Diagnosis and Management of ICU Delirium

June 24, 2010 - July 1, 2010Dave Miller, MD and Becky Logiudice, MS, RN

Talk Outline

• Why is this important?

• What is delirium?

• Using CAM-ICU to diagnose ICU delirium

• How do I treat delirium?

• Goal-oriented sedation

Why is this important?

 

Perspective from SB

About my delirium memories from the ICU, I have had few. The time I spent seems like it was in a huge, empty gray space, sort of like a monstrous underground parking garage with no cars, only me, floating or seeming to float, on something. Every once in a while I would get to an edge of something horrible and once I remember I thought, "if I just let go, then this horror will be over…” When I try to write about that time (and I have tried over and over), words just won't come and in my line of writing, personal essays, if it doesn't just come gushing out, I have to stop. And that's where I am now

http://www.icudelirium.org/outcomes.html#reports

Why is this important?

Pun B T , Ely E W Chest 2007;132:624-636

183 ÷ (183+41) = 0.82183 ÷ (183+41) = 0.82

Why is this important?

• Common

• Increased mortality

• Increased LOS

• Increased complications

• Increased costs

• May be associated with increased dementia and long-term cognitive impairment

Girard DT et al. Crit Care Med 2010;38(7):epub ahead of print

Pun BT and Ely EW. Chest 2007;132:624-636

What is Delirium?Answer # 1

You’ll Know it when you see it. . .

What is delirium?

Pun B T , Ely E W Chest 2007;132:624-636

What is delirium? Answer # 2

Disturbance of consciousnessInattentionChange in cognition or perceptual disturbanceDevelops over hours to daysFluctuates over time

How do I diagnose delirium?Case 1

Mr. D, a 70-year old with severe COPD, is in the MICU on a ventilator for respiratory failure. Initially he needed high levels of sedation, but now Propofol has been decreased and Mr. D is awake but agitated, grimacing, thrashing and trying to sit up in bed. He makes eye contact, but won’t follow commands

Is Mr. D delirious?How do you know?

Assessment of ICU patients

Patient Comfort

Pain Sedation Delirium

0 -10 scale

FRACC

Subjective/

physiologic factors

Sedation assessment scale

(RASS, SAS, MAAS)

CAM-ICU

Assessment tool: CAM-ICU

Assessment tool: CAM-ICU

Richmond Agitation-Sedation Scale (RASS)

RASS+4 Combative Combative, violent, immediate danger to staff

+3 Very agitated Pulls or removes tubes or catheters; aggressive

+2 Agitated Frequent non-purposeful movement, fights ventilator

+1 RestlessAnxious and apprehensive, but movements not aggressive or vigorous

0 Alert and calm

-1 DrowsyNot fully alert but has eye opening to voice and sustained eye contact (> 10 s)

-2 Light sedationBriefly awakens to voice with eye opening and eye contact (< 10 s)

-3Moderate sedation

Movement or eye opening to voice but no eye contact

-4 Deep sedationNo response to voice, but movement or eye opening to physical stimulation

-5 Not arousable No response to voice or physical stimulation

Assessment tool: CAM-ICU

Attention Screening Examination

Attention Screening Examination

• Auditory– Squeeze my hand each time I say the letter “A”– SAVEAHAART– More than 2 wrong responses = POSTIVE

• Visual (cannot hear or squeeze hands)– Show 5 pictures, then show 5 repeat and 5 new in

random order– More than 2 wrong responses = POSITIVE

Assessment tool: CAM-ICU

Assessing for Disorganized Thinking:

Answer 4 simple yes/no questions and follow a 2-step command:

• E.g.,“Will a stone float on water?”

•“Hold up 2 fingers on one hand, then on the other hand.”

Assessing for Disorganized Thinking:

Answer 4 simple yes/no questions and follow a 2-step command:

• E.g.,“Will a stone float on water?”

•“Hold up 2 fingers on one hand, then on the other hand.”

How do I diagnose delirium?Case 1 revisited

Mr. D, a 70-year old with severe COPD, is in the MICU on a ventilator for respiratory failure. Initially he needed high levels of sedation, but now Propofol has been decreased and Mr. D is awake but agitated, grimacing, thrashing and trying to sit up in bed. He makes eye contact, but won’t follow commands

Is Mr. D delirious?How do you know?

Case 1 revisited

STEP 1: Mr. D is assessed to be a RASS +2, which is an acute change from his baseline

STEP 2: He squeezes hands on “A” once out of 5 times (4 errors) so is inattentive

STEP 4: Because his level of consciousness is altered (RASS +2), STEP 3 does not need to be assessed.

Mr. D is delirious!

Case 2

• The next day, Mr. D is awake and calm (RASS 0). He was given several doses of lorazepam overnight for “agitation.” He remains intubated, but is following commands appropriately.

• Is Mr. D delirious now?

STEP 1: He is awake and calm (RASS 0) now, but fluctuated within the last 24 hours

STEP 2: He scores 6/10 on the Attention Screening Examination (POSITIVE)

STEP 3: Because his level of consciousness is not currently altered, he is tested for disorganized thinking. He scores 3 out of 5 because when asked “Are there elephants in the sea?” and “Can you use a hammer to cut wood?” he answers “YES!” (POSITIVE)

How should we manage Mr. D?

Managing ICU Delirium

1. Look for it

2. Communication between nursing and MDs

3. Identify and treat correctable risk factors

4. Optimize non-pharmacologic interventions

5. Goal-oriented sedation with daily wake-ups

6. Pharmacologic intervention

Managing ICU DeliriumModify Risk Factors

Host Factor Acute IllnessIatrogenic/

Environmental

Age Sepsis Metabolic disturbance

Baseline comorbidity

Hypoxemia Lights, noise, sleep pattern

Baseline cognitive impairment

Global severity of illness score

Anticholinergic, sedative and analgesic meds

Severity of illness and age are independent risk factors for delirium

Pandharipande et al. Anesthesiology 2006;104:21-26

Lorazepam dose is an independent risk factor for delirium

Also:• Other Benzos• Opiates• Propofol• Anticholinergics• H2 blockers• Steroids• Some antibiotics• Psych meds

Pandharipande et al. Anesthesiology 2006;104:21-26

Non-Pharmacologic Management

• Orientation– Visual and hearing aids– Communicate and re-orient frequently– Familiar objects and people– Consistent nursing staff– TV, news, music during the day

• Environment– Sleep hygiene: Lights off at night, on during day.

Sleep aids?– Control excess noise at night– Ambulate or mobilize early and often

Pun B T , Ely E W Chest 2007;132:624-636

Pharmacologic Management Antipsychotics

• Little controlled data, but anecdotal and case-series evidence– One small recent RCT comparing Haldol vs placebo

found no difference in mortality, LOS, side effects

• Haldol IV recommended by SCCM– Long half-life (18-54 hours)– Risk of: QT prolongation, NMS, akathisia– Monitor QTc BID, follow K, Mg, Ca. – Beware other drugs that prolong QT (MANY including

anti-arrhythmics, quinolones, erythromycin, methadone)

Jacobi et al. Crit Care Med 2002;30:119-141Girard et al. Crit Care Med 2010; 38: 428-37

Pharmacologic ManagementHaloperidol (Haldol)

– Action: CNS depressant and dopamine receptor antagonist

– Side Effects: Prolonged QT interval, Extrapyramidal symptoms, tardive dyskinesia (long term use)

– IV Dosing:• Starting dose: Mild agitation 2mg IV,

Moderate to severe agitation 5mg IV• After 20 min. of 1st dose, if still agitated increase the previous

doses by 5mg every 20min until calm. • Max dose 30 mg in 24 hours• Once pt is calm, 25% of loading dose should be given Q 6 hours

scheduled • Once pt is delirium free for 24 hours taper off haldol

Atypical Antipsychotics

• Recent double-blind RCT of quetiapine (Seroquil) 50mg BID vs placebo

• Haldol PRN – study drug increased if any PRN in 24 hours

• 36 ICU patients with delirium• Shorter time to resolution of delirium (1 vs 4.5

days)• Reduced duration of delirium (36 vs 120 hours)• More somnolence with quetiapine, other SEs

similar

Devlin JW et al. Crit Care Med 2010; 38: 419-426

Atypical Antipsychotics(Second Generation)

Not typically given IV or IM• Quetiapine (Seroquil)

– 25mg - 50mg PO

• Risperidone (Risperdal)– 1 mg - 3 mg PO daily

• Olanzapine (Zyprexa)– 5mg- 20 mg PO– 5mg -10 mg IM

1. AnalgesiaIn Pain?

2. SedationRASS at target (-1 to 0)?

3. DeliriumCAM-ICU positive?

Fentanyl prnMorphine prn

If not controlled with 2-3 doses/hour, start Fentanyl gtt

Reassess

OversedatedHold sedatives and analgesics to achieve RASS target. Restart at 50% if needed

Undersedated1. Benzo prn2. Propofol gtt3. Benzo gtt

Reassess

1. Underlying cause2. Non-pharm

management3. Pharm

management

Sedation Management• What is the Daily RASS Goal?

• What is the patient’s RASS now?

• Is the patient on optimal sedation for the RASS goal?

• Combination of sedative and narcotic is synergistic

• Side effects of most agents include:• Delirium• Hypotension• Respiratory depression• Increased tolerance with withdrawal syndromes• Risk of seizures if stopped abruptly• Difficulty assessing neurologic status

Sedation and Analgesia: Challenges

• Inappropriate sedation (over and under) is a frequent problem, causing:

– Increased levels of agitation, delirium

– Sleep fragmentation

– Increased rates of VAP, nosocomial infections, days on mechanical ventilation, hospital stays, costs

– Self-extubation, reintubation, accidental line removal

• Sedation is rarely discussed in a uniform fashion among health care providers

Sessler CN. Chest 2004;126:1727-1730

Wit M et al. Am J of Crit Care 2003; 12: 343-348.

Sessler CN. Am J Resp CCM 2002; 166:1338-1334

Sedation (short term)

Propofol• Sedative hypnotic with mild amnestic properties, NO analgesia, • Rapid induction, rapid recovery• Not recommended > 3 days• Side Effects:

– Hypotension 1/3 of all patients, respiratory depression, bradycardia, arrhythmia, Lipemia, hypertriglycerdemia, Pancreatitis, Infection Risk

– Propofol Infusion Syndrome: acute refractory bradycardia and metabolic acidosis, rhabdomyolysis, hyperlipidemia or an enlarged fatty liver

Dexmedetomidine (Precedex)• Alpha-2 agonist• Anxiolytic, analgesia, amnesia• No respiratory depression, patient sedate but arousable• Bradycardia, hypo/hypertension• Use < 24h

SedationBenzodiazepines

• Onset– midazolam<diazepam<lorazepam

– Start with IV push before starting an infusion

• Duration– diazepam>lorazepam>midazolam> propofol

– (NB midazolam and diazepam highly lipophilic)

• Elimination– renal failure: active metabolites accumulate for

midazolam and diazepam

– cirrhosis: prolongation of metabolism to active metabolites for midazolam & diazepam

Pain Management

Opiates• Consider non-opiate analgesics• Little amnestic effect• Active metabolites, lipid deposition (Fentanyl)• Side effects:

– Respiratory depression– Hypotension (Morphine > Fentanyl)– GI (constipation, ileus, gastroparesis, nausea)– Delirium– Tolerance followed by withdrawal syndromes

Goal-oriented Management• Multidisciplinary process that incorporates expertise from

physicians, nurses, pharmacy, and others

• Uses appropriate quantitative scales to assess and set treatment goals

• Provides etiology-driven treatment (treat pain with analgesics, anxiety with anxiolytics, etc)

• Avoids over-sedation & under-sedation– Minimizes the use of sedatives, which can lead to delirium, further agitation,

withdrawal syndromes

– Monitors response to therapeutic interventions

Kress JP, Hall JB. CCM 2006;2541-2546Sessler CN. Chest 2004; 1727-1730

Weinert et al. Am J Crti Care 2001; 156-167.

Managing ICU Delirium

1. Look for it2. Communication between nursing and

MDs3. Identify and treat correctable risk factors4. Optimize non-pharmacologic

interventions5. Goal-oriented sedation with daily wake-

ups6. Pharmacologic intervention

Daily Wake-UpsKress et al, NEJM 2000:

– 128 vented MICU patients randomized to daily awakening vs usual care AND midazolam vs propofol (all patients received morphine)

• Infusions off until following commands or agitated– Shorter time on vent (4.9 vs 7.3 days)– Shorter time in ICU (6.4 vs 9.9 days)– Fewer diagnostic tests for mental status– No difference in complications or PTSD

– No difference between propofol and midazolam

Kress JP. NEJM 2000. 342:1471-1477Sessler CN. Crit Care Clin 2009. 25: 489-513

Wake-Up and Breathe

• Multi-center RCT• 336 vented ICU patients randomized to

spontaneous awakening followed by spontaneous breathing trial vs usual sedation with daily SBT

• Safety screens for both SAT and SBT• SAT passed if patient opened eyes to

verbal stimuli or tolerated being off sedation for > 4 hours

Girard TD et al. Lancet 2008. 371:126-34

Hooper MH. Crit Care Clin 2009. 25:515-525

Wake-Up and Breathe

• Increased ventilator-free days (14.7 vs 11.6 days)

• Shorter ICU and hospital LOS (9.1 and 12.9 days; 14.9 and 19.2 days)

• 14% absolute reduction in risk of death at 1 year

Girard TD et al. Lancet 2008. 371:126-34

Expectations for Our ICU(as of July 1, 2010)

1. Documentation of RASS Q4 h (all patients)

2. Documentation of CAM-ICU Q8 h (all patients)

3. Discussion of RASS and CAM-ICU by team on daily work rounds

4. Use MAH Sedation Guideline for sedation and delirium management

5. Consideration of daily wake-up and daily SBT if appropriate

6. Inclusion of sedation goals on daily goal sheets

Case 3: 57F intubated for ARDS -- Day 10

Feature1. RASS is 0. Last shift, RASS was +2.2. SAVEAHAART: 50%3. Disorganized thinking:

Will a leaf float on water? YesAre elephants in the sea? YesDo 2 pounds weigh more than 1? YesCan you use a hammer to cut wood? YesFails to hold up 2 fingers Score: 2 of possible 5 points

4. Altered Level of Consciousness: RASS 0How should we manage her?

+

++

-

Summary

• Delirium is common and has serious negative consequences

• May be missed without assessment• Management is multidisciplinary

– Risk factor modification– Non-pharmacologic intervention– Pharmacologic intervention

• Optimize goal-directed sedation and analgesia

WWW.ICUDELIRIUM.ORG