1. Post-Intensive Care Syndrome and ICU Liberation
Shanon Harper, DNP, AG-ACNP, CCRN

2. Disclosures
There are no conflicts of interest or relevant financial interest that have been disclosed by this presenter.
We will not discuss off-label use and/or investigational use in this presentation.

3. Objectives
Upon completion of this session, learners should be able to:
Understand Post-ICU Syndrome
Identify PAD guidelines
Describe ICU Liberation
Explain considerations for Intensive Care (ICU) Delirium
Discuss how to apply ABCDEF: SAT-SBT, CAM- ICU, THINK, & Early Mobility

4. Post-Intensive Care Syndrome
Video

5. Post-Intensive Care Syndrome
Long-term consequences of critical illness
Physical Impairments
Cognitive Impairments
Mental Health Impairments
A conference convened by SCCM in September of 2010
Needham et al., 2012

6. Post-Intensive Care Syndrome
Needham et al., 2012

7. BRAIN-ICU Study
The Bringing to Light the Risk Factors and Incedence of Neuropsychological Dysfunction in the ICU Survivors or (BRAIN-ICU) study was conducted at Vanderbilt University Medical Center and Staint
Enrolled adults with respiratory failure or shock in the Medical or surgical intensive care unit.
Evaluated them for in-hospital delirium
Assessed global cognition and executive function 3 and 12 months after discharge with the use of the Repeatable Battery for the Assessment of Neuropsychological Status and the Trail Making Test, Part B

8. BRAIN-ICU STUDY 821 patients, 74% (606) affected by delirium
3 month follow up cognition scores
40% worse than moderate TBI
26% with scores similar to mild Alzheimer’s disease
Pandharipande et al., 2013

9. BRAIN-ICU STUDY 12 month follow up cognition scores 34% moderate TBI
24% mild Alzheimer’s disease

10. BRAIN-ICU STUDY
What was the most profound for me is in BRAIN ICU Study which is illustrated in Figure 1. Global Cognition Scores in Survivors of Critical illness
Cognitive impairment was not limited to older patients or to patients with coexisting conditions at baseline.
Among the pts 49 years of age or younger with no coexisting conditions at baseline
34% had global cognition scores at 12-month follow-up that were commensurate with moderate traumatic brain injury and approximately 20% had results similar to those for pts with mild Alzheimer’s disease.
Unlike Alzheimer’s disease, however, which affects delayed memory more than other domains, long-term cognitive impairment after critical illness tended to affect multiple cognitive domains.
Age was NOT a determining factor of Cognitive Impairment
Pandharipande et al., 2013

11. BRAIN-ICU STUDY
Longer duration of delirium an independent risk factor for:
Worse RBANS global cognition scores
Worse executive function
Worse function in several individual RBANS domains
RBANS
- global cognitions scores
- Executive function.

12. Pain, Agitation, & Delirium

13. ICU Liberation

14. ICU Delirium and Cognitive Impairment Study Group

15. Delirium What is Delirium?
Disturbance of consciousness and cognition that develops over a short period of time and fluctuates over time
Syndrome of brain dysfunction
Hyperactive, hypoactive, and mixed
American Psychiatric Association, 2013; Barr et al., 2013; Mansouri, 2013

16. Delirium VS Dementia Gradual Onset Intellectual impairment
Rapid onset
Inattention
Clouded
Consciousness (bewildered)
Fluctuating
Gradual Onset
Intellectual impairment
Memory disturbance
Personality/Mood change
No clouding of consciousness

17. Delirium Risk Factors Host Sepsis HTN Severity of illness Surgeries
Especially cardiovascular and orthopedic
Barr et al., 2013; Mansouri, 2013

18. Delirium Risk Factors Iatrogenic Mechanical Ventilation Restraints
Catheters and Lines
A multitude of medications
Barr et al., 2013; Mansouri, 2013

19. Delirium Risk Factors Environmental Factors Noise
Decrease meaningful sensory stimulation
Sleep deprivation
Barr et al., 2013; Mansouri, 2013

21. Clinical Problem Annual ICU admission in the U.S. 5.7 million
80% risk of acquiring ICU delirium
Increased morbidity, mortality and length of stay
Prolonged ventilator dependence
Considered a Major Public Health Problem
Annual costs $4 to $6 Billion in the U.S. alone
Barr et al., 2013; Society of Critical Care Medicine, 2012; Ely, 2010

22. ABCDEF Bundle Assess, Prevent, and Manage Pain
Both: Spontaneous Awakening Trials & Spontaneous Breathing Trials
Choice of Analgesia & Sedation
Delirium: Assess, Prevent, Manage
Early Mobility and Exercise
Family Engagement and Empowerment
Vanderbilt University, 2013

23. Assess, Prevent, and Manage Pain
Self Reported Gold Standard
Behavioral Pain Scale
Multimodal treatment plan
Opioids
Non-opioids
Nonpharmacological
Barr et al, 2013; Morandi, Brummel, & Ely, 2011; Ely 2010

24. Both: SAT & SBT SAT and SBT
More successful when paired
Liberation from mechanical ventilation and sedation removes multiple deliriogenic factors
Barr et al, 2013; Ely et al. 1996; Girard et al., 2008

26. Choice of Analgesia & Sedation
Patient-Oriented, Goal-Directed
Management of pain first.
Avoid over sedation to promote earlier extubation.
Goal for minimal sedation
Validated Tool
Sedation Agitation Scale (SAS)
Richmond Agitation-Sedation Scale (RASS)
Barr et al, 2013; Vanderbilt University, 2013

27. Delirium: Assess, Prevent, Manage
Assessment with a validated tool
The Confusion Assessment method for the ICU (CAM-ICU)
The Intensive Care Delirium Screening Checklist (ICDSC)
Barr et al, 2013; Vanderbilt University, 2013

28. Delirium: Assess, Prevent, Manage
Prevention and Management Strategies
Nonpharmacological
Pharmacologic
THINK Mnemonic
Barr et al, 2013; Vanderbilt University, 2013

29. Delirium: Assess, Prevent, Manage
THINK Mnemonic T
“TOXIC SITUATIONS” H
“HYPOXEMIA” I
“3 I’s” N
“Nonpharmacological interventions” K
“K or Electrolytes”
CHF
Shock
Dehydration Deliriogenic meds (Tight Titration) New organ failure, e.g, liver, kidney
Airway vs Ventilation vs oxygenation
Infection/Sepsis (nosocomial)
Inflammation
Immobilization
Hearing aids
Glasses
Reorientation
Sleep protocols
Music
Noise control Ambulation
Potassium
Sodium
Magnesium
Phosphorus
Vanderbilt University, 2013

30. Early Mobility and Exercise
Only intervention shown to decrease duration of delirium
Decreases days mechanically ventilated
ACT-ICU Trial
Decreased days of delirium, readmission, and 1-year death rates
Brummel et al., 2012; Truong, Fan, Bower, & Needham, 2009; Vanderbilt University, 2013

31. Family Engagement and Empowerment
Educate
Rounding with family daily
Encourage journaling
Assisting in creating a healing environment
Prepare them for the future
Vanderbilt University, 2013

32. Summary PICS is a consequence of ICU care
ABCDEF Bundle for ICU Liberation
Goal
Decrease the occurrence of ICU delirium
Improve long term outcomes
QUESTIONS??

33. References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. Retrieved from
Barr, J., Fraser, G. L., Puntillo, K., Ely, E. W., Gelinas, C., Dasta, J. F., Jaeschke, R. (2013). Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Critical Care Medicine, 41(1), doi: /CCM.0b013e b72; /CCM.0b013e b72
Brummel, N. E., Jackson, J. C., Girard, T. D., Pandharipande, P. P., Schiro, E., Work, B., Ely, E. W. (2012). A combined early cognitive and physical rehabilitation program for people who are critically ill: The activity and cognitive therapy in the intensive care unit (ACT-ICU) trial. Physical Therapy, 92(12), doi: /ptj [doi]
Ely, E. W., Baker, A. M., Dunagan, D. P., Burke, H. L., Smith, A. C., Kelly, P. T., Haponik, E. F. (1996). Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. The New England Journal of Medicine, 335(25), doi: /NEJM [doi]
Girard, T. D., Kress, J. P., Fuchs, B. D., Thomason, J. W., Schweickert, W. D., Pun, B. T., Ely, E. W. (2008). Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (awakening and breathing controlled trial): A randomised controlled trial. Lancet, 371(9607), doi: /S (08) [doi]
ICU Delirium and Cognitive Impairment Study Group. (2013). Vanderbilt University. ABCDEF’s of Prevention and Safety. Retrieved from
Mansouri, P., Javadpour, S., Zand, F., Ghodsbin, F., Sabetian, G., Masjedi, M., & Tabatabaee, H. R. (2013). Implementation of a protocol for integrated management of pain, agitation, and delirium can improve clinical outcomes in the intensive care unit: A randomized clinical trial. Journal of Critical Care, doi: /j.jcrc ; /j.jcrc
Morandi, A., Brummel, N. E., & Ely, E. W. (2011). Sedation, delirium and mechanical ventilation: The 'ABCDE' approach. Current Opinion in Critical Care, 17(1), doi: /MCC.0b013e ; /MCC.0b013e
Needham, D. M., Davidson, J., Cohen, H., Hopkins, R. O., Weinert, C., Wunsch, H.,… Harvey, M. A. (2012). Improving long- term outcomes after discharge from intensive care unit: Report from a stakeholders' conference. Critical Care Medicine, 40(2), doi: /CCM.0b013e318232da75
Pandharipande, P. P., Girard, T. D., Jackson, J. C., Morandi, A., Thompson, J. L., Pun, B. T., BRAIN-ICU Study Investigators. (2013). Long-term cognitive impairment after critical illness. The New England Journal of Medicine, 369(14), doi: /NEJMoa
Truong, A. D., Fan, E., Brower, R. G., & Needham, D. M. (2009, July 13). Bench-to-bedside review: Mobilizing patients in the intensive care unit - from pathophysiology to clinical trials. Critical Care, 13(216). doi: /cc7885