1. Incidence and risk factors for emergence and PACU delirium Elizabeth Card, RN, CPAN, CCRP Vanderbilt University Medical Center Peri-Operative Clinical Research Institute Nashville, TN 1

2. ICU psychosis? Sleep deprivation? Delirium? Delirium is described as an acute reversible state, the diagnosis dependent on the following criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV): 1. Disturbance in consciousness 2. A change in cognition 3. Acute and fluctuation course 4. H&P and/or lab findings indicate disturbance contributable to a general medical condition 2

3. Suspected etiology of delirium Anatomic Deficit: The higher cortical areas of the brain, such as the prefrontal and non-dominant posterior parietal regions, are suspected for involvement. Inflammatory and perfusion alterations likely key. Neurotransmitter Imbalances: Abnormal levels of serotonin, acetylcholine deficiency or dopamine excess (to name 3) are thought to contribute to delirium, but there are many other neurotransmitters that may be involved. Vasilevskis, et al. Intensive Care Medicine (2001)27:859-864; Saczynski, et al. New England Journal of Medicine (2012)37;1:30- 39; Ely, E.W., et al. JAMA. 291(14): 1753-1762, 2004.; Flacker, et al. Gerontol. Bio Scie 1999; 54A: B239-B246 3

4. Neurotransmitters related to delirium 4 Flacker, et al. Gerontol. Bio Scie 1999; 54A: B239-B246

5. Differential diagnosis for patients with delirium 5 ww.icudelirium.org/

6. Who is at risk for developing delirium in the ICU? Advanced age (>65 years old) Prior history of dementia Post-surgical (especially hip or cardiac procedures) History of depression Poor vision or hearing Uncontrolled pain Ventilated (80% prevalence in ICU) Heart failure, Sepsis 6

7. Emergence delirium versus emergence agitation Previously described as agitation when emerging from anesthesia (multiple potential causes) Prior research has utilized agitation/sedation scales to detect “emergence agitation” Virtually no studies have examined the prevalence of emergence/PACU delirium in the adult population using a validated delirium tool Unless delirium detection tool is utilized, it is unknown if your agitated patient is also experiencing delirium 7

8. Treatment Recommendations for Delirium No FDA approved therapies YET Identify etiologies (possible to have more than one) Risk factors you can modify? (decrease benzodiazepine usage, increase O2 if hypoxemia, re-orient, etc.) Haldol (2-5 mg IV q6h), atypical antipsychotics Dexmedetomidine Treat pain Early mobilization and/or ROM Keep current with literature, multiple on-going studies. Saczynski, et al. New England Journal of Medicine (2012)37;1:30-39; Ely, E.W., et al. JAMA. 291(14): 1753-1762, 2004. 8

9. Incidence and risk factors for emergence delirium 2010 discussion between PACU nurse and PI developed hypothesis, protocol development, meeting with statisticians for power analysis and input on outcome measurements. 2011 IRB approval, 5 PACU nurse investigators trained in research ethics, study procedures and delirium assessments 400 patients enrolled into the study 2011-2012 2013 statistical analysis completed, manuscript completed and submitted to Anesthesiology 9

10. How did the study assessed for delirium? Anesthesia staff record the highest RASS upon emergence from anesthesia in the OR PACU nurses to complete a RASS and CAM-ICU at admission, 30 minutes and PACU discharge 10

11. 1st steps in assessment of delirium: RASS (assesses consciousness) +4Combative Combative, violent, immediate danger to staff +3Very agitated Pulls or removes tube(s), or catheter(s), aggressive +2Agitated Frequent non-purposeful movements, fights the ventilator +1Restless Anxious, apprehensive but movements are not aggressive or vigorous 0Alert and calm Drowsy Not fully alert, but has sustained awakening to voice (eye opening & contact >10 seconds) -2Light sedation Briefly awakens to voice (eye opening & contact <10 seconds) -3Moderate sedation Movement or eye opening to voice, but no eye contact -4Deep sedation No response to voice, but movement or eye opening to physical stimulation -5Unarousable No response to voice or physical stimulation 11

12. 2 nd Step: CAM-ICU (content assessment) 12 (content)

13. Types of psychomotor expression of delirium Hyperactive delirium: RASS >+1 with positive CAM-ICU Hypoactive delirium: RASS <0 with positive CAM-ICU 13 Jackson, Crit Care Med 2003;31;1226-34

14. Emergence agitation is not necessarily emergence delirium Emergence Agitation: RASS> +1  Agitation maybe in response to pain, fear, needing to void, or delirium Emergence Delirium: positive CAM-ICU  RASS > +1=Hyperactive emergence delirium  RASS < 0= Hypoactive emergence delirium 14

15. Early data from the study 15

16. Early data from the study 16

17. Early data from the study Variable, N = 154 P Age 0.3 4 Preop + Intraop Benzo 0.6 0 Preop + Intraop Opioid 0.3 2 Anesthetic Duration 0.0 4 Inhalation Agent 0.9 5 ASA Classification 0.8 1 Emergence Delirium 17

18. How you can help: Assess your patients for delirium, report findings to the team Look for treatable causes (hypoxia, lab anomalies) Decrease stimuli Re-orient patient to time of day, date and situation Place patient glasses or hearing aids 18

19. Conclusion  Delirium occurs in a significant number of patients in the peri-operative setting and is associated with worse outcomes including a higher risk of death.  LTCI is 1% in post operative patients and in 33% of ICU survivors even after 1 year of discharge  Important to achieve a balance between sedation and analgesia and potential side effects/ risks  Protocols incorporating prevention/treatment need to be implemented  ? Role of targeting different receptors- alpha 2 / antipsychotic medications 19

20. Additional delirium research needed Can we identify combinations of medications to avoid in order to decrease the risk of emergence or PACU delirium? Are there better treatments for emergence or PACU delirium? Are there additional risk factors yet identified? Are the long term consequences of emergence or PACU delirium the same as ICU delirium? 20

21. Questions? Elizabeth Card, RN, CPAN, CCRP elizabeth.b.card@vanderbilt.edu www.icudelirium.org elizabeth.b.card@vanderbilt.edu www.icudelirium.org 21

22. References Pandharipande, et al. Chest. 2009 Jan;135(1):18-25. Epub 2008 Nov 18. WWW.ICUdelirium.org Vasilevskis, et al. Intensive Care Medicine (2001)27:859-864 Saczynski, et al. New England Journal of Medicine (2012)37;1:30-39 Ely, E.W., et al. JAMA. 291(14): 1753-1762, 2004. Flacker, et al. Gerontol. Bio Scie 1999; 54A: B239-B246 Marquis, AJRCCM 2000;161:A383 (Curtis) Al Saidi, AJRCCM 2003:167:A737 (Herridge) Sukantarat, Anaesthesia 2005;60:847-853 Suchyta, AJRCCM 2004; 169:A18 Christie, AJRCCM 2004; 169:A781 Rothenhausler, Gen Hosp Psych 2001;23:90-96 Hopkins, AJRCCM 1999;160:50-56 Jackson, Crit Care Med 2003;31;1226-34 Hopkins, JINS 2004; 10:1005-1017 Hopkins, AJRCCM 2005; 171:340-347 Lapouse BJA 2006; 96(6)747-53 22