1. Diagnosis and Management of ICU Delirium
June 24, July 1, 2010
Dave Miller, MD and Becky Logiudice, MS, RN

2. Talk Outline Why is this important? What is delirium?
Using CAM-ICU to diagnose ICU delirium
How do I treat delirium?
Goal-oriented sedation

3. Why is this important? Perspective from SB
Perspective from SB
About my delirium memories from the ICU, I have had few. The time I spent seems like it was in a huge, empty gray space, sort of like a monstrous underground parking garage with no cars, only me, floating or seeming to float, on something. Every once in a while I would get to an edge of something horrible and once I remember I thought, "if I just let go, then this horror will be over…” When I try to write about that time (and I have tried over and over), words just won't come and in my line of writing, personal essays, if it doesn't just come gushing out, I have to stop. And that's where I am now

4. Why is this important? 183 ÷ (183+41) = 0.82
Pun B T , Ely E W Chest 2007;132:

5. Why is this important? Common Increased mortality Increased LOS
Increased complications
Increased costs
May be associated with increased dementia and long-term cognitive impairment

6. Girard DT et al. Crit Care Med 2010;38(7):epub ahead of print

7. Pun BT and Ely EW. Chest 2007;132:624-636

8. What is Delirium? Answer # 1
You’ll Know it when you see it. . .

9. What is delirium?
Pun B T , Ely E W Chest 2007;132:

10. What is delirium? Answer # 2
Disturbance of consciousness
Inattention
Change in cognition or perceptual disturbance
Develops over hours to days
Fluctuates over time

11. How do I diagnose delirium? Case 1
Mr. D, a 70-year old with severe COPD, is in the MICU on a ventilator for respiratory failure. Initially he needed high levels of sedation, but now Propofol has been decreased and Mr. D is awake but agitated, grimacing, thrashing and trying to sit up in bed. He makes eye contact, but won’t follow commands
Is Mr. D delirious?
How do you know?

12. Assessment of ICU patients
Patient Comfort
Pain
Sedation
Delirium
0 -10 scale
FRACC
Subjective/
physiologic factors
Sedation assessment scale
(RASS, SAS, MAAS)
CAM-ICU

13. Assessment tool: CAM-ICU

14. Assessment tool: CAM-ICU
Richmond Agitation-Sedation Scale (RASS)

15. RASS +4 Combative Combative, violent, immediate danger to staff +3
Very agitated
Pulls or removes tubes or catheters; aggressive +2
Agitated
Frequent non-purposeful movement, fights ventilator +1
Restless
Anxious and apprehensive, but movements not aggressive or vigorous
Alert and calm -1
Drowsy
Not fully alert but has eye opening to voice and sustained eye contact (> 10 s) -2
Light sedation
Briefly awakens to voice with eye opening and eye contact (< 10 s) -3
Moderate sedation
Movement or eye opening to voice but no eye contact -4
Deep sedation
No response to voice, but movement or eye opening to physical stimulation -5
Not arousable
No response to voice or physical stimulation

16. Assessment tool: CAM-ICU
Attention Screening Examination

17. Attention Screening Examination
Auditory
Squeeze my hand each time I say the letter “A”
SAVEAHAART
More than 2 wrong responses = POSTIVE
Visual (cannot hear or squeeze hands)
Show 5 pictures, then show 5 repeat and 5 new in random order
More than 2 wrong responses = POSITIVE

18. Assessment tool: CAM-ICU
Assessing for Disorganized Thinking:
Answer 4 simple yes/no questions and follow a 2-step command:
E.g.,“Will a stone float on water?”
“Hold up 2 fingers on one hand, then on the other hand.”

19. How do I diagnose delirium? Case 1 revisited
Mr. D, a 70-year old with severe COPD, is in the MICU on a ventilator for respiratory failure. Initially he needed high levels of sedation, but now Propofol has been decreased and Mr. D is awake but agitated, grimacing, thrashing and trying to sit up in bed. He makes eye contact, but won’t follow commands
Is Mr. D delirious?
How do you know?

20. Case 1 revisited
STEP 1: Mr. D is assessed to be a RASS +2, which is an acute change from his baseline
STEP 2: He squeezes hands on “A” once out of 5 times (4 errors) so is inattentive
STEP 4: Because his level of consciousness is altered (RASS +2), STEP 3 does not need to be assessed.
Mr. D is delirious!

21. Case 2
The next day, Mr. D is awake and calm (RASS 0). He was given several doses of lorazepam overnight for “agitation.” He remains intubated, but is following commands appropriately.
Is Mr. D delirious now?

22. How should we manage Mr. D?
STEP 1: He is awake and calm (RASS 0) now, but fluctuated within the last 24 hours
STEP 2: He scores 6/10 on the Attention Screening Examination (POSITIVE)
STEP 3: Because his level of consciousness is not currently altered, he is tested for disorganized thinking. He scores 3 out of 5 because when asked “Are there elephants in the sea?” and “Can you use a hammer to cut wood?” he answers “YES!” (POSITIVE)
How should we manage Mr. D?

23. Managing ICU Delirium Look for it
Communication between nursing and MDs
Identify and treat correctable risk factors
Optimize non-pharmacologic interventions
Goal-oriented sedation with daily wake-ups
Pharmacologic intervention

24. Managing ICU Delirium Modify Risk Factors
Host Factor
Acute Illness
Iatrogenic/
Environmental
Age
Sepsis
Metabolic disturbance
Baseline comorbidity
Hypoxemia
Lights, noise, sleep pattern
Baseline cognitive impairment
Global severity of illness score
Anticholinergic, sedative and analgesic meds

25. Severity of illness and age are independent risk factors for delirium
Pandharipande et al. Anesthesiology 2006;104:21-26

26. Lorazepam dose is an independent risk factor for delirium
Also:
Other Benzos
Opiates
Propofol
Anticholinergics
H2 blockers
Steroids
Some antibiotics
Psych meds
Pandharipande et al. Anesthesiology 2006;104:21-26

27. Non-Pharmacologic Management
Orientation
Visual and hearing aids
Communicate and re-orient frequently
Familiar objects and people
Consistent nursing staff
TV, news, music during the day
Environment
Sleep hygiene: Lights off at night, on during day. Sleep aids?
Control excess noise at night
Ambulate or mobilize early and often
Pun B T , Ely E W Chest 2007;132:

28. Pharmacologic Management Antipsychotics
Little controlled data, but anecdotal and case-series evidence
One small recent RCT comparing Haldol vs placebo found no difference in mortality, LOS, side effects
Haldol IV recommended by SCCM
Long half-life (18-54 hours)
Risk of: QT prolongation, NMS, akathisia
Monitor QTc BID, follow K, Mg, Ca.
Beware other drugs that prolong QT (MANY including anti-arrhythmics, quinolones, erythromycin, methadone)
Jacobi et al. Crit Care Med 2002;30:
Girard et al. Crit Care Med 2010; 38:

29. Pharmacologic Management
Haloperidol (Haldol)
Action: CNS depressant and dopamine receptor antagonist
Side Effects: Prolonged QT interval, Extrapyramidal symptoms, tardive dyskinesia (long term use)
IV Dosing:
Starting dose: Mild agitation 2mg IV,
Moderate to severe agitation 5mg IV
After 20 min. of 1st dose, if still agitated increase the previous doses by 5mg every 20min until calm.
Max dose 30 mg in 24 hours
Once pt is calm, 25% of loading dose should be given Q 6 hours scheduled
Once pt is delirium free for 24 hours taper off haldol

30. Atypical Antipsychotics
Recent double-blind RCT of quetiapine (Seroquil) 50mg BID vs placebo
Haldol PRN – study drug increased if any PRN in 24 hours
36 ICU patients with delirium
Shorter time to resolution of delirium (1 vs 4.5 days)
Reduced duration of delirium (36 vs 120 hours)
More somnolence with quetiapine, other SEs similar
Devlin JW et al. Crit Care Med 2010; 38:

31. Atypical Antipsychotics (Second Generation)
Not typically given IV or IM
Quetiapine (Seroquil)
25mg - 50mg PO
Risperidone (Risperdal)
1 mg - 3 mg PO daily
Olanzapine (Zyprexa)
5mg- 20 mg PO
5mg -10 mg IM

32. 1. Analgesia 2. Sedation 3. Delirium
In Pain?
Fentanyl prn
Morphine prn
Reassess
If not controlled with
2-3 doses/hour, start Fentanyl gtt
2. Sedation
RASS at target (-1 to 0)?
Undersedated
Benzo prn
Propofol gtt
Benzo gtt
Oversedated
Hold sedatives and analgesics to achieve RASS target. Restart at 50% if needed
3. Delirium
CAM-ICU positive?
Underlying cause
Non-pharm management
Pharm management
Reassess

33. Sedation Management What is the Daily RASS Goal?
What is the patient’s RASS now?
Is the patient on optimal sedation for the RASS goal?
Combination of sedative and narcotic is synergistic
Side effects of most agents include:
Delirium
Hypotension
Respiratory depression
Increased tolerance with withdrawal syndromes
Risk of seizures if stopped abruptly
Difficulty assessing neurologic status

34. Sedation and Analgesia: Challenges
Inappropriate sedation (over and under) is a frequent problem, causing:
Increased levels of agitation, delirium
Sleep fragmentation
Increased rates of VAP, nosocomial infections, days on mechanical ventilation, hospital stays, costs
Self-extubation, reintubation, accidental line removal
Sedation is rarely discussed in a uniform fashion among health care providers
Sessler CN. Chest 2004;126:
Wit M et al. Am J of Crit Care 2003; 12:
Sessler CN. Am J Resp CCM 2002; 166:

35. Sedation (short term) Propofol Dexmedetomidine (Precedex)
Sedative hypnotic with mild amnestic properties, NO analgesia,
Rapid induction, rapid recovery
Not recommended > 3 days
Side Effects:
Hypotension 1/3 of all patients, respiratory depression, bradycardia, arrhythmia, Lipemia, hypertriglycerdemia, Pancreatitis, Infection Risk
Propofol Infusion Syndrome: acute refractory bradycardia and metabolic acidosis, rhabdomyolysis, hyperlipidemia or an enlarged fatty liver
Dexmedetomidine (Precedex)
Alpha-2 agonist
Anxiolytic, analgesia, amnesia
No respiratory depression, patient sedate but arousable
Bradycardia, hypo/hypertension
Use < 24h

36. Sedation Benzodiazepines Onset Duration Elimination
midazolam<diazepam<lorazepam
Start with IV push before starting an infusion
Duration
diazepam>lorazepam>midazolam> propofol
(NB midazolam and diazepam highly lipophilic)
Elimination
renal failure: active metabolites accumulate for midazolam and diazepam
cirrhosis: prolongation of metabolism to active metabolites for midazolam & diazepam

37. Pain Management Opiates Consider non-opiate analgesics
Little amnestic effect
Active metabolites, lipid deposition (Fentanyl)
Side effects:
Respiratory depression
Hypotension (Morphine > Fentanyl)
GI (constipation, ileus, gastroparesis, nausea)
Delirium
Tolerance followed by withdrawal syndromes

38. Goal-oriented Management
Multidisciplinary process that incorporates expertise from physicians, nurses, pharmacy, and others
Uses appropriate quantitative scales to assess and set treatment goals
Provides etiology-driven treatment (treat pain with analgesics, anxiety with anxiolytics, etc)
Avoids over-sedation & under-sedation
Minimizes the use of sedatives, which can lead to delirium, further agitation, withdrawal syndromes
Monitors response to therapeutic interventions
Kress JP, Hall JB. CCM 2006;
Sessler CN. Chest 2004;
Weinert et al. Am J Crti Care 2001;

39. Managing ICU Delirium Look for it
Communication between nursing and MDs
Identify and treat correctable risk factors
Optimize non-pharmacologic interventions
Goal-oriented sedation with daily wake-ups
Pharmacologic intervention

40. Daily Wake-Ups Kress et al, NEJM 2000:
128 vented MICU patients randomized to daily awakening vs usual care AND midazolam vs propofol (all patients received morphine)
Infusions off until following commands or agitated
Shorter time on vent (4.9 vs 7.3 days)
Shorter time in ICU (6.4 vs 9.9 days)
Fewer diagnostic tests for mental status
No difference in complications or PTSD
No difference between propofol and midazolam
Kress JP. NEJM :
Sessler CN. Crit Care Clin :

41. Wake-Up and Breathe Multi-center RCT
336 vented ICU patients randomized to spontaneous awakening followed by spontaneous breathing trial vs usual sedation with daily SBT
Safety screens for both SAT and SBT
SAT passed if patient opened eyes to verbal stimuli or tolerated being off sedation for > 4 hours
Girard TD et al. Lancet :126-34

42. Hooper MH. Crit Care Clin 2009. 25:515-525

43. Wake-Up and Breathe Increased ventilator-free days (14.7 vs 11.6 days)
Shorter ICU and hospital LOS (9.1 and 12.9 days; 14.9 and 19.2 days)
14% absolute reduction in risk of death at 1 year
Girard TD et al. Lancet :126-34

44. Expectations for Our ICU (as of July 1, 2010)
Documentation of RASS Q4 h (all patients)
Documentation of CAM-ICU Q8 h (all patients)
Discussion of RASS and CAM-ICU by team on daily work rounds
Use MAH Sedation Guideline for sedation and delirium management
Consideration of daily wake-up and daily SBT if appropriate
Inclusion of sedation goals on daily goal sheets

45. Case 3: 57F intubated for ARDS -- Day 10
Feature
1. RASS is 0. Last shift, RASS was +2.
2. SAVEAHAART: 50%
3. Disorganized thinking:
Will a leaf float on water? Yes
Are elephants in the sea? Yes
Do 2 pounds weigh more than 1? Yes
Can you use a hammer to cut wood? Yes
Fails to hold up 2 fingers
Score: 2 of possible 5 points
4. Altered Level of Consciousness: RASS 0
How should we manage her? + + + -

46. Summary Delirium is common and has serious negative consequences
May be missed without assessment
Management is multidisciplinary
Risk factor modification
Non-pharmacologic intervention
Pharmacologic intervention
Optimize goal-directed sedation and analgesia