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E. Wesley Ely, MD, MPH Professor of Medicine and Critical Care Vanderbilt University, Nashville, TN VA TN Valley Health Care System GRECC A New Frontier.

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Presentation on theme: "E. Wesley Ely, MD, MPH Professor of Medicine and Critical Care Vanderbilt University, Nashville, TN VA TN Valley Health Care System GRECC A New Frontier."— Presentation transcript:

1 E. Wesley Ely, MD, MPH Professor of Medicine and Critical Care Vanderbilt University, Nashville, TN VA TN Valley Health Care System GRECC A New Frontier in Critical Care: Saving the Injured Brain

2 Disclosures: ICU Physician Vanderbilt - Abbott, Hospira, Orion - NIH and VA U.S. Federal Funding - Author of PAD Guidelines of SCCM 2013

3 Agitation Pain Delirium SAG Guidelines for sustained use of sedatives and analgesics in the critically ill adult Jacobi, CCM 2002

4 Quote of the Day #1 Dr. Swenson explained, "I'll tell you the truth. What I have discovered…is not what I expected. It is something greater, much more ambitious than anything we had hoped for…in science: Never be so focused on what you are looking for that you overlook the thing you actually find." Ann Patchett , State of Wonder

5 Barr J, et al. PAD Guidelines. Crit Care Med. 2013;41: Agitation Pain Delirium

6 Barr J et al, CCM 2013;41:

7

8 Airplane Draft ICU Liberation - 3 Columns

9 © rustyrhodes via Flickr 50-70% Cognitively Impaired Wolters Intensive Care Med 2013; 39: 376 Jackson AJRCCM 2010; 182: 183 Girard Crit Care Med 2010; 38: 1513

10 Latronico Lancet Neurol 2011; 10: % Functionally Impaired Marcel Oosterwijk via Flickr

11 ICU Survivorship Family Hobbies Work Iwashyna Annals of Int Med 2010; 153:204-5

12 After 5 months I felt better and returned to work but was fired 10 weeks later... it didn't surprise me because I was struggling terribly. I couldn't organize my work; committed many errors in documentation; frequently lost things; forgot meetings, and did not manage my time well “ © Travis Smith via Flickr

13 When I returned to work, the work I did before seemed foreign and unfamiliar. I became isolated and excluded from everyone. No one wanted to be around me. My wife of more than 36 years told me that I was just “feeling sorry” for myself, and I just needed to get on with my life. I nearly ended my life a few times. Then after five years of this hell, Oct CBS News ran a report about people just like me. From that report I found your website. I cried for long time; it has changed my wife’s opinion about me. For the first time in the past five years, I think believe I have a future. “ © Travis Smith via Flickr

14 Mild Cognitive Impairment Moderate/Severe Cog Impairment % survivors cognitively impaired -3 years-1 year+1 year+ 3 years 25 p<0.001 After SepsisBefore Sepsis Iwashyna T, JAMA 2010;304: Cognitive Impairment: Sepsis

15 Ely EW, JAMA 2004;291:

16 Shehabi Y, et al. CCM 2010; 38:2311–2318 Delirium Duration & Mortality Relative Hazard of Death p<.001 Days of Delirium 0 vs 1HR < vs 2HR < vs 3HR <0.001

17

18 NEJM 2013;369: Editorial by M. Herridge

19 Gunther M et al. CCM 2012;40: (A) 46 year old, no delirium (B) 42 year old, 12 days of delirium Delirium and Brain Atrophy

20 The Picture of Dementia Following ICU Care

21 Global Cognitive Scores by Age

22 Global Cognitive Scores by Age and Comorbidity

23 Delirium and Executive Function

24 Confirmed: Delirium Risk Factor for Long- Term Cognitive Problems after ICU Stay 1,101 survivors of critical illness, 37% with delirium Studied only survivors and used self report Multivariable analysis with adjustment for gender, admission dx, severity of illness (both APACHE IV and cumulative SOFA) Delirium independent predictor of mild (O.R. 2.41, C.I ) and severe (3.1, ) LTCI 1 year Wolters AE, Crit Care 2014 June epub

25 If delirium is not screened for using a validated delirium screening tool it is missed ~75% of time. Inouye SK Arch Intern Med. 2001;161: Devlin JW Crit Care Med. 2007;35: Spronk PE Intensive Care Med. 2009;35: van Eijk MM Crit Care Med. 2009;37:

26 Take Home Message

27 “We recommend routine monitoring for delirium in adult ICU patients” Grade 1B Recommendation 2013 PAD Guidelines: Crit Care Med. 2013;41:

28 Medical Intensive Care Unit Don’t forget about Dr. DRE Diseases Sepsis, COPD, CHF Drug Removal SATs and stopping benzodiazepines/ narcotics Environment Immobilization, sleep and day/night, hearing aids, glasses, noise

29 So let’s focus on potentially modifiable aspects of care such as potent medications, delirium, and improving care and clinical outcomes…

30 E C B A ABCDEs: Building blocks of managing Pain, Agitation & Delirium

31 “Faced with the choice between changing one's mind and proving that there is no need to do so, almost everyone gets busy on the proof.” --John Kenneth Galbraith

32 Awake and Breathing Coordination Choose light sedation & avoid benzos Delirium monitoring & management Early Mobility & Environment  Duration of mechanical ventilation  Duration of coma  Mortality  Duration of mechanical ventilation  Mortality  Delirium  Duration of delirium  Disability  ICU Length of Stay  Rehospitalization/Mortality Morandi et al Curr Opin Crit Care 2011;17:43-9 Vasilevskis et al Crit Care Med 2010;38:S Vasilevskis et al Chest 2010;138: Zaal et al, ICM 2013;39: Colombo et al, Minerva Anest 1012;78:  Delirium detection

33

34 New Order Set: Benzodiazepine Use Median dose - Lorazepam equivalents (mg) Adjusted Ratio of Medians: 0.71 (95% CI: -1.31, -0.10) Dale CR & Treggiari M, Ann ATS 2014 epub Treggiari M et al. Crit Care Med 2009;37:

35 Probability of Delirium over Time Adjusted OR of delirium: 0.67 (95% CI: 0.49, 0.91) Dale CR & Treggiari M, Ann ATS 2014 epub Treggiari M et al. Crit Care Med 2009;37:

36 Balas M, CCM 2014 epub 1.5 year prospective QI (before/after) study of 296 ICU patients.

37 VENTILATOR FREE DAY RESULTS Days Balas M CCM 2014

38 DELIRIUM RESULTS p=0.003 Balas M CCM 2014

39 % p=0.07

40 28 DAY MORTALITY RESULTS p=0.04 Balas M CCM 2014 p=0.07

41 ADJUSTED ANALYSIS Controlling for age, sex, mechanical ventilation, APACH II score, Charlson Comorbidity Index Delirium anytime - OR 0.55 ( ); p=0.03 OOB anytime in ICU - OR 2.11 ( ) p=0.003 Balas M CCM 2014

42 Outcome Pre-QI (n=27) Post-QI (n=30) p Days with any benzodiazepine use**150 (50%)118 (26%).002 Days alert (RASS -1 to +1)88 (30%)311 (67%)<.001 PT/OT in MICU19 (70%)28 (93%).040 Number of PT/OT treatments in ICU1 (0-3)7 (3-15)<.001 Days without delirium61 (21%)243 (53%).003 Days of delirium in ICU107 (36%)125 (28%) Days of Coma129 (43%)86 (19%) Hopkins QI Project = Reduced Delirium via less benzodiazepines and more mobility Needham DM Arch Phys Med Rehabil 2010; 91: ** Benzodiazepine dose (median midazolam eq) from 47mg down to 15 mg/day

43 “I had never before understood how much good nursing care contributes to patients’ safety and comfort, especially when they are very sick or disabled. This is a lesson all physicians and hospital administrators should learn. When nursing is not optimal, patient care is never good.” Dr. Bud Relman Remember: Monitoring of delirium in critical illness, while not a feat resting solely in the hands of nurses, will succeed only under the guidance of nursing leadership and via the day-to-day actions of nurses intersecting with the other critical INTER- disciplinary members of our ICU teams at every bed in ICUs across the land.

44 Pain, Agitation, and Delirium Are Interrelated Barr J, et al. Crit Care Med. 2013;41: Agitation Pain Delirium

45 “Pain should be routinely monitored in all adult ICU patients” Grade 1B Recommendation 2013 PAD Guidelines: Crit Care Med. 2013;41:

46 Pain, Agitation, and Delirium Are Interrelated Barr J, et al. Crit Care Med. 2013;41: Agitation Pain Delirium

47 Targeted Level of Consciousness Choose Target RASS Assess Actual RASS Modify treatment so Actual = Target

48 “We recommend either daily sedation interruption or a light level* of target sedation be routinely used…” Grade 1B Recommendation *Light sedation = RASS 0 to PAD Guidelines: Crit Care Med. 2013;41:

49 Awake and Breathing Coordination Choose light sedation & avoid benzos Delirium monitoring & management Early Mobility & Environment  Duration of mechanical ventilation  Duration of coma  Mortality  Duration of mechanical ventilation  Mortality  Delirium  Duration of delirium  Disability  ICU Length of Stay  Rehospitalization/Mortality Morandi et al Curr Opin Crit Care 2011;17:43-9 Vasilevskis et al Crit Care Med 2010;38:S Vasilevskis et al Chest 2010;138: Zaal et al, ICM 2013;39: Colombo et al, Minerva Anest 1012;78:  Delirium detection

50 Ely EW, et al. N Engl J Med 1996;335: Patients on Ventilator (%) Control (n =151) Protocol (n =149) p<.001 Time (Days) Liberating from Ventilator SBT reduced weaning time by = 2 days

51 Patients on Ventilator (%) Control (n=60) Protocol (n=68) Adjusted p<.001 Time (Days) Liberating from Sedation Kress JP, et al. N Engl J Med 2000;342: SAT reduced ventilator time by = 2 days

52 Quote of the Day #2 “I came awake on the fifth day. My first memory is that of floating up from the ocean bottom, my eyes still waterlogged and with what felt like scuba gear stuffed in my mouth and throat. I couldn’t speak. As I broke to the surface, I understood that I was still in the ICU at Our Lady, but I heard nothing of what anybody said. Abraham Verghese , Cutting for Stone Ann Patchett , State of Wonder

53 SAT + SBT = 4 day shorter ICU/hosp LOS

54 Patients Alive (%) Days Control (n=168) ABC approach (n=167) ABC Trial: One-Year Survival p=.01 NNT=7 Girard TD, et al. Lancet 2008;371:126-34

55 Mehta S, JAMA 2012;308: Sedation Interruption in SLEAP

56 Benzodiazepine Use in Trials * StudyControlTreatment Kress NEJM mg/day53 mg/day Girard ABC Lancet mg/day54 mg/day Mehta SLEAP JAMA mg/day102 mg/day OSCILLATE NEJM mg/day199 mg/day * All values converted and expressed as mean midazolam dose per patient, median for ABC study were 8 mg and 5 mg, respectively

57 From Canadian Authors of SLEAP… n=712 and 3,620 patient-days “We found that nearly all patients were managed with continuous-infusion opioids and sedatives. We also found that actual practice was different from what we expected because the available clinical tools – such as protocols and assessment scales – were not necessarily applied at the bedside.” Burry LD, Can J Anesth May 2014 epub Data collected

58 SPICE Study – first 48 hours mean 50 mg/d benzos Shehabi AJRCCM 2012;186:724-31

59 Awake and Breathing Coordination Choose light sedation & avoid benzos Delirium monitoring & management Early Mobility & Environment  Duration of mechanical ventilation  Duration of coma  Mortality  Duration of mechanical ventilation  Mortality  Delirium  Duration of delirium  Disability  ICU Length of Stay  Rehospitalization/Mortality Morandi et al Curr Opin Crit Care 2011;17:43-9 Vasilevskis et al Crit Care Med 2010;38:S Vasilevskis et al Chest 2010;138: Zaal et al, ICM 2013;39: Colombo et al, Minerva Anest 1012;78:  Delirium detection

60 No Sedation: ICU Length of Stay 0 Days Patients Remaining in ICU (%) Intervention (n=55) Control (n=58) Strom T, et al. Lancet 2010;375: ICU stay reduced by 9.7 days

61 “We suggest that sedation strategies using non-benzodiazepines (propofol or dexmedetomidine) may be preferred over sedation with benzodiazepines (midazolam or lorazepam)” Grade 2B Recommendation 2013 PAD Guidelines: Crit Care Med. 2013;41:

62 Buffalos to Beer to Brain Cells Cliff the mailman and philosopher Cliff: “Well you see, Norm, it's like this.. A herd of buffalo can only move as fast as the slowest buffalo. And when the herd is hunted, it is the slowest and weakest ones at the back that are killed first. This natural selection is good for the herd as a whole, because the general speed and health of the whole group keeps improving by the regular killing of the weakest members.” sitcom CHEERS

63 Buffalos to Beer to Brain Cells “In much the same way, Norm, the human brain can only operate as fast as the slowest brain cells. Now, as we know, excessive intake of alcohol kills brain cells. But naturally, it attacks the slowest and weakest brain cells first. In this way, regular consumption of beer eliminates the weaker cells, making the brain a faster and more efficient machine. And that, Norm, is why you always feel smarter after a few beers.” sitcom CHEERS

64 Daily Risk of Delirium in MENDS p=0.02 Pandharipande PP, et al. Crit Care 2010;14:R38

65 Daily Risk of Delirium in SEDCOM Riker, et al. JAMA 2009;301: p<0.001

66 Pain, Agitation, and Delirium Are Interrelated Barr J, et al. Crit Care Med. 2013;41: Agitation Pain Delirium

67 Awake and Breathing Coordination Choose light sedation & avoid benzos Delirium monitoring & management Early Mobility & Environment  Duration of mechanical ventilation  Duration of coma  Mortality  Duration of mechanical ventilation  Mortality  Delirium  Duration of delirium  Disability  ICU Length of Stay  Rehospitalization/Mortality Morandi et al Curr Opin Crit Care 2011;17:43-9 Vasilevskis et al Crit Care Med 2010;38:S Vasilevskis et al Chest 2010;138: Zaal et al, ICM 2013;39: Colombo et al, Minerva Anest 1012;78:  Delirium detection

68 Cardinal Symptoms of Delirium and Coma Morandi A, et al. Intensive Care Med. 2008;34:

69 Ely EW, JAMA 2001;286:

70 Ely EW, JAMA 2003;289:

71 CAM-ICU Sensitivity and Specificity Over a dozen studies have now compared the 30 second CAM-ICU evaluation to Geriatric psychiatrists’ 30 to 45 minute evaluations: – Sensitivity 80% to 95% – Specificity 90% to 97% – Inter-rater reliability, kappa = 0.96 ( ) – Delirium prevalence rates in mechanically ventilated ICU patients consistently 60% to 80% Ely EW, JAMA 2001;286: Gusmao-Flores Crit Care 2012;16:R115

72 Medical Intensive Care Unit Don’t forget about Dr. DRE Diseases Sepsis, COPD, CHF Drug Removal SATs and stopping benzodiazepines/ narcotics Environment Immobilization, sleep and day/night, hearing aids, glasses, noise

73 SLEEP Consider reading these citations: Patel J et al, Anesthesia 2014;69: Watson P et al, CCM 2013;41: Weinhouse G, CO-Anesthesiology 2014;27:epub Kamdar B et al, Anesthesia 2014;69: Kamdar B et al, CCM 2013;41:800-09

74 Hopkins Sleep Protocol Associated with Reductions in Delirium No overhead pages No TV Dim hall lights Grouping Care Activities Mobilization Lights on, blinds open Decrease naps No caffeine after 3pm Ear plugs Eye masks Soothing Music Avoiding Benzos, Opiates & trazodone as sleep aides Zolpidem if CAM – Haloperidol if CAM + Environmental Non-PharmacologicPharmacologic Following QI intervention, fewer patients developed delirium (Adjusted OR 0.46, 95% CI , p=0.02) Intervention patients had more days of ‘normal’ brain function (Adjusted OR 1.64, 95% CI , p=0.03) Kamdar B CCM 2013;41:800-09

75 Average ICU has background noise of crowded restaurant, louder next to patient’s head Noise spikes of >85dBA at least every 8 minutes Darbyshire JL CCM 2013;17:R187

76 Sleep Promotion In ICU Reduces Delirium Prevalence SLEEP Program Rummelhard D, Schelle-Chaple H (UCSF) CCM 2012 Weeks %

77 Modifying the Impact of ICU-Associated Neurological Dysfunction MIND-USA

78 Brain Road Map (A framework for bedside rounds) 3. How did they get there? Drugs 1. Where is the patient going? Target RASS 2. Where is the patient now? Current RASS Current CAM-ICU © Brian Sloan via Flickr

79 Awake and Breathing Coordination Choose light sedation & avoid benzos Delirium monitoring & management Early Mobility & Environment  Duration of mechanical ventilation  Duration of coma  Mortality  Duration of mechanical ventilation  Mortality  Delirium  Duration of delirium  Disability  ICU Length of Stay  Rehospitalization/Mortality Morandi et al Curr Opin Crit Care 2011;17:43-9 Vasilevskis et al Crit Care Med 2010;38:S Vasilevskis et al Chest 2010;138: Zaal et al, ICM 2013;39: Colombo et al, Minerva Anest 1012;78:  Delirium detection

80 The Iconic Picture of Early Mobility Point prevalence study in Germany showed <10% walking “Yes ‘n How many deaths will it take, Till he knows that too many people have died?” Dylan, Times They Are A-Changin’ Needham DM, JAMA 2008;300: Nydahl P et al, CCM 2014;42: Clemmer T, CCM 2014;42:

81 VariableIntervention (n=49) Control (n=55) P-value ICU/Hosp Delirium Days 2 days4 days0.03 Time in ICU with Delirium 33%57%0.02 Time in Hosp. with Delirium 28%41%0.01 Schweickert et al, Lancet 2009;373: Mobilization = Less Delirium

82 Minimum Criteria for Consulting PT/OT and Initiating Early Exercise M – Myocardial Stability No evidence of active myocardial ischemia Stable heart rate and cardiac rhythm O – Oxygenation adequate on FIO 2 <0.6 PEEP<10 cm H 2 O. V – Vasopressor(s) Minimal No increase dose of any vasopressor infusion for at least 2 hours* E – Engages to Voice Patient response to verbal stimulation (RASS > -3)

83 Mobilizing the Brain with Sudoku & Scrabble

84 RETURN to Land of the Living Returning to Everyday Tasks Utilizing Rehabilitation Networks

85 RETURN – Cognitive Rehabilitation 3 Month Follow-UpEnrollment Executive Function Intervention Control Jackson et al, Critical Care Med. 2012

86 E C B A ABCDEs: Building blocks of managing Pain, Agitation & Delirium

87 Airplane Draft ICU Liberation - 3 Columns

88 abcdef… F = FAMILY Family rounding Family visitation Family importance to reducing delirium Good EOL planning Good transitions of care, IMPACT project

89 Excellence Aristotle: “We are what we repeatedly do. Excellence is not an act, but a habit” Jiro Dreams of Sushi - Tokyo

90 “ I survived and that is the main thing. And I am so grateful to God that I survived and am now off all oxygen and consider myself all well except that I can’t remember to take my medications... -SB “ © Cappi Thompson via Flickr

91 The ICU Delirium and Cognitive Impairment Study Group at the Loveless Café, Nashville TN

92 ICU Delirium and Cognitive Impairment Study Group: selected local members Pratik Pandharipande Jim Jackson Jin Han Ed Vasilevskis Chris Hughes Alessandro Morandi Paula Watson Lorraine Ware Gordon Bernard Bob Dittus Ted Speroff Wes Ely Leanne Boehm Joyce Okahashi Cayce Strength Brenda Pun Lauren Hardy Amy Lipsey Ryan Black Jessica McCurley Michael Santoro Carrie Jones Morgan Crawford Mayur Patel Tim Girard John Gore Baxter Rogers Stephan Heckers Cathy Fuchs Heidi Smith Ty Berutti Brad Strohler Elizabeth Card Jennifer Thompson Ayumi Shintani Stephanie Hamilton


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