Lindsay Trantum ACNP-BC VUMC Neuroscience ICU DELIRIUM Lindsay Trantum ACNP-BC VUMC Neuroscience ICU

Objectives By the end of the presentation…… Identify the key features of delirium Identify risk factors for delirium Demonstrate understanding of the treatment plan for delirium

Delirium = Brain Dysfunction Definition: DSM IV officially defines delirium as a disturbance of consciousness with inattention accompanied by a change in cognition or perceptual disturbance that develops over a short period of time (hours to days) and fluctuates over time “The 6th vital sign”

Subtypes Hyperactive Hypoactive Mixed characterized by agitation, restlessness, and emotional lability Hypoactive decreased responsiveness, withdrawal, and apathy Mixed Periods of hyperactivity and lethargy Critical Care 2008; 12 (Suppl 3): S3

Incidence 60%-80% of mechanically ventilated patients 50%-70% of non-ventilated patients Hypoactive delirium = 43.5% Hyperactive delirium = 1.6% Mixed delirium = 54.1% (Girard, 2008) Critical Care 2008; 12 (Suppl 3): S3

Outcomes 3 fold increase in 6 month mortality 1 in 3 delirium survivors develop permanent cognitive impairment Associated with….. New nursing home placement Increased length of stay > 8.0 days Increased mortality Increased number of days on the ventilator Ely EW, Shintani A, Truman B, Speroff T, Gordon SM, Harrell FE, Jr, Inouye SK, Bernard GR, Dittus RS. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA Does Delirium Contribute to Poor Hospital Outcomes?A Three-Site Epidemiologic StudySharon K Inouye, MD, MPH,1 Julia T Rushing, MSt,2 Marquis D Foreman, PhD, RN,3 Robert M Palmer, MD, MPH,5 and Peter Pompei, MD

Outcomes Continued…. Associated with……. Depression/PTSD Increased risk of aspiration Increased need for re-intubation Increased hospital cost: national burden $38 billion/year (Ely, 2004); (Inouye, 1998)

Risk Factors I WATCH DEATH (many acronyms) Infection Withdrawl (Etoh, Sedatives) Acute Metabolic (renal/liver failure, electrolytes, etc) Trauma CNS Pathology Hypoxia Deficiencies (B12, thiamine, folate, niacin) Endocrine (hyper/hypo) Acute vascular Toxins Heavy metals

Pathophysiology Multi-factorial and poorly understood Neurotransmitter imbalance Dopamine (excess) & acetlycholine (depleation) Results in neuroexcitability and unpredictable synapses GABA, serotonin, endorphins and glutamate

Pathophysiology Inflammation Inflammatory mediators cross blood-brain barrier and increase vascular permeability Result = decrease cerebral blood flow (CBF) Platelets, fibrin, neutrophils obstruct CBF (Gunther, 2008)

Monitoring Step 1: RASS= Richmond Agitation Sedation Scale RASS goal Actual RASS Minimize Sedation Step 2: CAM-ICU = Confusion Assessment Method Takes approximately 1 minute Sensitivity/Specificity 95%

Targets 4 Key Features AND Feature 2: Inattention Feature 1: Acute onset of mental status changes, or Fluctuating course. AND Feature 2: Inattention AND Feature 3: Disorganised thinking Feature 4: Altered level of consciousness OR

CAM-ICU Worksheet

CAM-ICU Video http://www.youtube.com/watch?v=1hSDNOVHMVs

Management of Delirium Environmental Early mobility Maintaining a day/night cycle Minimize light/noise Promoting sleep at night Assessing for extubation Daily sedation interruption Correct hearing/visual deficits Hearing aids Glasses/magnifying glasses

Management of Delirium Pharmacologic Options (intubated) Sedation choices Pain relief? Morphine, fentanyl, dilaudid Sedation? Dexamedatomidine Not for patients that need RASS -2 or greater Propofol Avoid benzodiazepines except in ETOH withdrawal

Management of Delirium Pharmacologic Options (non-intubated) Antipsychotics Haldol 2.5-10mg q2h prn Monitor daily EKG Add Seroquel 25mg BID and titrate by 25mg q12h Zyprexa Dex Benzodiazepines Don’t use unless managing ETOH withdrawal

Delirium Timeline Usually seen within the first 24 to 48 hrs Can last as long as 2 weeks or longer Be patient

Questions????

Icudelirium.org Surgicalcriticalcare.net Resources Icudelirium.org Surgicalcriticalcare.net

Delirium Review Article

References Girard, Timothy; Pandharipande, Pratik; Ely, Wesley; (2008). Delirium in the Intensive Care Unit.; Critical Care. 12 (Suppl 3); S3 Gunther, Max, L.; Morandi, Alessandro; Ely, Wesley; (2008) Pathophysiology of Delirium in the ICU. Critical Care Clinics. 24: 45-6 Inouye, S. et al. (1998). Does delirium contribute to poor hospital outcomes? A three-site epidemiological study. Journal of General Internal Medicine. 13(4): 234-42. Ely, EW et al. (2004). Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA. 14; 291 (14): 1753-62. Barr, J. et al. (2013). Clinical Practice Guidelines for the Management of Pain, Agitation and Delirium in Adult Patients in the Intensive Care Unit. Critical Care Medicine. Jan 41(1): 263-306. Cheatham, M.D. (Jan 4, 2011); Delirium Management Guidelines. Retrieved from http://www.surgicalcriticalcare.net/Guidelines/delirium_2011.pdf