Presentation on theme: "Diagnosis and Management of ICU Delirium"— Presentation transcript:
1Diagnosis and Management of ICU Delirium June 24, July 1, 2010Dave Miller, MD and Becky Logiudice, MS, RN
2Talk Outline Why is this important? What is delirium? Using CAM-ICU to diagnose ICU deliriumHow do I treat delirium?Goal-oriented sedation
3Why is this important? Perspective from SB Perspective from SBAbout 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
4Why is this important? 183 ÷ (183+41) = 0.82 Pun B T , Ely E W Chest 2007;132:
5Why is this important? Common Increased mortality Increased LOS Increased complicationsIncreased costsMay be associated with increased dementia and long-term cognitive impairment
6Girard DT et al. Crit Care Med 2010;38(7):epub ahead of print
8What is Delirium? Answer # 1 You’ll Know it when you see it. . .
9What is delirium?Pun B T , Ely E W Chest 2007;132:
10What is delirium? Answer # 2 Disturbance of consciousnessInattentionChange in cognition or perceptual disturbanceDevelops over hours to daysFluctuates over time
11How 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 commandsIs Mr. D delirious?How do you know?
15RASS +4 Combative Combative, violent, immediate danger to staff +3 Very agitatedPulls or removes tubes or catheters; aggressive+2AgitatedFrequent non-purposeful movement, fights ventilator+1RestlessAnxious and apprehensive, but movements not aggressive or vigorousAlert and calm-1DrowsyNot fully alert but has eye opening to voice and sustained eye contact (> 10 s)-2Light sedationBriefly awakens to voice with eye opening and eye contact (< 10 s)-3Moderate sedationMovement or eye opening to voice but no eye contact-4Deep sedationNo response to voice, but movement or eye opening to physical stimulation-5Not arousableNo response to voice or physical stimulation
17Attention Screening Examination AuditorySqueeze my hand each time I say the letter “A”SAVEAHAARTMore than 2 wrong responses = POSTIVEVisual (cannot hear or squeeze hands)Show 5 pictures, then show 5 repeat and 5 new in random orderMore than 2 wrong responses = POSITIVE
18Assessment 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.”
19How 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 commandsIs Mr. D delirious?How do you know?
20Case 1 revisitedSTEP 1: Mr. D is assessed to be a RASS +2, which is an acute change from his baselineSTEP 2: He squeezes hands on “A” once out of 5 times (4 errors) so is inattentiveSTEP 4: Because his level of consciousness is altered (RASS +2), STEP 3 does not need to be assessed.Mr. D is delirious!
21Case 2The 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?
22How should we manage Mr. D? STEP 1: He is awake and calm (RASS 0) now, but fluctuated within the last 24 hoursSTEP 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?
23Managing ICU Delirium Look for it Communication between nursing and MDsIdentify and treat correctable risk factorsOptimize non-pharmacologic interventionsGoal-oriented sedation with daily wake-upsPharmacologic intervention
25Severity of illness and age are independent risk factors for delirium Pandharipande et al. Anesthesiology 2006;104:21-26
26Lorazepam dose is an independent risk factor for delirium Also:Other BenzosOpiatesPropofolAnticholinergicsH2 blockersSteroidsSome antibioticsPsych medsPandharipande et al. Anesthesiology 2006;104:21-26
27Non-Pharmacologic Management OrientationVisual and hearing aidsCommunicate and re-orient frequentlyFamiliar objects and peopleConsistent nursing staffTV, news, music during the dayEnvironmentSleep hygiene: Lights off at night, on during day. Sleep aids?Control excess noise at nightAmbulate or mobilize early and oftenPun B T , Ely E W Chest 2007;132:
28Pharmacologic Management Antipsychotics Little controlled data, but anecdotal and case-series evidenceOne small recent RCT comparing Haldol vs placebo found no difference in mortality, LOS, side effectsHaldol IV recommended by SCCMLong half-life (18-54 hours)Risk of: QT prolongation, NMS, akathisiaMonitor 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:
29Pharmacologic Management Haloperidol (Haldol)Action: CNS depressant and dopamine receptor antagonistSide Effects: Prolonged QT interval, Extrapyramidal symptoms, tardive dyskinesia (long term use)IV Dosing:Starting dose: Mild agitation 2mg IV,Moderate to severe agitation 5mg IVAfter 20 min. of 1st dose, if still agitated increase the previous doses by 5mg every 20min until calm.Max dose 30 mg in 24 hoursOnce pt is calm, 25% of loading dose should be given Q 6 hours scheduledOnce pt is delirium free for 24 hours taper off haldol
30Atypical Antipsychotics Recent double-blind RCT of quetiapine (Seroquil) 50mg BID vs placeboHaldol PRN – study drug increased if any PRN in 24 hours36 ICU patients with deliriumShorter time to resolution of delirium (1 vs 4.5 days)Reduced duration of delirium (36 vs 120 hours)More somnolence with quetiapine, other SEs similarDevlin JW et al. Crit Care Med 2010; 38:
31Atypical Antipsychotics (Second Generation) Not typically given IV or IMQuetiapine (Seroquil)25mg - 50mg PORisperidone (Risperdal)1 mg - 3 mg PO dailyOlanzapine (Zyprexa)5mg- 20 mg PO5mg -10 mg IM
321. Analgesia 2. Sedation 3. Delirium In Pain?Fentanyl prnMorphine prnReassessIf not controlled with2-3 doses/hour, start Fentanyl gtt2. SedationRASS at target (-1 to 0)?UndersedatedBenzo prnPropofol gttBenzo gttOversedatedHold sedatives and analgesics to achieve RASS target. Restart at 50% if needed3. DeliriumCAM-ICU positive?Underlying causeNon-pharm managementPharm managementReassess
33Sedation 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 synergisticSide effects of most agents include:DeliriumHypotensionRespiratory depressionIncreased tolerance with withdrawal syndromesRisk of seizures if stopped abruptlyDifficulty assessing neurologic status
34Sedation and Analgesia: Challenges Inappropriate sedation (over and under) is a frequent problem, causing:Increased levels of agitation, deliriumSleep fragmentationIncreased rates of VAP, nosocomial infections, days on mechanical ventilation, hospital stays, costsSelf-extubation, reintubation, accidental line removalSedation is rarely discussed in a uniform fashion among health care providersSessler CN. Chest 2004;126:Wit M et al. Am J of Crit Care 2003; 12:Sessler CN. Am J Resp CCM 2002; 166:
35Sedation (short term) Propofol Dexmedetomidine (Precedex) Sedative hypnotic with mild amnestic properties, NO analgesia,Rapid induction, rapid recoveryNot recommended > 3 daysSide Effects:Hypotension 1/3 of all patients, respiratory depression, bradycardia, arrhythmia, Lipemia, hypertriglycerdemia, Pancreatitis, Infection RiskPropofol Infusion Syndrome: acute refractory bradycardia and metabolic acidosis, rhabdomyolysis, hyperlipidemia or an enlarged fatty liverDexmedetomidine (Precedex)Alpha-2 agonistAnxiolytic, analgesia, amnesiaNo respiratory depression, patient sedate but arousableBradycardia, hypo/hypertensionUse < 24h
36Sedation Benzodiazepines Onset Duration Elimination midazolam<diazepam<lorazepamStart with IV push before starting an infusionDurationdiazepam>lorazepam>midazolam> propofol(NB midazolam and diazepam highly lipophilic)Eliminationrenal failure: active metabolites accumulate for midazolam and diazepamcirrhosis: prolongation of metabolism to active metabolites for midazolam & diazepam
37Pain Management Opiates Consider non-opiate analgesics Little amnestic effectActive metabolites, lipid deposition (Fentanyl)Side effects:Respiratory depressionHypotension (Morphine > Fentanyl)GI (constipation, ileus, gastroparesis, nausea)DeliriumTolerance followed by withdrawal syndromes
38Goal-oriented Management Multidisciplinary process that incorporates expertise from physicians, nurses, pharmacy, and othersUses appropriate quantitative scales to assess and set treatment goalsProvides etiology-driven treatment (treat pain with analgesics, anxiety with anxiolytics, etc)Avoids over-sedation & under-sedationMinimizes the use of sedatives, which can lead to delirium, further agitation, withdrawal syndromesMonitors response to therapeutic interventionsKress JP, Hall JB. CCM 2006;Sessler CN. Chest 2004;Weinert et al. Am J Crti Care 2001;
39Managing ICU Delirium Look for it Communication between nursing and MDsIdentify and treat correctable risk factorsOptimize non-pharmacologic interventionsGoal-oriented sedation with daily wake-upsPharmacologic intervention
40Daily 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 agitatedShorter time on vent (4.9 vs 7.3 days)Shorter time in ICU (6.4 vs 9.9 days)Fewer diagnostic tests for mental statusNo difference in complications or PTSDNo difference between propofol and midazolamKress JP. NEJM :Sessler CN. Crit Care Clin :
41Wake-Up and Breathe Multi-center RCT 336 vented ICU patients randomized to spontaneous awakening followed by spontaneous breathing trial vs usual sedation with daily SBTSafety screens for both SAT and SBTSAT passed if patient opened eyes to verbal stimuli or tolerated being off sedation for > 4 hoursGirard TD et al. Lancet :126-34
43Wake-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 yearGirard TD et al. Lancet :126-34
44Expectations 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 roundsUse MAH Sedation Guideline for sedation and delirium managementConsideration of daily wake-up and daily SBT if appropriateInclusion of sedation goals on daily goal sheets
45Case 3: 57F intubated for ARDS -- Day 10 Feature1. RASS is 0. Last shift, RASS was +2.2. SAVEAHAART: 50%3. Disorganized thinking:Will a leaf float on water? YesAre elephants in the sea? YesDo 2 pounds weigh more than 1? YesCan you use a hammer to cut wood? YesFails to hold up 2 fingersScore: 2 of possible 5 points4. Altered Level of Consciousness: RASS 0How should we manage her?+++-
46Summary Delirium is common and has serious negative consequences May be missed without assessmentManagement is multidisciplinaryRisk factor modificationNon-pharmacologic interventionPharmacologic interventionOptimize goal-directed sedation and analgesia