1. DELIRIUM Lindsay Trantum ACNP-BC VUMC Neuroscience ICU

2. 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

3. Delirium = Brain Dysfunction Definition: DSM V 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 6 th vital sign”

4. Subtypes Hyperactive – characterized by agitation, restlessness, and emotional lability Hypoactive – decreased responsiveness, withdrawal, and apathy Mixed – Periods of hyperactivity and lethargy

5. 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)

6. 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

7. 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)

8. 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

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

10. 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)

11. Wake Up and Breathe Awakening and Breathing Coordination – Spontaneous Awakening Trial – Spontaneous Breathing Trial Choice of Sedation Delirium Monitoring Early Mobility and Exercise – Passive Range of Motion to Ambulation Family (Girard, 2008)

12. 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%

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

14. CAM-ICU Worksheet

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

16. Special Population: Neurologically Impaired CAM-ICU has been validated in post-stroke patients Should be considered an aid in delirium diagnosis Look for non-verbal indicators – Fidgeting, signs of hallucination, waxing and waning mental status (Mitasova, A., 2012)

17. 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

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

19. Management of Delirium Pharmacologic Options (non-intubated) – Antipsychotics Haldol 2.5-10mg q2h prn – Monitor daily EKG Add Quetiapine 25mg BID and titrate by 25mg q12h Olanzipine Dexamedatomidine – Benzodiazepines Don’t use unless managing ETOH withdrawl

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

21. Long-Term Outcomes >12 months post-ICU admission (800 pts) – 1/3 Cognitive impairment similar to a moderate TBI – 1/4 Cognitive impairment similar to mild Alzheimer’s (Pandharipande, 2013)

22. Questions????

23. Resources Icudelirium.org Surgicalcriticalcare.net

24. Delirium Review Article

25. 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

26. References Girard, et. al (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 control trial. Lancet: Jan 12;371(9607):126-34 Pandharipande, PP et al (2013). Long-term cognitive impairment in critical illness. New England Journal of Medicine. Oct 3: 369 (14) 1306-16 Mitasova, A. et al (2012). Poststroke delirium incidence and outcomes: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Critical Care Medicine. Feb;40(2):484-90.