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CAM-ICU Basics ICU Delirium and Cognitive Impairment Study Group

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Presentation on theme: "CAM-ICU Basics ICU Delirium and Cognitive Impairment Study Group"— Presentation transcript:

1 CAM-ICU Basics ICU Delirium and Cognitive Impairment Study Group www.ICUdelirium.org delirium@vanderbilt.edu

2 What is Delirium? Delirium is a common clinical syndrome characterized by: Inattention Acute cognitive dysfunction Pathophysiology: Disruption of neurotransmission (drug action, inflammation, acute stress response) Delirium: Think rapid onset, inattention, clouding of consciousness (bewildered), fluctuation Dementia: Think gradual onset, intellectual impairment, memory disturbance, personality/mood change, no conscious clouding

3 Hyperactive Patient may be combative with agitation that may require sedation (is diagnosed more frequently). Subtypes of Delirium Hypoactive Patient may be quiet and even peaceful, despite cognitive impairment. More difficult to assess. Mixed Combination of both types

4 Why monitor for Delirium? 50-80% of ventilated patients develop delirium 20-50% of lower severity ICU patients develop delirium Over 40,000 ventilated patients are delirious every day Delirium leads to increased mortality, longer hospital stay, poorer recovery, higher costs of healthcare, long-term neurocognitive problems. Ely EW JAMA 2001;286,2703-2710 Ely EW CCM 2001;29,1370-79

5 ICU Delirium: The Canary in the Coal Mine Under recognized form of organ dysfunction 3-fold increase in mortality at 6 months Each DAY a patients is delirious = 10% INCREASE in risk of death

6 Delirium in the ICU Clinical Value of RASS/CAM-ICU Measurement Stimulates thinking of Rx: –Delirium recognition is a Burglar Alarm for us (early sign of danger) –Forces us to consider treatable causes earlier –Utilize nonpharmacologic interventions –Do NOT automatically link delirium monitoring with a specific drug treatment

7 The ABCDE s of Critical Care A wakening B reathing C oordination, C hoice D elirium monitoring/management E arly mobility and Exercise

8 www.ICUdelirium.org Educational Delirium Website

9 A Two Step Approach to Assessing Consciousness Step 1 Level of Consciousness (arousal): RASS Step 2 Content of Consciousness (delirium): CAM-ICU

10 Step 1: LOC Assessment Assess for arousal

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12 Step 1: Arousal Assessment (RASS) +3 +2 +1 0 - 1 - 2 - 3 - 4 - 5 Richmond Agitation- Sedation Scale (RASS)

13 Step 2: Content Assessment Assess for Delirium

14 Confusion Assessment Method for the ICU (CAM-ICU) Feature 1: Acute change or fluctuating course of mental status And Feature 2: Inattention And Feature 3: Altered level of consciousness Feature 4: Disorganized Thinking Or Inouye, et. al. Ann Intern Med 1990; 113:941-948.1 Ely, et. al. CCM 2001; 29:1370-1379.4 Ely, et. al. JAMA 2001; 286:2703-2710.5

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16 Feature 1: Alteration/Fluctuation in Mental Status Is the pt different than his/her baseline mental status? OR Has the patient had any fluctuation in mental status in the past 24 hours (eg fluctuating RASS, GCS, previous delirium assessments, etc) Present: If either question is YES.

17 Feature 1: Alteration/Fluctuation in Mental Status Common Questions: What if you do not know the patients baseline? –Assume normal unless you have red flags that make you suspicious –Red Flag: patient came from institution What about dementia? –Ask family What could she/he do prior to this illness?

18 Feature 2: Inattention Screening for Attention– two options Letter A test Letters: S A V E A H A A R T (or numbers) Say 10 letters (or numbers) and instruct the patient to squeeze on the letter A (or on a certain number) Pictures Similar test with pictures (instructions are in picture packets)

19 Feature 2: Inattention 1. Attempt Letters first. 2. If pt is able to perform the Letter test you are sure of the results, you are done with Inattention test. 3. If pt is unable to perform the Letter test or you are unsure of the results, use the Pictures. If you perform both tests, use the Pictures result to determine if inattention is present. Inattention Present : If >2 errors

20 Feature 2: Inattention What if the patient only squeezes once and then falls back to sleep? or What if the patient is too hyperactive/combative to participate in squeezing? –Remember what you are assessingAttention –This patient is inattentive If you have to explain the directions more than twice, start to be suspicious for inattention

21 If either Feature 1 or 2 are absent, Stop Overall CAM-ICU is Negative If Features 1 and 2 are present, Proceed to Feature 3

22 Feature 3: Alt Level of Consciousness Any LOC other than Alert. Present: If the Actual RASS score is anything other than 0 (zero). You have already done this assessment. It was the first thing you did when you walked in the room!

23 Feature 4: Disorganized Thinking Yes/No Questions (Use either Set A or Set B) : Set A Set B 1. Will a stone float on water? 1. Will a leaf float on water? 2. Are there fish in the sea? 2. Are there elephants in the sea? 3. Does one pound weigh more than 3. Do two pounds weigh two pounds? more than one pound? 4. Can you use a hammer to pound a nail? 4. Can you use a hammer to cut wood? Note: Use whatever form of communication that works (nodding, hand squeezing, blinking, etc).

24 Feature 4: Disorganized Thinking Command Say to patient: Hold up this many fingers (Examiner holds two fingers in front of patient) Now do the same thing with the other hand (Not repeating the number of fingers). Patient gets credit only if able to successfully complete the entire command

25 Feature 4: Disorganized Thinking Present: If there is >1 error for the combined questions + command. Notes: –If pt is unable to move both arms, for the second part of the command ask patient Add one more finger. –If patient is unable to move arms at all (quadriplegic), then feature 4 is present if patient misses more than 1 question.

26 Confusion Assessment Method for the ICU (CAM-ICU) Feature 1: Acute change or fluctuating course of mental status And Feature 2: Inattention And Feature 3: Altered level of consciousness Feature 4: Disorganized Thinking Or Inouye, et. al. Ann Intern Med 1990; 113:941-948.1 Ely, et. al. CCM 2001; 29:1370-1379.4 Ely, et. al. JAMA 2001; 286:2703-2710.5

27 Case Studies

28 Case #1: Mr. Icy 45 y/o man, lawyer with no previous memory or attention problem Dx: DKA, Intubated In the past 24hrs the RASS scores have been -3 to +1. Step 1: Arousal Assessment Currently: Awake and moving around restless in bed, but not aggressive. RASS = +1 What do we do next?

29 Step 2: CAM-ICU - Feature 1: Is he at his MS baseline? Fluctuation? - Feature 2: Letters = 4 errors - Feature 3: RASS = +1 - Feature 4 PosNeg Feature 1 Feature 2 Feature 3 Feature 4 Case #1: Mr. Icy

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31 Step 2: CAM-ICU - Feature 1: Is he at his MS baseline? Fluctuation? Other RASS Scores: -3 +1 - Feature 2: Letters = 4 errors - Feature 3: RASS = +1 - Feature 4 PosNeg Feature 1 X Feature 2 X Feature 3 X Feature 4 Is this patient delirious?? Case #1: Mr. Icy

32 Case #2 Mrs. Dapple 75 y/o female Dx: Severe pneumonia requiring prolonged mechanical ventilation and difficulty weaning In past 24 hours: RASS scores -3 to -1 Step 1: Arousal Assessment Eyes closed, but awakens to voice; maintains eye contact for >10 seconds RASS = -1 What do we do next?

33 Step 2: CAM-ICU - Feature 1: Is she at her MS baseline? Fluctuation? - Feature 2: Letters = 1 error - Feature 3 - Feature 4 PosNeg Feature 1 Feature 2 Feature 3 Feature 4 Case #2 Mrs. Dapple

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35 Step 2: CAM-ICU - Feature 1: Is he at his MS baseline? Fluctuation? RASS Variance: 2 - Feature 2: Letters = 1 error - Feature 3 - Feature 4 PosNeg Feature 1 X Feature 2 X Feature 3 Feature 4 Is this patient delirious?? Case #2 Mrs. Dapple

36 Case # 3 Miss Universe Miss Universe was successfully extubated from the Vent at 0800. All sedation and analgesia had been stopped earlier in the AM. Yesterday evening and last night she had periods of agitation with a documented RASS range of -1 to +3. Step 1: Arousal Assessment Pt alert and calm. RASS = 0 What do we do next?

37 Step 2: CAM-ICU - Feature 1: Is she at her MS baseline? Fluctuation? - Feature 2: Letters = 3 errors, but you arent sure Pictures = 4 errors - Feature 3: RASS = 0 - Feature 4 PosNeg Feature 1 Feature 2 Feature 3 Feature 4 Case #3: Miss Universe

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39 Step 2: CAM-ICU - Feature 1: Is she at her MS baseline? Fluctuation? RASS Variance = 4 - Feature 2: Letters = 3 errors, but you arent sure. Pictures = 4 errors - Feature 3: RASS = 0 - Feature 4 PosNeg Feature 1 X Feature 2 X Feature 3 X Feature 4 Case #3: Miss Universe Do you need to do Feature 4??

40 Step 2: CAM-ICU - Feature 1: Is she at her MS baseline? Fluctuation? - Feature 2: Letters = 3 errors, but you arent sure. Pictures = 4 errors - Feature 3: RASS = 0 - Feature 4: Answered half the questions wrong Unable to perform 2-step command 3 errors PosNeg Feature 1 Feature 2 Feature 3 Feature 4 Case #3: Miss Universe

41 Step 2: CAM-ICU - Feature 1: Is she at her MS baseline? Fluctuation? - Feature 2: Letters = 3 errors, but you arent sure. Pictures = 4 errors - Feature 3: RASS = 0 - Feature 4: Answered half the questions wrong Unable to perform 2-step command 3 errors PosNeg Feature 1 X Feature 2 X Feature 3 X Feature 4 X Case #3: Miss Universe Is this patient delirious??

42 What if Miss Universe had gotten all 4 of her questions right?

43 Step 2: CAM-ICU - Feature 1: Is she at her MS baseline? Fluctuation? - Feature 2: Letters = 3 errors, but you arent sure. Pictures = 4 errors - Feature 3: RASS = 0 - Feature 4: Answered all 4 questions correct Unable to perform 2-step command 1 error PosNeg Feature 1 X Feature 2 X Feature 3 X Feature 4 X Case #3: Miss Universe Is this patient delirious??

44 Case # 4 Mr. Bubble Mr. Bubble works as a traveling salesman, and has been fully independent until admission. He is admitted with acute pancreatitis. His sedatives were turned off 30 minutes ago for a Spontaneous Awakening Trial (SAT). Step 1: Arousal Assessment Eyes closed, moves head to verbal stimulation, no eye contact RASS = -3 What do we do next?

45 Step 2: CAM-ICU - Feature 1: Is he at his MS baseline? Fluctuation? - Feature 2: Letters= no squeeze for any letters - Feature 3: RASS = -3 - Feature 4: PosNeg Feature 1 Feature 2 Feature 3 Feature 4 Case #4: Mr. Bubble

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47 Step 2: CAM-ICU - Feature 1: Is he at his MS baseline? Fluctuation? - Feature 2: Letters= no squeeze for any letters - Feature 3: RASS = -3 - Feature 4: PosNeg Feature 1 X Feature 2 X Feature 3 X Feature 4 Case #4: Mr. Bubble Is this patient delirious??

48 Confusion Assessment Method for the ICU (CAM-ICU) Feature 1: Acute change or fluctuating course of mental status And Feature 2: Inattention And Feature 3: Altered level of consciousness Feature 4: Disorganized Thinking Or Inouye, et. al. Ann Intern Med 1990; 113:941-948.1 Ely, et. al. CCM 2001; 29:1370-1379.4 Ely, et. al. JAMA 2001; 286:2703-2710.5

49 Stop and THINK Do any meds need to be stopped or lowered? Especially consider sedatives Is patient on minimal amount necessary? –Daily sedation cessation –Targeted sedation plan –Assess target daily Do sedatives need to be changed? Remember to assess for pain! T oxic Situations CHF, shock, dehydration New organ failure (liver/kidney) H ypoxemia I nfection/sepsis (nosocomial), I mmobilization N onpharmacologic interventions Hearing aids, glasses, reorient, sleep protocols, music, noise control, ambulation K + or electrolyte problems Consider antipsychotics after evaluating etiology & risk factors

50 Nonpharmacologic Interventions Environmental changes (e.g. noise reduction) Sensory aids (e.g. hearing aids, glasses) Reorientation and stimulation Sleep preservation & enhancement Exercise and mobility

51 RASS (N/D & reason if not done) CAM-ICU Feature 1 (MS change or fluctuation) Absent Present CAM-ICU Feature 2 (Inattention) Absent Present CAM-ICU Feature 3 (Altered LOC) Absent Present CAM-ICU Feature 4 (Disorganized thinking) Absent Present Overall CAM-ICU 1 + 2 + [3 or 4] = CAM-ICU+ Negative Positive UTA (RASS -4/-5 only) Not done:­­­­________

52 Brain Road Map for Rounds (Script for Interdisciplinary Communication) Skipping any of these steps could leave the clinical team wanting more information! Investigate (Ask these questions)Report (only takes 10 seconds) Where is the patient going?Target sedation score (RASS, SAS, etc) Where is the patient now? Actual sedation score (RASS, SAS, etc) Delirium assessment (CAM-ICU, ICDSC, etc) How did they get there?Drug exposures

53 Case Study - Day 1 Female, age 61 Hx: hypertension CC: altered mental status, pneumonia Dx: Septic shock, ARDS, acute renal failure Vent settings: A/C rate 16, TV 400, PEEP 14, FiO2 70% Infusions: Levophed 8 mcg/min, vasopressin 0.4 units/min, insulin gtt, IVF Assessment: Target RASS -3, actual RASS +1 to +2, displaying vent asynchrony, CAM-ICU positive, bilateral rhonchi, pulses present Drugs: Receiving intermittent boluses of fentanyl and midazolam What next?

54 Review your Road Map Report: Action: What do you do now? Where is the patient going?Target sedation score: RASS -3 Where is the patient now? Actual sedation score: RASS +1 to +2 Delirium: CAM-ICU positive How did they get there?Drug exposures: Intermittent fentanyl & midazolam

55 Case Study – Day 3 Vent settings: AC rate 16, TV 400, PEEP 6, FiO2 40% Infusions: propofol 40 mcg/kg/hr, Levophed 4 mcg/min, vasopressin 0.4 units/min, insulin gtt, IVF Drugs: Intermittent fentanyl for analgesia Assessment: Target RASS -1, actual RASS -3, CAM-ICU positive, not breathing over vent set rate, bilateral rhonchi, pulses present, moving extremities spontaneously What next?

56 Review your Road Map Report: Action: What do you do now? Where is the patient going?Target sedation score: RASS -1 Where is the patient now? Actual sedation score: RASS -3 Delirium: CAM-ICU positive How did they get there? Drug exposures: Propofol infusion 40 mcg/kg/min & intermittent fentanyl for pain

57 Case Study – Day 5 Vent settings: Pressure support 5, PEEP 5, 40% and tolerating spontaneous breathing trial Infusions: Levophed/vasopressin off, insulin gtt, IVF, propofol off Septic shock resolved, passed SAT/SBT Assessment: Target RASS 0, actual RASS 0, CAM-ICU positive, lungs clear, moves all extremities What next?

58 Review your Road Map Report: Action: What do you do now? Where is the patient going?Target sedation score: RASS 0 Where is the patient now? Actual sedation score: RASS 0 Delirium: CAM-ICU positive How did they get there?Drug exposures: No sedatives/analgesics in the past 24h

59 Questions? www.ICUdelirium.org delirium@vanderbilt.edu


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