Delirium During Intra-Aortic Balloon Pump Therapy Incidence and Management KATHY M. SANDERS, M.D. THEODORE
A.
STERN, M.D.
PATRICK T. O'GARA, M.D. TERRY S. FIELD, M.S., M.P.H. SCOTT
L.
RAUCH, M.D.
RACHEL E. LIPSON, M.D. KIM
D
A.
EAGLE, M.D.
elirium, or acute confusional state. is a complication that occurs in approximately 10% of hospitalized medical and surgical patients. I Its clinical manifestations include dysfunction of cognition and attention, disturbance of the sleepwake cycle. and psychomotor agitation. ' -6 The signs and symptoms of delirium vary widely from a mild and clinically unrecognized state to one in which severe agitation endangers the safety of the patient. When a delirious patient being treated with intra-aonic balloon pump (lABP) therapy becomes agitated, the cardiovascular system can be compromised. In addition to the acute threat to life, untreated delirium puts the patient at increased risk for the development of residual cognitive impainnents.2.7·8 Agitated delirium has been observed in patients after the placement of an IABP. Some of these patients require four-point restraints and large amounts of psychotropic medications.9--'4 The IABP provides mechanical circulatory assistance during cardiac pump failure or cardiogenic shock that results from a variety of conditions (e.g., hemodynamic instability following acute myocardial infarction [MIl. unstable or postinfarction angina. and severe left ventricular dysfunction following cardiopulmonary bypass). VOLUME 33· NUMBER 1• WINTER 1992
It is also used for adjunctive suppon in patients undergoing percutaneous transluminal coronary angioplasty (PTCA). The IABP is usually insened percutaneously over a guide wire through the femoral anery and is then advanced under fluoroscopic guidance into the descending thoracic aona. The balloon's inflation and deflation are coupled to the cardiac cycle. Inflation occurs during diastole and deflation during systole. Cardiac perfonnance and coronary perfusion improve as the net effect of this counterpulsation results in afterload reduction and increased diastolic perfusion pressures. 15 Our recent retrospective study has shown a Dr. Sanders is assistant in psychiatry, Dr. Stem is psychiatrist and director, Residenl Psychiatric ConsultationILiaison Service; and Dr. Rauch is clinical assistant in psychiatry; Depanment of Psychiatry. Dr. O'Gara is associate physician and director. Coronary Care Unit; Dr. Field is epidemiologist, General Internal Medicine Unit; and Dr. Eagle is assistant physician and associate director, Clinical Cardiology; Depanment of Medicine, Massachusetts General Hospital. Boston, MA. Dr. Lipson is clinical instructor of psychiatry, Depanment of Psychiatry. University of Michigan, Ann Arbor. MI. All authors are also affiliated with Harvard Medical School. Boston.MA. Copyright © 1992 The Academy of Psychosomatic Medicine. 35
Festschrift for Thomas P. Hackett
previously unreported incidence of delirium in patients on the (ABP of 34%.16 This report reviews the clinical course, associated risk factors, and different approaches to management of 67 patients who became delirious while on the (ABP during a I-year study period (1988). METHODS A retrospective chart review was conducted of 198 consecutive patients who underwent (ABP (Aires 700 Control System, Aires Medical (nTABLE l.
Demographics
Variable Mean age
or IABP·treated patients with and without delirium Delirious Nondelirious (N=67) (N=I28)
48 (72) 19 (28)
Marital status Married Widowed Single Divorced
45 14 5 3
Psychiatric history Depressive disorder Anxiety disorder Bipolar
(67) (21 ) (7) (5)
(96) 2 (3)
64
I (I) 10 (15) 5 (7) 4 (6) I ( 1.5)
Psychotropic use on admission II (16) Medical history Stroke Seizures Diabetes Insulin dependent Degenerative joint disease Peripheral vascular Chronic renal failure COPD Hypenension Angina Congestive hean failure Previous Mis Previous CABG
61
64
Gender Males Females
Race Caucasian Hispanic Afro-American
corporated. Woburn. MA) insertion during the calendar year 1988 at Massachusetts General Hospital. Of the 198 patients. 195 charts were retrieved and reviewed. The computerized data base drawn from the chart review included demographics, medical and psychiatric history. indication for IABP placement, complications associated with its use, and outcome. We studied the medical and neuropsychiatric complications that patients developed during the course of (ABP treatment. The diagnosis of delirium was made when the diagnostic criteria
6 3 17 6 16 17 5 14 43 53 19 36 9
(9) (4) (25)
(9) (24) (25) (7) (21) (64)
(79) (28) (54)
(13)
98 (77) 30 (23) 101
(79)
13 (10) 10 (8) 4 (3) 121 (95) 5 (4) 1 (I) 14 9 5 0
(II) (7) (4) (0)
19 (15) 8 (6) 0 (0)' 36 (28) 10 (8) 19 (15) 29 (23) 7 (5) 18 (14) 73 (57) 106 (83) 39 (30) 76 (59) 32 (25)
Delirious Nondelirious Variable Procedure perfonned Ihis hospitalization CABG PTCA No procedure
(N=67)
(N=I28)
43 (64) 15 (22) 9 (14)
78 (61) 29 (23) 21 (16)
44 (66) 9 (14) 13 (20)
75 (61) 18 (15) 30 (24)
Indication for IABP placement 39 (58) Shock 24 (36) Angina Intraoperative 4 (6)
63 (SO) 47 (37) 16 (13)
Psychiatric consultation
13 (10)'
Timing of IABP insenion to procedure Pre (or no procedure) During Post
23 (34)
Days on Ihe IABP. mean Outcome Overall monalily Monality on IABP (% of survivors) Organic brain syndrome (% of survivors)
4.9
17 (25) 6 (9) 8 (16)
Days from IABP to discharge. mean
4.2 (24)
31
16 (16) 2 (2)'
,
24
15
High doses of psychotropics used during IABP
51
Minimal or no psychotropics used during IABP
16 (24)
(76)
24 (19)
,
104 (81 )'
Note: Values are N (%).IABP=intra-aonic balloon pump; TIA=transient ischemic attack; COPD=chronic obstructive pulmonary disease; MI=myocardial infarction; CABG=coronary anery bypass graft; PTCA=percutaneous transluminal coronary angioplasty. 'p t'~
S mo O
A.
STERN, M.D.
PATRICK T. O'GARA, M.D. TERRY S. FIELD, M.S., M.P.H. SCOTT
L.
RAUCH, M.D.
RACHEL E. LIPSON, M.D. KIM
D
A.
EAGLE, M.D.
elirium, or acute confusional state. is a complication that occurs in approximately 10% of hospitalized medical and surgical patients. I Its clinical manifestations include dysfunction of cognition and attention, disturbance of the sleepwake cycle. and psychomotor agitation. ' -6 The signs and symptoms of delirium vary widely from a mild and clinically unrecognized state to one in which severe agitation endangers the safety of the patient. When a delirious patient being treated with intra-aonic balloon pump (lABP) therapy becomes agitated, the cardiovascular system can be compromised. In addition to the acute threat to life, untreated delirium puts the patient at increased risk for the development of residual cognitive impainnents.2.7·8 Agitated delirium has been observed in patients after the placement of an IABP. Some of these patients require four-point restraints and large amounts of psychotropic medications.9--'4 The IABP provides mechanical circulatory assistance during cardiac pump failure or cardiogenic shock that results from a variety of conditions (e.g., hemodynamic instability following acute myocardial infarction [MIl. unstable or postinfarction angina. and severe left ventricular dysfunction following cardiopulmonary bypass). VOLUME 33· NUMBER 1• WINTER 1992
It is also used for adjunctive suppon in patients undergoing percutaneous transluminal coronary angioplasty (PTCA). The IABP is usually insened percutaneously over a guide wire through the femoral anery and is then advanced under fluoroscopic guidance into the descending thoracic aona. The balloon's inflation and deflation are coupled to the cardiac cycle. Inflation occurs during diastole and deflation during systole. Cardiac perfonnance and coronary perfusion improve as the net effect of this counterpulsation results in afterload reduction and increased diastolic perfusion pressures. 15 Our recent retrospective study has shown a Dr. Sanders is assistant in psychiatry, Dr. Stem is psychiatrist and director, Residenl Psychiatric ConsultationILiaison Service; and Dr. Rauch is clinical assistant in psychiatry; Depanment of Psychiatry. Dr. O'Gara is associate physician and director. Coronary Care Unit; Dr. Field is epidemiologist, General Internal Medicine Unit; and Dr. Eagle is assistant physician and associate director, Clinical Cardiology; Depanment of Medicine, Massachusetts General Hospital. Boston, MA. Dr. Lipson is clinical instructor of psychiatry, Depanment of Psychiatry. University of Michigan, Ann Arbor. MI. All authors are also affiliated with Harvard Medical School. Boston.MA. Copyright © 1992 The Academy of Psychosomatic Medicine. 35
Festschrift for Thomas P. Hackett
previously unreported incidence of delirium in patients on the (ABP of 34%.16 This report reviews the clinical course, associated risk factors, and different approaches to management of 67 patients who became delirious while on the (ABP during a I-year study period (1988). METHODS A retrospective chart review was conducted of 198 consecutive patients who underwent (ABP (Aires 700 Control System, Aires Medical (nTABLE l.
Demographics
Variable Mean age
or IABP·treated patients with and without delirium Delirious Nondelirious (N=67) (N=I28)
48 (72) 19 (28)
Marital status Married Widowed Single Divorced
45 14 5 3
Psychiatric history Depressive disorder Anxiety disorder Bipolar
(67) (21 ) (7) (5)
(96) 2 (3)
64
I (I) 10 (15) 5 (7) 4 (6) I ( 1.5)
Psychotropic use on admission II (16) Medical history Stroke Seizures Diabetes Insulin dependent Degenerative joint disease Peripheral vascular Chronic renal failure COPD Hypenension Angina Congestive hean failure Previous Mis Previous CABG
61
64
Gender Males Females
Race Caucasian Hispanic Afro-American
corporated. Woburn. MA) insertion during the calendar year 1988 at Massachusetts General Hospital. Of the 198 patients. 195 charts were retrieved and reviewed. The computerized data base drawn from the chart review included demographics, medical and psychiatric history. indication for IABP placement, complications associated with its use, and outcome. We studied the medical and neuropsychiatric complications that patients developed during the course of (ABP treatment. The diagnosis of delirium was made when the diagnostic criteria
6 3 17 6 16 17 5 14 43 53 19 36 9
(9) (4) (25)
(9) (24) (25) (7) (21) (64)
(79) (28) (54)
(13)
98 (77) 30 (23) 101
(79)
13 (10) 10 (8) 4 (3) 121 (95) 5 (4) 1 (I) 14 9 5 0
(II) (7) (4) (0)
19 (15) 8 (6) 0 (0)' 36 (28) 10 (8) 19 (15) 29 (23) 7 (5) 18 (14) 73 (57) 106 (83) 39 (30) 76 (59) 32 (25)
Delirious Nondelirious Variable Procedure perfonned Ihis hospitalization CABG PTCA No procedure
(N=67)
(N=I28)
43 (64) 15 (22) 9 (14)
78 (61) 29 (23) 21 (16)
44 (66) 9 (14) 13 (20)
75 (61) 18 (15) 30 (24)
Indication for IABP placement 39 (58) Shock 24 (36) Angina Intraoperative 4 (6)
63 (SO) 47 (37) 16 (13)
Psychiatric consultation
13 (10)'
Timing of IABP insenion to procedure Pre (or no procedure) During Post
23 (34)
Days on Ihe IABP. mean Outcome Overall monalily Monality on IABP (% of survivors) Organic brain syndrome (% of survivors)
4.9
17 (25) 6 (9) 8 (16)
Days from IABP to discharge. mean
4.2 (24)
31
16 (16) 2 (2)'
,
24
15
High doses of psychotropics used during IABP
51
Minimal or no psychotropics used during IABP
16 (24)
(76)
24 (19)
,
104 (81 )'
Note: Values are N (%).IABP=intra-aonic balloon pump; TIA=transient ischemic attack; COPD=chronic obstructive pulmonary disease; MI=myocardial infarction; CABG=coronary anery bypass graft; PTCA=percutaneous transluminal coronary angioplasty. 'p t'~
S mo O
