ICU Delirium and Cognitive Impairment Study Group ABCDE Protocol ICU Delirium and Cognitive Impairment Study Group www.icudelirium.org delirium@vanderbilt.edu

Why the ABCDE Protocol?

Need for Sedation and Analgesia Prevent pain and anxiety Decrease oxygen consumption Decrease the stress response Patient-ventilator synchrony Avoid adverse neurocognitive sequelae Depression, PTSD Rotondi AJ, et al. Crit Care Med. 2002;30:746-752. Weinert C. Curr Opin in Crit Care. 2005;11:376-380. Kress JP, et al. Am J Respir Crit Care Med. 1996;153:1012-1018.

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 Background on purpose and hazzard of potent psychoactive medications Kollef MH, et al. Chest. 1998;114:541-548. Pandharipande PP, et al. Anesthesiology. 2006;104:21-26.

Cognitive and Functional Impairment, Institutionalization, Mortality Patient with Sepsis Mechanical Ventilation Sedation Weakness Delirium Cognitive and Functional Impairment, Institutionalization, Mortality Vasilevskis et al Chest 2010; 138;1224-1233

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 Pull and add pratik’s here. Vasilevskis et al Chest 2010; 138;1224-1233

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

Awakening and Breathing Coordination ABC Awakening and Breathing Coordination

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

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

Structured Approaches to Sedation & Analgesia in the ICU Multidisciplinary development, implementation Establish goals/targets, frequently re-evaluate Measure key components using validated scales Select medications based on characteristics, evidence Incorporate key patient considerations Prevent oversedation, yet control pain and agitation Promote multidisciplinary acceptance and integration into routine care Sessler & Pedram. Crit Care Clinics 2009; 25:489-513

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)

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 A sedation goal or endpoint should be established and regularly redefined for each patient. Regular assessment and response to therapy should be systematically documented. Give examples of Insulin, Pressors and how we titrate to endpoint Grade of recommendation = C The use of a validated sedation assessment scale is recommended. Grade of recommendation = B

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

Discontinue all sedative and analgesic medications 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

Daily Awakening Trial Results Shorter duration of mechanical ventilation Shorter ICU LOS Fewer tests for altered mental status Kress et al. N Engl J Med 2000; 342:1471-7

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? Wake Up and Breathe Sessler CN. Crit Care Med 2004 Kress et al. NEJM. 2000

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

“SAT + SBT” Was Superior to Conventional Sedation + SBT Intervention (SAT) group = Less benzodiazepine Extubated faster Discharged from ICU sooner P = 0.01 P = 0.02 Girard et al. Lancet 2008; 371:126-34

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

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

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% FiO2 < 50% PEEP < 7.5 cm H2O No active myocardial ischemia (24h) No significant vasopressor use Girard et al. Lancet 2008; 371:126-34. Kress et al. Crit Care Med 2004; 32(6):1272-6 Ely et al. NEJM 1996; 335:184-9

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

Delirium Monitoring and Management

Delirium: Key Features Disturbance of consciousness with reduced ability to focus, sustain or shift attention A change in cognition or the development of a perceptual disturbance that is not better accounted for by pre-existing, established or evolving dementia Develops over a short period of time and tends to fluctuate over the course of the day 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

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

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 Each additional day spent in delirium was associated with a 20% increased risk of remaining in hospital and a 10% increased risk of death (7). We are stressing that delirium is not the cause of these, but is one of the biggest predictors. Ely, et al. ICM2001; 27, 1892-1900 Ely, et al, JAMA 2004; 291: 1753-1762 Lin, SM CCM 2004; 32: 2254-2259 Milbrandt E, et al, Crit Care Med 2004; 32:955-962. Ouimet, et al, ICM 2007: 33: 66-73.

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; 113:941-948.1 Ely, et. al. CCM 2001; 29:1370-1379.4 Ely, et. al. JAMA 2001; 286:2703-2710.5

Delirium Management 30 1. Identify etiology 2. Identify risk factors 3. Consider pharmacologic treatment CPG provided this framework. The best thing is they get us to look at etiology and risk factors before jumping to pharmacologic treatment. Jacobi J, et al. Crit Care Med 2002;30:119-141 30

Consider antipsychotics after evaluating etiology & risk factors 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! Toxic Situations CHF, shock, dehydration New organ failure (liver/kidney) Hypoxemia Infection/sepsis (nosocomial), Immobilization Nonpharmacologic interventions Hearing aids, glasses, reorient, sleep protocols, music, noise control, ambulation K+ or electrolyte problems Consider antipsychotics after evaluating etiology & risk factors

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;340:669-676.

Standardized Intervention Elder Life Program Targeted Risk Factor Standardized 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) “Targeted risk factors were selected on the basis of evidence of their association with the risk of delirium and because they were amenable to intervention strategies considered feasible in the context of current hospital practice.” Intervention provided by a trained interdisciplinary team: geriatric nurse specialist, ELP specialists, recreational therapist, PT consultant, geriatrician, trained volunteers. Inouye, et al. NEJM. 1999;340:669-676.

Results Improved (p=0.04) orientation score with targeted intervention Outcome Intervention Control P-value Incidence of delirium, N (%) 42 (9.9) 64 (15) 0.02 Total days of delirium 105 161 Episodes of delirium 62 90 0.03 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;340:669-676.

Delirium Nonpharmacologic Interventions Eligibility = RASS ≥ -3 +4 COMBATIVE Combative, violent, immediate danger to staff +3 VERY AGITATED Pulls to remove tubes or catheters; aggressive +2 AGITATED Frequent non-purposeful movement, fights ventilator +1 RESTLESS Anxious, apprehensive, movements not aggressive 0 ALERT & CALM Spontaneously pays attention to caregiver -1 DROWSY Not fully alert, but has sustained awakening to voice (eye opening & contact >10 sec) -2 LIGHT SEDATION Briefly awakens to voice (eyes open & contact <10 sec) -3 MODERATE SEDATION Movement or eye opening to voice (no eye contact) -4 DEEP SEDATION No response to voice, but movement or eye opening to physical stimulation -5 UNAROUSEABLE No response to voice or physical stimulation

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

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)

Early Exercise and Mobility

Early Exercise in the ICU Early exercise = progressive mobility Study design: paired SAT/SBT protocol with PT/OT from earliest days of mechanical ventilation Wake Up, Breathe, and Move Schweickert WD, et al. Lancet. 2009;373:1874-1882.

Early Exercise Study Results Outcome Intervention (n=49) Control (n=50) P Functionally independent at discharge 29 (59%) 19 (35%) 0.02 ICU delirium (days) 2.0 (0.0-6.0) 4.0 (2.0-7.0) 0.03 Time in ICU with delirium (%) 33 (0-58) 57 (33-69) Hospital delirium (days) 4.0 (2.0-8.0) Hospital days with delirium (%) 28 (26) 41 (27) 0.01 Barthel index score at discharge 75 (7.5-95) 55 (0-85) 0.05 ICU-acquired paresis at discharge 15 (31%) 27 (49%) 0.09 Ventilator-free days 23.5 (7.4-25.6) 21.1 (0.0-23.8) Length of stay in ICU (days) 5.9 (4.5-13.2) 7.9 (6.1-12.9) 0.08 Length of stay in hospital (days) 13.5 (8.0-23.1) 12.9 (8.9-19.8) 0.93 Hospital mortality 9 (18%) 14 (25%) 0.53 24% improvement (1.7-fold better) return to independent functional status at discharge (NNT=4) Standing Marching Walking Transferring *P<0.001 Milestones achieved safely ~3 dyas earlier Schweickert WD, et al. Lancet. 2009;373:1874-1882.

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

Perform Safety Screen First Patient responds to verbal stimulation (i.e., RASS > -3) FIO2 <0.6 PEEP <10 cmH2O 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

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

No Exercises, but Passive Range of Motion allowed 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

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

Questions? www.ICUdelirium.org delirium@vanderbilt.edu The website is a great resource. www.ICUdelirium.org delirium@vanderbilt.edu