Delirium & Sedation Nov 2013

Outline  Definition, incidence & prognosis  Causes  Assessment  Treatment  Sedation

Definition  Acute change in mental status with a fluctuating course, characterized by inattention and disorganized thinking  Brain failure, part of MOF  Hyperactive/Hypoactive/Mixed

Incidence & prognosis  15-80% of critically ill patients  Easily missed  Up to 3x increased mortality  Increased days ventilated/length of stay  Long term cognitive impairment

Causes  Iatrogenic  Sleep disturbance  Pain  Sepsis/hypoxia/electrolytes etc  Pre-existing cognitive problems  Drugs  Legal and illegal  Alcohol

Assessment  CAM-ICU  Richmond Agitation Sedation Score  Don’t miss an alternative diagnosis  CVA  Intracranial bleed  Thyroid disease  Psychiatric disease

Treatment  General & non- pharmacological  Treat organic problems inc withdrawal  Good nursing & orientation  Day-night cycle protection  Glasses/hearing aids  Pharmacological  Haloperidol  Olanzapine  α agonists  Trazadone  No benzodiazepines & watch out for long qt

Sedation – why?  Airway protection  Mechanical ventilation  Haemodynamic stability  To facilitate patient care  Other procedures – endoscopy, interventional radiology, sengstaken

Sedation  Propofol/fentanyl unit standard  Alfentanil/remifentanil  Morphine & midazolam  Paediatrics  Propofol infusion syndrome  Thiopentone  Status epilepticus  Raised ICP  Dexmedetomidine

Sedation  Daily sedation hold if at all feasible  Aim is RASS 0 to -2  Nurses vs doctors  Don’t forget analgesia or local anaesthesia  PTSD

Summary  Definition & importance of delirium  Causes  Assessment and treatment  Methods and aims of sedation