Title:Challenges of Delirium Management in Patients with Traumatic Brain Injury: From Pathophysiology to Clinical Practice
Volume: 19
Issue: 9
Author(s): Shawniqua Williams Roberson, Mayur B. Patel, Wojciech Dabrowski, E. Wesley Ely, Cezary Pakulski and Katarzyna Kotfis *
Affiliation:
- Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University in Szczecin,Poland
Keywords:
Traumatic brain injury, critical care, delirium, electroencephalography, post-traumatic delirium, dexmedetomidine,
barbiturates, xanthohumol.
Abstract:
Traumatic brain injury (TBI) can initiate a very complex disease of the central nervous
system (CNS), starting with the primary pathology of the inciting trauma and subsequent inflammatory
and CNS tissue response. Delirium has long been regarded as an almost inevitable consequence
of moderate to severe TBI, but more recently has been recognized as an organ dysfunction syndrome
with potentially mitigating interventions. The diagnosis of delirium is independently associated with
prolonged hospitalization, increased mortality and worse cognitive outcome across critically ill populations.
Investigation of the unique problems and management challenges of TBI patients is needed
to reduce the burden of delirium in this population.
In this narrative review, possible etiologic mechanisms behind post-traumatic delirium are discussed,
including primary injury to structures mediating arousal and attention and secondary injury due to
progressive inflammatory destruction of the brain parenchyma. Other potential etiologic contributors
include dysregulation of neurotransmission due to intravenous sedatives, seizures, organ failure,
sleep cycle disruption or other delirium risk factors. Delirium screening can be accomplished in TBI
patients and the presence of delirium portends worse outcomes.
There is evidence that multi-component care bundles including an analgesia-prioritized sedation
algorithm, regular spontaneous awakening and breathing trials, protocolized delirium assessment,
early mobility and family engagement can reduce the burden of ICU delirium. The aim of this review
is to summarize the approach to delirium in TBI patients with an emphasis on pathogenesis and management.
Emerging CNS-active drug therapies that show promise in preclinical studies are highlighted.
