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PREVENZIONE E TERAPIA DEL DELIRIUM
NEI REPARTI DI CURA INTENSIVA
Giuseppe Natalini Terapia Intensiva
Fondazione Poliambulanza Brescia
TERAPIA FARMACOLOGICA
Devlin JW. Efficacy and safety of quetiapine in critically ill patients with delirium: A prospective, multicenter, randomized, double-blind, placebo-controlled pilot study Crit Care Med 2010; 38:419-27
Quetiapina
...meglio prevenire...
PREVENZIONE FARMACOLOGICA
Wang W et al. Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery: a randomized controlled trial. Crit Care Med 2012; 40:731-9
Page VJ. Effect of intravenous haloperidol on the duration of delirium and coma in
critically ill patients (Hope-ICU): a randomised, double-blind, placebo-
controlled trial. Lancet Respir Med 2013; 1:515–23
Girard TD. Feasibility, efficacy, and safety of
antipsychotics for intensive care unit delirium: The
MIND randomized, placebo-controlled trial. Crit Care
Med 2010; 38:428-37
...anche la prevenzione farmacologica...
LA SEDAZIONE
van den Boogaard M. Development and validation of PRE-DELIRIC (PREdiction of
DELIRium in ICu patients) delirium prediction model for intensive care patients:
observational multicentre study. BMJ 2012;344:e420
Pandharipande PP. JAMA. 2007; 298:2644-53 Maldonado JR. Psychosomatics 2009; 50:206-17
Riker RR. JAMA 2009; 301:489-99 Shehabi Y. Anesthesiology 2009; 111:1075-84
Rubino AS. Interact Cardiovasc Thorac Surg 2010; 10:58-62
alfa-2 agonisti: buona alternativa (dexmedetomidina, clonidina?)
Dubois MJ. Intensive Care Med 2001; 27:1297-304 Ouimet S. Intensive Care Med 2007; 33:66–73
Pandharipande PP. J Trauma 2008; 65:34-41 Pisani MA. Crit Care Med 2009; 37:177-83
Agarwal V. J Burn Care Res 2010; 31:706-15
oppioidi: solo a dose analgesica
Conclusione: farmaci e delirium
Prevenzione: forse anziani con bassa gravità
Terapia: aloperidolo per trattare episodi acuti (quetiapina?)
Sedativo di prima scelta (per il delirium): dexmedetomidina
Oppioidi: solo per analgesia
PREVENZIONE NON FARMACOLOGICA
Colombo R. A reorientation strategy for reducing delirium in the critically ill. Results of an interventional study. Minerva Anestesiol 2012; 78:1026-33
Strategia di riorientamento
HR 0.50 [95% CI: 0.31-0.89] (p=0.03)
Rispetto del sonno notturno
Van Rompaey B. The effect of earplugs during the night on
the onset of delirium and sleep perception:
randomized controlled trial in intensive care patients.
Crit Care 2012; 16:R73
Schweickert WD. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009; 373:1874-82
Terapia fisica ed occupazionale precoce
Zaal IJ. Intensive care unit environment may affect the course of delirium. Intensive Care Med 2013: 39:481-88
Balas MC. Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle. Crit Care Med 2014; 42:1024-36
Khan BA. Effectiveness of Implementing a Wake Up and Breathe Program on Sedation and Delirium in the ICU. Crit Care Med 2014; 42:791-5
Prevenzione non farmacologica
Nei gruppi di controllo i pazienti erano sottoposti a condizioni di disorientamento e depersonalizzazione, inutilmente immobilizzati nel letto, tenuti inutilmente svegli, senza privacy...
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th edition.2013.
Maldonado JR. Am J Geriatr Psychiatry 2013; 21:1190-222
Girard TD. Associations of markers of inflammation and coagulation with delirium during critical illness. Intensive Care Med 2012; 38:1965-73
Hsieh SJ. The association between Acute Respiratory Distress Syndrome, delirium,
and in-hospital mortality in Intensive Care Unit patients. Am J Respir Crit
Care Med 2015; 191:71-8
Delirium e ARDS
INFIAMMAZIONE E VENTILAZIONE
Pelosi P. The lung and the brain: a dangerous cross-talk. Critical Care 2011, 15:168
Dreyfuss D. Ventilator-induced Lung Injury. Lessons from experimental studies. Am J Respir Crit Care Med 1998; 157:294-323 Slutsky AS. Ventilator-Induced Lung Injury. N Engl J Med 2013;369:2126-36.
Pintado MC et al. Individualized PEEP setting in subjects with ARDS: A randomized controlled pilot study. Respir Care 2013
;58:1416-23
Ranieri MV. Effect of mechanical ventilation on inflammatory mediators in patients with acute respiratory distress
syndrome. JAMA. 1999;282:54-61
Amato MBP. Driving pressure and survival in the Acute Respiratory Distress Syndrome. N Engl J Med 2015; 372:747-55
Ranieri VM. Pressure–time curve predicts minimally injurious ventilatory strategy in an isolated rat lung model. Anesthesiology 2000; 93:1320-8
paziente passivo + flusso inspiratorio costante
SONNO E VENTILAZIONE
Ozsancak A. Sleep and mechanical ventilation. Crit Care Clin 2008; 24:517-31
60% dei pazienti ventilati ha disturbi del sono dovuti alla ventilazione meccanica Bergbom-Engberg I. Assessment of patients’ experience of discomforts during respirator therapy. Crit Care Med 1989; 17:1068–1072
Il problema della PSV
Meza S. Susceptibility to periodic breathing with assisted ventilation during sleep in normal subjects. J Appl Physiol 1998; 85:1929-40
Parthasarathy S. Effect of ventilator mode on sleep quality in critically ill patients. Am J Respir Crit Care Med 2002; 166:1423-9
ACV vs PSV
PSV con basso volume corrente
Cabello B. Sleep quality in mechanically ventilated patients: Comparison of three ventilatory modes. Crit Care Med 2008; 36:1749-55
Toublanc B. Assist-control ventilation vs. low levels of pressure support ventilation on sleep quality in intubated
ICU patients. Intensive Care Med 2007 33:1148-54
insufficienza respiratoria acuta
su cronica
insufficienza respiratoria acuta su cronica
Andrejak C. Does using pressure-controlled ventilation to rest respiratory muscles improve sleep in ICU patients? Respir Med 2013; 107:534-41
impostazione PSV sulla meccanica respiratoria
Fanfulla F. Effects of different ventilator settings on sleep and inspiratory effort in patients with neuromuscular disease. Am J Respir Crit Care Med 2005; 172:619-24
Come migliorare il sonno durante la ventilazione meccanica
1) ventilazione assistita-controllata: prima scelta
- spt malattie polmonari croniche
2) PSV:
- ottimale: scegliere PEEP e supporto su PEEPi e sforzo inspiratorio del paziente (40-80%)
- supporto inspiratorio: volume corrente max 7-8 ml/kg peso ideale, limitare asincronie e apnee
Meza S. Susceptibility to periodic breathing with assisted ventilation during sleep in normal subjects. J Appl Physiol 1998; 85:1929-40 Parthasarathy S. Effect of ventilator mode on sleep quality in critically ill patients. Am J Respir Crit Care Med 2002; 166:1423-9 Fanfulla F. Effects of different ventilator settings on sleep and inspiratory effort in patients with neuromuscular disease. Am J Respir Crit Care Med 2005; 172:619-24 Toublanc B. Assist-control ventilation vs. low levels of pressure support ventilation on sleep quality in intubated ICU patients. Intensive Care Med 2007 33:1148-54 Bosma K. Patient-ventilator interaction and sleep in mechanically ventilated patients: pressure support versus proportional assist ventilation. Crit Care Med 2007;35:1048-54. Cabello B. Sleep quality in mechanically ventilated patients: Comparison of three ventilatory modes. Crit Care Med 2008; 36:1749-55 Andrejak C. Does using pressure-controlled ventilation to rest respiratory muscles improve sleep in ICU patients? Respir Med 2013; 107:534-41
Conclusioni: trattare e prevenire il delirium in Terapia Intensiva
- approccio farmacologico al delirium al momento poco efficace
- efficace la prevenzione non farmacologica (rivoluzione culturale)
- ottimizzare la cura delle cause di delirium: infezioni, ventilazione, ecc.
per curare bene il delirium non bisogna curare il delirium