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ABCDE Protocol ICU Delirium and Cognitive Impairment Study Group

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1 ABCDE Protocol ICU Delirium and Cognitive Impairment Study Group

2 Why the ABCDE Protocol?

3 Need for Sedation and Analgesia Prevent pain and anxiety Decrease oxygen consumption Decrease the stress response Patient-ventilator synchrony Avoid adverse neurocognitive sequelae Rotondi AJ, et al. Crit Care Med. 2002;30: Weinert C. Curr Opin in Crit Care. 2005;11: Kress JP, et al. Am J Respir Crit Care Med. 1996;153: Depression, PTSD

4 Potential Drawbacks of Sedative and Analgesic Therapy Oversedation: Failure to initiate spontaneous breathing trials (SBT) leads to increased duration of mechanical ventilation (MV) Longer duration of ICU stay Impede assessment of neurologic function Increase risk for delirium Numerous agent-specific adverse events Kollef MH, et al. Chest. 1998;114: Pandharipande PP, et al. Anesthesiology. 2006;104:21-26.

5 Sedation Mechanical Ventilation DeliriumWeakness Patient with Sepsis Cognitive and Functional Impairment, Institutionalization, M ortality Vasilevskis et al Chest 2010; 138;

6 We Need Coordinated Care Many tasks and demands on critical care staff Great need to align and supporting the people, processes, and technology already existing in ICUs ABCDE protocol is multiple components, interdependent, and designed to: Improve collaboration among clinical team members Standardize care processes Break the cycle of oversedation and prolonged ventilation Vasilevskis et al Chest 2010; 138;

7 What is the MIND-USA ABCDE Protocol? Awakening and Breathing Coordination Delirium Identification and Management Early Exercise and Mobility ABC D D E E

8 Awakening and Breathing Coordination ABC

9 Over sedation Patient Comfort and Ventilatory Optimization ICU Sedation: It’s a Balancing Act

10 Consequences of Suboptimal Sedation Inadequate sedation/analgesia Anxiety Pain Patient-ventilator dyssynchrony Agitation – Self-removal of tubes/catheters Care provider assault Myocardial ischemia Family dissatisfaction Excessive sedation Prolonged mechanical ventilation, ICU LOS – Tracheostomy – DVT, VAP Additional testing Added cost Inability to communicate Cannot evaluate for delirium

11 Structured Approaches to Sedation & Analgesia in the ICU 1.Multidisciplinary development, implementation 2.Establish goals/targets, frequently re-evaluate 3.Measure key components using validated scales 4.Select medications based on characteristics, evidence 5.Incorporate key patient considerations 6.Prevent oversedation, yet control pain and agitation 7.Promote multidisciplinary acceptance and integration into routine care Sessler & Pedram. Crit Care Clinics 2009; 25:

12 Validated ICU Sedation Scales Richmond agitation-sedation scale (RASS) Sedation agitation scale (SAS) Ramsay sedation scale Motor activity assessment scale (MAAS) Vancouver interactive and calmness scale (VICS) Adaptation to intensive care environment (ATICE) Minnesota sedation assessment tool (MSAT)

13 Setting Targets Provide for agitation/anxiety free, amnesia, comfort Trying to achieve a balance TIGHT TITRATION Adjust target depending on current need Per patient Different over the course of Illness/Treatment

14 Use Protocols to Achieve Goals, Minimize Drug Accumulation, Maximize Alertness Patient-focused drug selection Preference for analgesia > sedation Intermittent therapy via boluses Frequent evaluation of sedation, pain, ICU therapy tolerance – Titrate therapy for lowest effective dose Daily interruption of sedation

15 RCT: 2x2 factorial design – Midazolam vs propofol – Daily interruption of sedation vs routine Discontinue all sedative and analgesic medications Monitor patient closely until awake or agitated, i.e., can perform at least 3 of 4 on command: – Open eyes – Squeeze hand – Lift head – Stick out tongue Restart medications at half dosage (if necessary) Kress et al. N Engl J Med 2000; 342:1471-7

16 Shorter duration of mechanical ventilation Shorter ICU LOS Fewer tests for altered mental status Kress et al. N Engl J Med 2000; 342: Daily Awakening Trial Results

17 Why Is Interruption of Sedation Effective? Less accumulation of sedative drug and metabolites – Significantly less midazolam and morphine with DIS in midazolam subgroup – But… no difference in amount of propofol and morphine with DIS in propofol subgroup Opportunity for more effective weaning from mechanical ventilation? Sessler CN. Crit Care Med 2004 Kress et al. NEJM Wake Up and Breathe

18 Multicenter RCT: 168 patients with “spontaneous awakening trial” (SAT) – i.e., daily interruption of sedation (SAT) + spontaneous breathing trial (SBT) 168 patients with standard sedation + SBT


20 “SAT + SBT” Was Superior to Conventional Sedation + SBT Intervention (SAT) group = Less benzodiazepine Girard et al. Lancet 2008; 371: P = 0.02 P = 0.01 Extubated fasterDischarged from ICU sooner

21 “SAT + SBT” Was Superior to Conventional Sedation + SBT Intervention (SAT) group = More unplanned extubation, but not more reintubation P = 0.02 P = 0.01 Discharged from hospital soonerBetter survival at 1 yr Alive P = 0.01 P = 0.04 Girard et al. Lancet 2008; 371:126-34

22 Awakening & Breathing Coordination Synergy of daily awakening – via interruption of sedation – plus spontaneous breathing trial – Less medication accumulation, less excessive sedation – Opportunity for more effective independent breathing (SBT) Perform safety screens for SAT and for SBT

23 ABC Safety Screens Wake Up Safety Screen No active seizures No active alcohol withdrawal No active agitation No active paralytic use No myocardial ischemia (24h) Normal intracranial pressure Breathe Safety Screen No active agitation Oxygen saturation >88% FiO 2 < 50% PEEP < 7.5 cm H 2 O No active myocardial ischemia (24h) No significant vasopressor use Girard et al. Lancet 2008; 371: Kress et al. Crit Care Med 2004; 32(6): Ely et al. NEJM 1996; 335:184-9

24 ABC Awakening & Breathing Coordination Eligibility = On the ventilator 1.SAT Safety Screen - pass/fail 2.If pass safety screen, perform SAT If fail ; restart sedatives if necessary (1/2 dose) If pass ; continue to SBT safety screen 3.SBT Safety Screen - pass/fail 4.If pass safety screen, perform SBT If fail ; return to previous ventilatory support If pass ; consider extubation

25 D D Delirium Monitoring and Management

26 Delirium: Key Features 1.Disturbance of consciousness with reduced ability to focus, sustain or shift attention 2.A change in cognition or the development of a perceptual disturbance that is not better accounted for by pre-existing, established or evolving dementia 3.Develops over a short period of time and tends to fluctuate over the course of the day 4.There is evidence from the H&P and/or labs that the disturbance is caused by a medical condition, substance intoxication or medication side effect

27 Delirium Subtypes Alert & Calm Combative Agitated Restless Lethargic Sedated Stupor Hyperactive Delirium Hypoactive Delirium Mixed Delirium

28 ICU Delirium Increased ICU length of stay (8 vs 5 days) Increased hospital length of stay (21 vs 11 days) Increased time on ventilator (9 vs 4 days) Higher ICU costs ($22,000 vs $13,000) Higher ICU mortality (19.7% vs 10.3%) Higher hospital mortality (26.7% vs 21.4%) 3-fold increased risk of death at 6 months Ely, et al. ICM2001; 27, Ely, et al, JAMA 2004; 291: Lin, SM CCM 2004; 32: Milbrandt E, et al, Crit Care Med 2004; 32: Ouimet, et al, ICM 2007: 33:

29 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: Ely, et. al. CCM 2001; 29: Ely, et. al. JAMA 2001; 286:

30 Delirium Management 1. Identify etiology 2. Identify risk factors 3. Consider pharmacologic treatment Jacobi J, et al. Crit Care Med 2002;30:

31 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

32 A Multicomponent Intervention to Prevent Delirium in Hospitalized Older Patients 852 patients ≥70 years old on general medicine service, no delirium at time of admission Intervention: standardized protocol for management of 6 delirium risk factors (n=426) Usual care: standard hospital services (n=426) Primary Outcome: Delirium incidence & prevalence Inouye, et al. NEJM. 1999;340:

33 Elder Life Program Targeted Risk FactorStandardized Intervention Cognitive impairment Orientation & therapeutic activity protocol (discuss current events, word games, reorient, etc) Sleep deprivation Sleep enhancement & nonpharm sleep protocol (noise reduction, back massages, schedule adjustment) Immobility Early mobilization protocol (active ROM, reduce restraint use, ambulation, remove catheters) Visual impairment Vision protocol (glasses, adaptive equipment, reinforce use) Hearing impairment Hearing protocol (amplification devices, hearing aids, earwax disimpaction) Dehydration Dehydration protocol (early recognition of dehydration & volume repletion) Inouye, et al. NEJM. 1999;340:

34 Results OutcomeInterventionControlP-value Incidence of delirium, N (%)42 (9.9)64 (15)0.02 Total days of delirium Episodes of delirium Improved (p=0.04) orientation score with targeted intervention Reduced rate of sedative use for sleep (p=0.001) 87% overall adherence to protocol Inouye, et al. NEJM. 1999;340:

35 Eligibility = RASS ≥ -3 Delirium Nonpharmacologic Interventions +4 COMBATIVECombative, violent, immediate danger to staff +3VERY AGITATEDPulls to remove tubes or catheters; aggressive +2AGITATEDFrequent non-purposeful movement, fights ventilator +1RESTLESSAnxious, apprehensive, movements not aggressive 0ALERT & CALMSpontaneously pays attention to caregiver -1DROWSYNot fully alert, but has sustained awakening to voice (eye opening & contact >10 sec) -2LIGHT SEDATIONBriefly awakens to voice (eyes open & contact <10 sec) -3MODERATE SEDATIONMovement or eye opening to voice (no eye contact) -4DEEP SEDATIONNo response to voice, but movement or eye opening to physical stimulation -5UNAROUSEABLE No response to voice or physical stimulation

36 Delirium Nonpharmacologic Interventions Pain: Monitor and manage pain using an objective scale (e.g., FACES, BPS, VAS, CPOT, etc.) Orientation: Convey the day, date, place, and reason for hospitalization Update the whiteboards with caregiver names Request placement of a clock and calendar in room Discuss current events

37 Nonpharmacologic Interventions Sensory: Determine need for hearing aids and/or eye glasses If needed, request surrogate provide these for patient when appropriate Sleep: Noise reduction strategies (e.g. minimize noise outside the room, offer white noise or earplugs) Normal day-night variation in illumination Use “time out” strategy to minimize interruptions in sleep Maintain ventilator synchrony Promote comfort and relaxation (e.g., back care, oral care, washing face/hands, and daytime bath, massage)

38 Early Exercise and Mobility E E

39 Early Exercise in the ICU Early exercise = progressive mobility Study design: paired SAT/SBT protocol with PT/OT from earliest days of mechanical ventilation Schweickert WD, et al. Lancet. 2009;373: Wake Up, Breathe, and Move

40 Early Exercise Study Results Outcome Intervention (n=49) Control (n=50)P Functionally independent at discharge29 (59%)19 (35%)0.02 ICU delirium (days) 2.0 ( ) 4.0 ( )0.03 Time in ICU with delirium (%)33 (0-58)57 (33-69)0.02 Hospital delirium (days) 2.0 ( ) 4.0 ( )0.02 Hospital days with delirium (%)28 (26)41 (27)0.01 Barthel index score at discharge75 (7.5-95)55 (0-85)0.05 ICU-acquired paresis at discharge15 (31%)27 (49%)0.09 Ventilator-free days23.5 ( )21.1 ( )0.05 Length of stay in ICU (days)5.9 ( )7.9 ( )0.08 Length of stay in hospital (days)13.5 ( )12.9 ( )0.93 Hospital mortality9 (18%)14 (25%)0.53 Schweickert WD, et al. Lancet. 2009;373:

41 Early Exercise and Mobility Eligibility = All patients are eligible for Early Exercise and Mobility

42 Perform Safety Screen First Safety Screen Patient responds to verbal stimulation (i.e., RASS > -3) FIO 2 <0.6 PEEP <10 cmH 2 O No  dose of any vasopressor infusion for at least 2 hours No evidence of active myocardial ischemia (24 hrs) No arrhythmia requiring the administration of new antiarrhythmic agent (24hrs) If patient passes Exercise/Mobility Safety Screen, move on to Exercise and Mobility Therapy If patient fails, s/he is too critically ill to tolerate exercise/mobility

43 1.Active range of motion in bed and sitting position in bed 2.Dangling 3.Transfer to chair (active), includes standing without marching in place 4.Ambulation (marching in place, walking in room or hall) *All may be done with assistance. Early Exercise & Mobility Levels of Therapy*

44 Early Exercise and Mobility Protocol Progression Active ROM (in bed) Sit/ Dangle March/ Walk Transfer No Exercises, but Passive Range of Motion allowed Progress as tolerated ICU Discharge Exercise screen RASS ≥ -3 RASS -5 / -4

45 Morandi A et al. Curr Opin Crit Care,2011;17:43-9 Benefits of ABCDE Protocol

46 Questions?

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