Prevention And Treatment of Critical Care Delirium Catherine Dudick MD FACS

Prevention And Treatment of Critical Care Delirium
Catherine Dudick MD FACS
AtlantiCare Trauma Symposium
May 20 2013
Disclosures
icudelirium.org
Morandi et al Int Care Med 2008;34:1907-
Critical Care Delirium
 What is it?
 Why is it important?
 How can it be prevented/treated?
Delirium Defined
Morandi et al Int Care Med 2008;34:1907-15
What is delerium?
 Disturbance of consciousness (inattention)
 Acute in onset
 Accompanied by change in perception
 Generally reversible
 NOT dementia
 Generalized cognitive impairment
 Deterioration of previously acquired intellectual abilities
 Gradual in onset
 No clouding of consciousness
Arousal AND Content
Delirium Subtypes
Combative
Agitated
Restless
Hyperactive Delirium
Mixed
Delirium
Alert & Calm
Lethargic
Sedated
Stupor
Hypoactive Delirium
Prevalence in the ICU
 Occurs in up to 80% MICU/TICU/SICU ventilated
patients
 20-50% of lower severity ICU patients
 65-70% goes undiagnosed if routine monitoring
not done
 10% remain delirious at hospital discharge
Eli et al JAMA 2004;291:1753-62
Pathophysiology of Delirium
Flacker, et al J Gerontol Bio Scien 1999; p47
Pathophysiology of Delirium
Flacker, et al J Gerontol Bio Scien 1999; p47
Risk Factors of Delirium
 Medical conditions
 Preexisting dementia
 Substance intoxication or
 h/o HTN and/or alcholism
withdrawl
 Toxin exposure
 Preexisting cognitive
dysfunction
 severity of illness at admission
 Coma (independent risk factor)
 Benzodiazepines
 Age>70 years
 ? Propofol
 AAA surgery
 Sleep deprivation
 Poor functional status
 Combination
 Psychoactive medication
Flynn et al JACS 2009;209:261-268
Panharepande, Anesthesiology 2006;104:21-26
Panharepande, Anesthesiology 2006;104:21-26
Panharepande, Anesthesiology 2006;104
Delirium in Pneumonia
 “altered mental status” strongest independent
predictor of mortality in CAP (p<0.001)
 Relationship stronger with increasing age
Waterer et al AJRCCM
2004;169:910-914
Delirium post op in SICU
 100 non elective Surgical ICU patients
 Delirium prevalence 69%
 Average 4 days longer in ICU (p=0.03)
 Fewer days alive and vent-free (p=0.001)
 Midazolam was strongest modifiable predictor
Pandharepande et al, SCCM 2006
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
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.
P<0.00
1
Ely et al JAMA 2004;291:1753-176
Ely et al JAMA 2004;291:1753-17
P<0.008
Ely et al JAMA 2004;291:1753-
Ely et al JAMA 2004;291:1753-1762
Pisani et al Am J RCCM 2009;180:1092-1097
Cost of Delirium
Milbrandt et al Crit Care Med
2004;32:955-62
Importance of Delirium
 ICU delirium is a predictor of:
  Mortality
  LOS
  Ventilator time
  Cost
  Reintubation
  Long term cognitive impairment
  Discharge to LTC facility
Diagnosis and Management
 Occurs in up to 80% of MICU/SICU/TICU
ventilated patients
 Occurs in 20-50% of lower severity ICU patients
 Hypoactive & mixed forms most common
 65-70% goes undiagnosed if routine monitoring
not done
Delirium Management
1. Screen
2. Identify risk factors/etiology
3. Consider NON pharmacologic &
pharmacologic treatment
Jacobi J, et al. Crit Care Med 2002;30:119-141
Delirium Risk Factors Pneumonics
icudelirium.org
 Assess and treat pain
 Assess and adjust sedation
 Screen for delirium and its treatable causes
Crit Care Med 2013;41:263-306
 Assess and treat pain
 Assess and adjust sedation
 Screen for delirium and its treatable causes
Crit Care Med
Arousal AND Content
Delirium monitoring
 Screening recommended (B)
 75% of delirium missed if screening not done
 The Confusion Assessment Method for the
ICU(CAM-ICU) & Intensive Care Delirium
Screening Checklist (ISDSC) most reliable
 Routine monitoring is feasible in clinical practice
SCCM Guidelines, Crit Care Med 2013;41:263-306
CAM-ICU
ICDSC
 Assess and treat pain
 Assess and adjust sedation
 Screen for delirium and its treatable causes
SCCM Guidelines, Crit Care Med
Sedation
 Light levels of sedation associated with improved
clinical outcome (B)
 Light sedations causes increased physiologic
stress but no increased myocardial ischemia (B)
 RASS (Richmond Agitation-Sedation Scale) or
SAS (Sedation Agitation Scale) most reliable (B)
SCCM Guidelines, Crit Care Med 2013;41:26
Sedation
 “Non benzodiazepine sedatives (either propofol
or dexmedeomidine) may be preferred over
sedation with benzodiazepines (either
midazolam or lorazepam) to improve clinical
outcomes in mechanically ventilated ICU
patients” (+2B)
 Change from 2002 guidelines (midazolam, short
term sedation; lorazepam, long term sedaiton;
propofol for intermittent awakening)
SCCM Guidelines, Crit Care Med 2013;41:263-306
Benzodiazepines
 Activate γ-aminobutyric acid A (GABA) neuronal receptors
in brain
 Anxiolytic, sedating, hypnotic, anticonvulsant properties
 NO analgesia
 Amnestic effects extend beyond sedative effects
 Tolerance with long term administration
 Metabolized in liver
Benzodiazepines
 Cause respiratory depression
 Systemic hypotension
 Elderly more sensitive
 Lorazepam cleared slower
 Studies suggest longer awakening with midazolam versus
lorazepam
 Diazepam has prolonged duration of action
Panharepande, Anesthesiology 2006;104
Propofol
 Binds to multiple CNS receptors (GABAA, glycine,
nicotinic, M1 muscarinic)
 Sedative, hypnotic, anxiolytic, amnestic,
antiemetic, anticonvulsant
 NO analgesia
 Dose dependent respiratory depression and
hypotension
 PRIS (propofol infusion syndrome
dexmedetomidine
 Selective α2 receptor agonist
 Sedative, analgesic/opiod sparing
sympathomimetic properties
 Side effects of hypotension and bradycardia
 No significant effect on respiratory drive
SCCM Guidelines, Crit Care Med 2013;41:263-306
SCCM Guidelines, Crit Care Med 2013;41:263-306
Sedation Strategy
 Analgesia first sedation
 Propofol or dexmedetomidate before
benzodiazepines?
SCCM Guidelines, Crit Care Med 2013;41:263-306
 Assess and treat pain
 Assess and adjust sedation
 Screen for delirium and its treatable causes
SCCM Guidelines, Crit Care Med 2013;41:263-306
Acute Pain
 Unrelieved pain has significant and long term
consequences
 Majority(82%) of non-ICU hospitalized patients
remember ETT discomfort and ICU pain
 Increased catecholamines
 Arteriolar vasoconstriction, impaired tissue perfusion,
decreased tissue paO2
 Hypermetabolism (lipolysis, slow healing, catabolism)
 Risk factor for developing chronic, often neuropathic
pain
SCCM Guidelines, Crit Care Med 2013;41:263-306
Acute Pain
 IV opiods are the first line drug of choice for non
neuropathic pain in ICU patients(+1C)
 All equally effective when titrated to similar pain
intensity endpoints(C)
 Enteral gabapentin or carbamazepine should be
added for neuropathic pain(+1A)
 Use non opiod meds to decrease opiod
load(+2C)
 Thoracic epidural considered for rib fractures
(+2B)
SCCM Guidelines, Crit Care Med 2013;41:263-306
It’s a Balance
 Analgesia, amnesia, sedation vs. delirium risk
 Seek goal but don’t overshoot
 Arousal and content
Pharmacologic treatment
11. Milbrandt et al. Critical care medicine 2005 Jan;33(1):2269
Pharmacologic management
www.surgicalcriticalcare.net/Guidelines/delirium_2011
Prevention
 Early mobilization (+1B)
 NO recommendation for pharmacologic, non-
pharmacologic or combined prevention
protocol
 No recommendation for use of Haldol
 No recommendation for use of
Dexmedetomidate
SCCM Guidelines, Crit Care Med 2013;41:26
Early Mobilization
 Early Mobilization
 Safe
 Decreases ICU LOS
 Improves skin integrity
 Saves money
Bailey et al, Crit Care Med
2007;35:1
“Wake up and Breathe”
Awakening and Breathing Controlled
(ABC)Trial
\
 Paired daily interruption of
sedation with spontaneous
breathing trials
 3 less days on vent (p=0.02)
 3 less days in ICU (p=0.03)
 5 less days in hosp (p=0.03)
 Improved mortality (p=0.01)
 For every 7 patients treated,
one life saved
Girard et al, Lancet 2008;371:126-134
www.icudelirium.org
Girard et al, Lancet 2008;371:126-134
Girard et al, Lancet 2008;371:126-134
Sleep
 Sleep loss associated with irritability, memory loss,
inattention, delusions, slurred speech, blurred
vision, uncoordination
 Sleep loss and delirium
Sleep in the ICU
 Long sleep onset
 Sleep fragmentation/frequent arousals
 Predominance of stage 1 &2 non REM sleep
 Decreased or absent stage 3 NREM sleep and
REM sleep
 Melatonin production decrease in critically ill
patients
Mistraletti et al, Minerva Anestesiol 2008;74:329-33
Sleep and Hypnotics
 Increase total sleep time
 Alter physiological progression of sleep phases
 Decrease time in restorative phases
Mistraletti et al, Minerva Anestesiol 2008;74:329-33
Melatonin
 Nocturnal sleep quality severely compromised
 Melatonin use associated with increased
nocturnal sleep efficiency
 1-2mg
Bournel et al, Critical Care 2008;12:R52
14 subjects in simulated ICU environment
poorer perceived sleep quality
more light sleep
(P <
longer rapid eye movement (REM) latency
0.05)
less REM sleep
decreased nocturnal melatonin (P = 0.007)
increased cortisol secretion levels (P = 0.004)
anxiety levels similar (P = 0.06).
Use of earplugs and eye masks
more REM time
shorter REM latency
less arousal (P < 0.05)
elevated melatonin levels (P = 0.002).
ABCDE Protocol
ICU Delirium and Cognitive Impairment Study Group
www.icudelirium.org
[email protected]
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
E
Early Exercise and Mobility
Early Exercise and Mobility
Eligibility = All patients are
eligible for 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
Intervention
(n=49)
Control
(n=50)
P
29 (59%)
19 (35%)
0.02
2.0 (0.0-6.0)
4.0 (2.0-7.0)
0.03
33 (0-58)
57 (33-69)
0.02
2.0 (0.0-6.0)
4.0 (2.0-8.0)
0.02
28 (26)
41 (27)
0.01
75 (7.5-95)
55 (0-85)
0.05
15 (31%)
27 (49%)
0.09
Ventilator-free days
23.5 (7.4-25.6)
21.1 (0.0-23.8)
0.05
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
9 (18%)
14 (25%)
0.53
Outcome
Functionally independent at
discharge
ICU delirium (days)
Time in ICU with delirium (%)
Hospital delirium (days)
Hospital days with delirium (%)
Barthel index score at discharge
ICU-acquired paresis at
discharge
Hospital mortality
Schweickert WD, et al. Lancet. 2009;373:1874-1882.
Perform Safety Screen First
Safety Screen
 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*
1.
Active range of motion in bed and sitting position in bed
2.
Dangling
3.
Transfer to chair (active), includes standing without
marching in place
4.
Ambulation (marching in place, walking in room or hall)
*All may be done with assistance.
Benefits of ABCDE Protocol
Morandi A et al. Curr Opin Crit Care,2011;17:43-9
Questions????
Resources and References
 www.icudelirium.org
 www.sccm.org
 www.surgicalcriticalcare.net
 icusteps.org
 journals.lww.com/ccmjournal
Delirium per CMS
 2008 “Never Event”: errors in medical care that
are clearly identifiable, preventable, and serious
I consequences and indicate a problem in the
safety of a healthcare facility.
 2009 discussion: The next “never” event?
 Delirium has gained publicity
Prevalence in the News