative positive fluid balance but not hypoxemia were independently associated with development of delirium in patients with shock.</abstract><cop>United States</cop><pub>Public Library of Science</pub><pmid>30086136</pmid><doi>10.1371/journal.pone.0200495</doi><orcidid>https://orcid.org/0000-0002-1034-6289</orcidid><oa>free_for_read</oa></addata></record> |
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| subjects | Aged Alcohol Blood pressure Brain Complications and side effects Critical care Delirium Delirium - diagnosis Delirium - etiology Diagnosis Diastolic pressure Edema Female Fluid-electrolyte balance Health aspects Humans Hypertension Hypotension Hypotension - complications Hypotension - physiopathology Hypoxemia Intensive care Laboratories Male Medicine and Health Sciences Mental disorders Middle Aged Monitoring, Physiologic Mortality Nosocomial infections Observational studies Oxygen Oxygen content Pathogenesis Patients Pressure effects Prospective Studies Resuscitation Risk Factors Saturation Sepsis Shock Shock - complications Shock - physiopathology Survival Trauma Traumatic brain injury Water-Electrolyte Balance |
| title | Hypotension and a positive fluid balance are associated with delirium in patients with shock |
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