Delirium is frequently observed in the postoperative and intensive care unit (ICU) population. Due to the multifactorial origin of delirium and according to international guidelines (e.g., American Geriatrics Society; Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption (PADIS) guideline), there are several but no incontestable options for prevention and symptomatic treatment. The purpose of the Baden PRIDe (Prevention and Reduction of Incidence of postoperative Delirium) trial was to determine whether postoperative cognitive dysfunction and delirium could be prevented by the combination of possible preventive agents such as haloperidol and ketamine. In addition, pre- and postoperative levels of the biomarkers cortisol, neuron specific enolase (NSE) and S100β were measured to investigate their dynamics in delirious and non-delirious patients after surgery. The Baden PRIDe Trial was an investigator-initiated, phase IV, two-centre, randomised, placebo-controlled, double-blind clinical trial. Perioperative care. 182 adult patients that underwent elective or emergency surgery under general or combined (i.e., general and regional) anaesthesia. Pre-anaesthetic, pharmacologic prevention of postoperative brain dysfunction with haloperidol, ketamine, and the combination of both vs. placebo. Assessment of cognitive performance pre- and postoperatively with the MMSE, the DOS, the Nursing Delirium Screening Scale (Nu-DESC) or the Intensive Care Delirium Screening Checklist (ICDSC) during ICU stay. None of the three study arms - haloperidol, ketamine, or both drugs combined - was significantly superior to placebo for prevention of postoperative brain dysfunction and delirium (P = 0.39). Measured levels of postoperative cortisol were significantly higher in delirious patients. S-100β levels were significantly higher in all postoperative outcome groups (cognitive impairment, delirium, no cognitive decline), whereas postoperative NSE levels declined in all groups. The study results offer no possibility for a novel recommendation for prevention of postoperative cognitive decline including delirium. Perioperative S-100β trajectories in patients with cognitive deterioration suggest affection of glial cells in particular. ClinicalTrials.govNCT02433041; registered on April 7, 2015.

Delirium after surgery and in the intensive care unit (ICU) remains a challenge for patients, families, and caregivers. Over the years, many promising biomarkers have been investigated as potential instruments for risk stratification of delirium. This review aimed to identify and assess the clinical usefulness of candidate serum biomarkers associated with hospital delirium in patients aged 60 years and older. We performed a time-unlimited review of publications indexed in PubMed, Cochrane, Embase, and MEDLINE databases until June 2019 that evaluated baseline and/or longitudinal biomarker measurements in patients suffering from delirium at some point during their hospital stay. A total of 32 studies were included in this review reporting information on 7610 patients. Of these 32 studies, twenty-four studies reported data from surgical patients including four studies in ICU cohorts, five studies reported data from medical patients (1026 patients), and three studies reported data from a mixed cohort (1086 patients), including one study in an ICU cohort. Findings confirm restricted clinical usefulness to predict or diagnose delirium due to limited evidence on which biomarkers can be used and limited availability due to non-routine use.

Early detection of secondary events is a major target of neuromonitoring in critically ill patients. Intracranial pressure (ICP) and cerebral perfusion pressure are the most widely accepted neuromonitoring parameters. Many studies have shown both to be related to mortality after traumatic brain injury. However, the benefit of ICP monitoring has not been established by a randomized controlled trial, and the efficacy of ICP-guided management has indeed been challenged. This review considers current neuromonitoring techniques in critical care medicine.

Background and Aims: Peri-operative myocardial infarction/injury (PMI) is a common cardiac complication following non-cardiac surgery. It remains unclear whether involvement of cardiologists in the management of patients developing PMI improves outcomes. Methods: This multicentre, prospective study included high-risk patients undergoing non-cardiac surgery, eligible for the institutional PMI active surveillance and response programme. Due to staffing constraints, cardiologist evaluation of patients with PMI was inconsistently available on weekends, on public holidays, or when care for more urgent patients had to be prioritized, allowing a comparison between patients receiving cardiologist evaluation and those who did not. The primary endpoint was major adverse cardiac events, defined as a composite of cardiovascular death, myocardial infarction, acute heart failure, and life-threatening arrhythmia at 365 days. The secondary endpoint was all-cause death at 365 days. Cox proportional hazards models were used to evaluate the association between cardiologist evaluation and outcomes. Results: Among 14 294 patients, 1048 developed PMI and were eligible for this analysis, of whom 614 patients (58.6%) received post-operative cardiologist evaluation. Baseline characteristics were similar between groups. After adjustment, cardiologist evaluation was independently associated with lower risk of major adverse cardiac events (adjusted hazard ratio .54, P = .001) and all-cause death (adjusted hazard ratio .65, P = .037) at 365 days. Sensitivity analyses confirmed these findings. Patients receiving cardiology evaluation were more likely to undergo non-invasive cardiac imaging and to receive dual antiplatelet and statin therapy. Conclusions: Cardiologist evaluation of patients with PMI following major non-cardiac surgery was associated with a reduced risk of major adverse cardiac events and all-cause mortality at 365 days after surgery, suggesting that interdisciplinary management may improve post-operative outcomes.