Bad, Mad, or Delirious?

•Dealing with confusion in Intensive Care

David Quayle PgC, RGN, FETC

Charge Nurse, CTCC, JRH

Acknowledgments

• Vanderbilt University, USA

• Pharmacy Department, John Radcliffe Hospital

Delirium? – What is it!

• “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 Diagnostic and Statistical Manual of

Mental Disorders )

Subtypes

• Hyperactive– ICU Psychosis

• Hypoactive– acute encephalopathy

• Mixed

At Risk?

• On average ICU patients have greater than 10 risk factors for delirium which places them at a very high risk for this complication.

• One of the most frequent forms of organ dysfunction experienced by critically ill patients

• Despite this prevalence, delirium (usually in the hypoactive state) remains unrecognized in 66% to 84% of patients whether they be in the ICU, hospital ward, or A&E

• In a recent study Jason et al (2005) demonstrated that 48% of a cohort in ICU experienced at least 1 episode of delirium

• http://ccforum.com/content/9/4/R375

Delirium – The Cost?• Ely et al (2001) identified delirium as

the strongest independent determinant of length of stay in the hospital

• Ely et al (2004) identified delirium as a cause of higher mortality

• Milbrant et al (2004) calculated that delirium was associated with an increase in the cost of care by 39% in ICU and 31% across the whole hospital stay

• Delirium may also predispose ICU survivors to prolonged neuropsychological deficits

Our Perspective

• Self Harm• Harm to other patients• Harm to staff• Concerns about the Use of

Restraint (physical or chemical)(physical or chemical)

– Staff Discomfort– Not Trained– Using correct drugs?– Using correct doses– Over sedation?

• The need to protect patients from self harm, to protect staff from incidents of aggressive behaviour from patients and the need to avoid increases in the levels of post operative morbidity and mortality, make a coordinated approach to the care of delirium a very high priority.

How Do We Identify It?

•Richmond Aggitation & Sedation Scale

– RASS

•ICU - Confusion Assessment Method

– ICU-CAM

Score Term Description Stimulation

+4 Combative Overtly combative, violent, immediate danger to staff

+3 Very Aggitated Pulls or removes tubes; aggressive

+2 Agitated Frequent non purposeful movements. Fights ventilator

+1 Restless Anxious, but movements not aggressive

0 Alert & Calm

-1 Drowsy Not fully alert, but has sustained wakening (eye opening/ eye contact) to voice >/= 10s

-2 Light Sedation Briefly awakens with eye contact to voice <10s Verbal

-3 Moderate Sedation Movement or eye opening to voice (but no eye contact)

Verbal

-4 Deep Sedation No response to voice, but movement or eye opening to physical stimulation

Physical

-5 Unrousable No response to voice or physical stimulation Physical

If RASS is -4 or -5 then Stop & Reassess patient at a later time Ref: Sessler et al, Am J Respir Crit Care Med 2002 and Ely et al JAMA 2003 If RASS is above -4 (-3 to +4) then proceed to step two

1. Acute onset of mental status changes or a fluctuating course

2. Inattention

3. Disorganised Thinking

= DELIRIUM

4. Altered Level of Consciousness

And

And / Or

WHAT NOW?

• Is it Delirium? – Assessment

• Hyper/ Hypo/ Mixed?

• Treatment Plan

• Restraint?

BACCN Position Statement• The purpose of restraint is to facilitate optimal care of the

patient• Use of restraint must not be an alternative to inadequate

human or environmental resources• Restraint should only be used when alternative therapeutic

measures have proved to be ineffective to obtain the desired outcome.

• Decisions regarding the use or non-use of restraint must be made following a detailed patient assessment by the interdisciplinary team.

• Critical care areas must develop and implement protocol/ guidelines in order to assist nurses and others in this process.

• Whatever form of restraint is used there must be appropriate, continual assessment tools used and the findings acted upon

• Clear concise documentation of decisions, plans and treatment must be held within the patient’s record.

• The patient and their family should be engaged within the discussions to inform them of the reason for choice of the restraint method.

• Education for all staff regarding chemical, physical and psychological restraint must encompass training and competency programmes in critical care units

Ethical Planning• Nursing Care

– Environment– Noise Levels– Orientation

• Assessment– Are they Delirious?

• Treatment– Right drug, right time,

right diagnosis

Nursing care• minimise risk factors• repeated reorientation of patients• provisions of stimulating activities

for the patients throughout the day• avoidance of night sedation• early mobilization • the earliest possible removal of

invasive lines/ catheters etc • use of spectacles and hearing aids

to facilitate effective communication• early correction of dehydration• effective pain control• minimization of unnecessary

noise/stimuli.

Standard For The Night Environment on CTCC

(based on staff identified issues)• Blinds to outside windows will be drawn by 22.00• Main lights (not including night lights) will be switched off by 22.00• Pre-prescribed night sedation will be given by 22.00• Radios will be switched off by 22.00 • Printing will not be done between 22.00 & 07.00• All phone ringers will be set to low• Patients will not be woken for a non essential wash• Alarm limits will be checked at the beginning of the night shift & adjusted to

individually required parameters• Alarms will be cancelled & attended to within 20 seconds of onset• Alarm parameters will be adjusted when an alarm reoccurs for a known condition

which is being attended to• Alarms will be cancelled prior to undertaking a planned procedure (e.g. . removal

of an arterial line, taking an ABG, etc)• Routine medical examinations will take place before 22.00 & after 07.00• All main corridor light switches will be labelled to identify which switch controls

which light• Registrars ward round will be completed by 23.00• Restocking will take place before 22.00 & after 07.00• Patient care activities will be grouped into the fewest possible interventions based

upon individual assessment• Staff noise to be kept to a minimal level between 22.00 & 07.00

Treatment?• Use an antipsychotic to treat the

delirium PLUS a benzodiazepine for rapid control of agitation

• Neuroleptics are superior to benzodiazepines in treating delirium that has been caused by factors other than alcohol withdrawal or sedative hypnotics.

• Haloperidol is the preferred antipsychotic because it has fewer active metabolites, limited anticholinergic effects, less sedative and hypotensive effects and can be administered by different routes.

• Lorazepam is the benzodiazepine of choice due to its sedative properties, rapid onset and short duration of action; it also has a low risk of accumulation.

Treating Hyper Active Delirium• ADMINISTRATION OF IV LORAZEPAM/

MIDAZOLAM:

• Midazolam intravenously 0.5-2mg stat• This can be repeated as often as required to attain

appropriate sedation• Give one dose and wait for the haloperidol to take

effect if possible• If available use Lorazepam intravenously 1-2mg stat• This can be repeated up to a max of 2mg every 4

hours • Flumazenil should be available to rapidly reverse

side effects if they occur• Start Haloperidol intravenously at 0.5-5mg stat• Observe the patient for 20-30mins• If the patient remains unmanageable but has not

had any adverse effects (e.g. hypotension, neuroleptic effects) DOUBLE the dose and continue monitoring

• Repeat the cycle until an acceptable response or unacceptable side effects occur

• Upper limits on doses have not been clearly established

• Haloperidol IV up to 100mg in 24 hours• Haloperidol IV in conjunction with benzodiazepines

up to 60mg in 24 hours.

Treating Hypo Active Delirium

• Haloperidol IV/PO 0.5-5mg 2-3 times a day

• Regular treatment for a few days may be required to treat delirium.

• Reduce the dose gradually over the following few days.

Alcohol Withdrawal?

• Benzodiazepines are the first line treatment

• Antipsychotics are not effective in treating delirium associated with alcohol withdrawal

• Take note of your patients history

Any Other Factors?

• Drug therapy can contribute to the development of delirium

• Prompt cessation of medication that is no longer required can help to minimise the risk

• Drugs that exhibit antimuscarinic activity are particularly associated with the development of delirium

• Establishing a day / night cycle is widely held to be important and many drugs are known to affect sleep pattern.

Analgesics-Codeine-Fentanyl-Morphine-PethidineAntidepres

sants-Amitriptyline-ParoxetineAnticonvuls

ants-Phenytoin-

PhenobarbitoneAntihistami

nes-

Chlorphenamine-

Promethazine

Antiemetics-

ProchlorperazineAntipsychotic

s-ChlorpromazineAntimuscarini

cs-Atropine-HyoscineCardiovascula

r agents-Atenolol-Digoxin-Dopamine-Lignocaine

Corticosteroids

-Dexamethasone

-Hydrocortisone

-PrednisoloneHypnotic

agents-

Chlordiazepoxide-Chloral

Hydrate-Diazepam-ThiopentoneMiscellaneou

s agents-Frusemide-Ranitidine-

Suxamethonium

Drug or Drug Class Sleep Disorder

Benzodiazepines REM, SWS

Opioids REM, SWS

Clonidine REM

Non steroidal anti-inflammatory drugs TST, SE

Norepinephrine/ Epinephrine Insomnia, REM, SWS

Dopamine Insomnia, REM, SWS

-Blockers Insomnia, REM, Nightmares

Amiodarone Nightmares

Corticosteroids Insomnia, REM, SWS

Aminophylline Insomnia, REM, SWS, TST, SE

Quinolones Insomnia

Tricyclic antidepressants REM

Selective Serotonin Reuptake Inhibitors REM, TST, SE

Phenytoin Sleep Disturbances

Phenobarbital REM

Carbamazepine REM

In Conclusion

• Ethics – Are we contributing?– Environment– Drugs

• Assessment– 2 Step Approach– RASS & ICU-CAM

• Treatment Plan– HyperActive Delirium– HypoActive Delirium

References• BNF No 49 March 2005• Bray et al. British Association of Critical Care Nurses position statement on the

use of restraint in adult critical care units, BACCN, Nursing in Critical Care, 2004, Vol 9, No 5.

• Bourne RS and Mills GH. Sleep disruption in critically ill patients - pharmacological considerations. Anaesthesia 2004; 59: 374-84.

• Ely E.W. and Vanderbilt University. http://www.icudelirium.org/delirium/training-pages/trainingman.pdf. 2002

• Ely EW, Gautam S, Margolin R, Francis J, May L, Speroff T et al. The impact of delirium in the intensive care unit on hospital length of stay. Intensive Care Med 2001; 27:1892-1900.

• Ely, E.W., Shintani, A., Truman, B., Speroff, T., Gordon, S.M., Harrell, F.E., Inouye, S.K., Bernard, G.R., Dittus, R.S. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA. 291(14): 1753-1762, 2004.

• Han L et al. Use of medications with anticholinergic effect predicts clinical severity of delirium symptoms in older medical inpatients. Arch Intern Med 2001; 161: 1099-1105.

• Jacobi J et al. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med 2002; 30: 119-41.

• Jason WW Thomason, Ayumi Shintani, Josh F Peterson, Brenda T Pun, James C Jackson and E Wesley Ely. 2005. Intensive care unit delirium is an independent predictor of longer hospital stay: a prospective analysis of 261 non-ventilated patients. http://ccforum.com/content/9/4/R375

• Mayo-Smith, M et al. 2004 Management of alcohol withdrawal delirium. Arch Intern Med (164) 1405-1412

• Meagher D. ‘Delirium: Optimising Mangement’, BMJ 2001; 322: 144-9• Milbrandt, E.B., Deppen, S., Harrison, P.L., Shintani, A.K., Speroff, T., Stiles, R.A.,

Truman, B., Bernard, G.R., Dittus, R.S., Ely, E.W. Costs Associated with Delirium in Mechanically Ventilated Patients. Crit. Care Med. 32 (4):955-962,2004.

• NICE Guidance. 2005. Violence – The short-term management of disturbed/violent behaviour in psychiatric in-patient settings and emergency departments

• Sessler et al, Am J Respir Crit Care Med 2002 and Ely et al JAMA 2003• Skrobik Y, Bergeron N, Dumont M, Gottfried S (2004) “Olanzapine vs Haloperidol:

treating delirium in a critical care setting” Intensive Care Med 30:444-449• Truman B, Ely EW. Monitoring delirium in critically ill patients. Crit Care Nurse • 2003; 23:25-36.

Any Questions

• Please feel free to wake up and ask any questions that you may have!