Delirium In ICU by Kirsty Ryan

Contents: What is Delirium? Why is it important? How do we recognise it? What causes it? How do we prevent it? How do we treat it?

Definition: An acute state of confusion (NICE, 2010) Acute onset, fluctuating confusion Inattention Impaired consciousness Disordered thinking

Types of Delirium Hyperactive delirium: restlessness, agitation, aggression. Hypoactive delirium: (Most Common) sleepy, withdrawn and quiet, difficult to recognise. Mixed! Hypo-Hyperactive Delirium

Why is it important? Prevalence! 33 - 50% of people who have had cardiac surgery develop delirium. Delirium is associated with poor short and long term outcomes. It increases mortality. It increases risk of long hospital stays. It causes distress to patients, families and staff. Approximately half of all episodes of delirium are reversible.

How would it feel? Frustrating. Anxiety provoking. Confusing.   Frustrating. Anxiety provoking. Confusing. Upsetting. Despair. Exhausting. People can also develop PTSD from their experience of delirium!

PTSD and Delirium in ICU A patient who has experienced Delirium in ICU can go onto develop PTSD well after their delirium has resolved. PTSD: when a person has flash backs, anxieties and fears surrounding their past experiences in ICU with Delirium, to the point where it is affecting their day-to-day activities. They may be so affected they refuse appointments, or even stop going out. Early recognition and referral to psychology!

How do we recognised it? Symptom recognition Regular CAM ICU assessments!

Symptoms Less aware of surroundings. Auditory hallucinations. Visual hallucinations. Concerned that other people are trying to harm them. Sleeping during the day and waking up during the night. Have moods that quickly change. Confusion at particular times: evenings and nights. Less aware of surroundings. Reduced ability to orientate to surroundings. Unable to follow conversation/ speak clearly. Paranoia. Vivid dreams that may continue when someone wakes up.

CAM ICU It takes 2 minutes to do Fast access: on the back of your ICU flowchart It is evidence based.

What Causes Delirium? Patient Illness Iatrogenic Pre-morbid Cognitive Status Infection / Sepsis Surgical / Bypass Time Co-morbidities Organ Dysfunction Drugs / Sedatives Age ARDS Blood Transfusion + Anaemia Hearing/Visual Impairment Metabolic Disturbance Environment Alcohol/ Smoking Hypotension Sleep

How do we prevent it? Treat Illnesses as much as possible. Adjust Iatrogenic causes as much as possible! Use a Targeted RASS system! Delirium is not always preventable!

Targeted RASS RED (RASS -3/-5) Clinical condition requires deeper level of sedation (RASS -3/-5) to facilitate resuscitation, interventions and stabilisation. AMBER (RASS -2/-1) Clinical condition requires moderate level of sedation (RASS -2/-1) to enable continued stabilisation and optimisation of clinical condition. GREEN (RASS> -1) Clinical condition ready for sedation to be stopped and trail of extubation.

Targeted RASS Less sedation lowing the risk of delirium Amber sedation can allow for CAM-ICU assessment – early recognition. Communication is clear between Consultant and Nursing staff. Amber and green are the best, allowing for spontaneous breathing (good for lungs and delirium prevention).

How do we treat it? Early recognition through CAM-ICU Assessment! Non-Pharmacological Treatment Pharmacological Treatment

Non-Pharmacological Management Sleep Hygiene Orientation Family Early Mobilisation Early De-catheterisation “Peek-a-Boo” Mitts Support the family too – offer diaries.

Sleep Hygiene Lack of sleep can cause delirium! Promote a healthy sleep pattern. Reduce noises and lights at night. Reduce as much as possible the number of interventions. Make sure people are not too warm/cold as this disturbs sleep. Don’t let sleep deprivation go on for days!

Pharmacological Treatment Sedation can cause delirium! Aim for a Low RASS with minimal sedation Daily sedation holds and spontaneous breathing trials Try analgesia instead of anaesthetic Consider Alpha Agonists: Clonidine/ Dexmedetomidine Avoid Benzodiazepines Treat withdrawal Treat underlying illnesses – Temp, sepsis, metabolic, Anemia Haloperidol in acute circumstances as a very last resort!

How patients and family said they wanted to be looked after … Ensure patient and staff safety - monitoring - increase staff to patient ratio. Communicate with MDT. Consistency and sharing of knowledge between staff. Stay calm - including family members! Ensure staff and family are well supported. Education. Humour. Flexible visiting. Reassurance delirium is not permanent. Use patient dairies!!!

Quiz! How common is Delirium in ICU? Name two types of delirium. What is the most common type of delirium? Name 2 things that increase the risk of delirium. Name 2 things that we may do in ICU that increase risk of delirium. Where is the CAM-ICU assessment tool? Name 2 different non-pharmacological treatment approaches. Name 2 Pharmacological treatment approaches.

References / Useful Resources Burns, K. et al. 2009. Delirium after Cardiac Surgery: A retrospective case-control study of incidence and risk factors in a Canadian Sample. BC Medical Journal. 51(5). Pp206-210. Healthcare Improvement Scotland. 2013. Staff, patients and families experiences of giving and receiving care during an episode of delirium in an acute hospital care setting. [Online]. [Accessed: 14/04/2016]. Available from: http://www.healthcareimprovementscotland.org/our_work/person- centred_care/opac_improvement_programme/delirium_report.aspx Kostera, S. et al. 2011. Risk Factors of Delirium after Cardiac Surgery: A Systematic Review. European Journal of Cardiovascular Nursing. 10(4). Pp197-204. National Institute for Health and Care Excellence. 2010. Delirium: prevention, diagnosis and management. [Online]. [Accessed: 12/04/2016]. Available from: https://www.nice.org.uk/guidance/cg103/chapter/introduction Page, V et al. 2009. Routine delirium monitoring in a UK critical care unit. Critical Care. 13(1), R16. Peterson, J. et al. 2006. Delirium and its motoric subtypes: a study of 614 critically ill patients. Journal of the American Geriatrics Society. 54(3). Pp479-484 Royal College of Psychiatrists. 2012. Delirium. [Online]. [Accessed:12/04/2016]. Available from: http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/delirium.aspx Zaal, J. et al. 2015 A systematic Review of risk factors for delirium in the ICU. Critical Care. 43(1). Pp40-47. http://www.icudelirium.org/ http://www.icudelirium.org/docs/CAM_ICU_training.pdf