Bogota delirium051110

New Frontiers in Critical Care:Saving the Injured Brain

Leanne Boehm, MSN, RN, ACNS-BCICU Delirium and Cognitive Impairment Study Group

Vanderbilt University Medical CenterNashville, TN USA

Disclosures

Educational grant from HospiraOff label drug use

No drug is FDA approved for delirium

Learning Objectives

Define delirium and its subtypesIdentify delirium outcomesDiscuss risk factors for deliriumIdentify components of an ‘ABCDE’

interdisciplinary bundle of care for the ICU

Objectives



What is delirium?

Common clinical syndrome that is characterized by: Inattention Acute cognitive dysfunction

Thought to be due to disruption of neurotransmission related to: Drug toxicity Inflammation Acute stress responses

Prevalence of Delirium in the ICU

60–80% MICU/SICU/TICU ventilated patients develop delirium

20–50% of lower severity ICU patients develop delirium

Hypoactive or mixed forms most common Majority goes undiagnosed if routine

monitoring is not implemented

Ouimet S, et al. Intensive Care Med. 2007;33:66-73 Ely EW, et al. JAMA. 2001;286,2703-2710Pandharipande PP, et al. J Trauma. 2008;65:34-41 Ely EW, et al. Intensive Care Med. 2001;27:1892-1900.Dubois MJ, et al. Intensive Care Med 2001;27:1297-1304

.

Objectives



After Hospital Discharge

During the ICU/Hospital Stay

Sequelae of Delirium

- Increased mortality - 3x greater re-intubation rate - Average 10 additional days in hospital - Higher costs of care

- Increased mortality - Long-term cognitive impairment- d/c requirement for chronic care facility- Decreased functional status at 6 months

Milbrandt EB, et al. Crit Care Med. 2004;32:955-962. Nelson JE, et al. Arch Intern Med. 2006;166:1993-1999.Ely EW, et al. JAMA. 2004;291:1753-1762. Jackson JC, et al. Neuropsychol Rev. 2004;14(2):87-98.

Risk of death rises 10% per day

1. Ely EW, JAMA 2004;291:1753-622. Pisani M, AJRCCM 2009 Sept 10,

After adjusting for covariates, each day spent in delirium was associated with 10% increased risk of death at:

• 6 months

• 1 year

Long-term Cognitive Impairment

50% of ICU survivors will have new dementia-like illness

Delirium duration is a risk factor for poorer cognitive function (p=0.05)

Hopkins, R. O. & Jackson, J. C. (2009) Clin Chest Med 30:143-153

Jackson, J.C., et al. AJRCC, ahead of print

Objectives



Patient FactorsIncreased ageAlcohol useMale genderLiving aloneSmokingRenal diseaseDepressionVision/Hearing impaired

EnvironmentAdmission via ED or through transferIsolationNo clockNo daylightNo visitorsNoiseUse of physical restraintsSleep deprivation

Predisposing DiseaseCardiac diseaseCognitive impairment (eg, dementia)Pulmonary diseaseHIV

Acute IllnessLength of stayFeverMedicine service Lack of nutritionHypotensionSepsisMetabolic disorders Tubes/cathetersMedications:- Anticholinergics- Corticosteroids- Benzodiazepines

Less Modifiable

More Modifiable

DELIRIUM

Inouye SK, et al. JAMA .1996;275:852. Van Rompaey B, et al. Crit Care 2009;13:R77.Skrobik Y. Crit Care Clin. 2009;25(3):585-591. Devlin J, et al. ICM, 2007; 33:929-940.

Lorazepam & delirium

Pandharipande, P.P., et al. Anesthesiology 2006; 124: 21-26

N= 198 MICU pts What’s the chance of being

delirious the next day? Covariates controlled:

Age Pre-existing cognitive

function Severity of illness Co-morbidities Etc.

Objectives



ABCDE interdisciplinary bundle

ABC Awakening & Breathing Coordination Choice of sedative

D Delirium ID & management

E Early mobilization





•Reduce exposure to sedatives•Link spontaneous awakening &

breathing trials•Optimize sedation choice

Sedation Protocols: The Evidence

Setting Targets

Aim for Cooperative: Calm & Easily Arousable State while minimizing

pain, anxiety, or agitation unless contraindicated Easy transition from sleep to wakefulness1

Can participate in weaning and physical therapy1

Perform therapeutic maneuvers Allows for cognitive evaluation

Adjust depending on patient need Over the course of Illness/Treatment Initial Intubation vs Stabilization Weaning Phase

1Bekker AY, et al. Neurosurgery 2005;57(1 Suppl 1):1-10

Daily Awakening

Kress JP, et al. NEJM. 2000;342:1471-1477.

0

20

40

60

80

100

Pa

tie

nts

Rec

eiv

ing

Me

ch

anic

al V

enti

lati

on

(%

)

0 302010 155 25

Control (n=60)

Protocol (n=68)

(Adjusted P<.001)

Time (Days)

Reduced Vent time by 2.5 days

The ABC Trial(both groups get patient targeted sedation)

OUTCOMESdelirium, LOS, 12-mo NPS testing, QOL

Spontaneous Breathing Trial (SBT)ventilator off

safely monitored

OUTCOMESdelirium, LOS, 12-mo NPS testing, QOL

Spontaneous Breathing Trial (SBT)ventilator off

safely monitored

Spontaneous Awakening Trial (SAT)turn sedation/narcotics off

monitor safely

Medical ICU on VentilatorSurrogate Informed ConsentControl Intervention

Study Day

Da

ily D

os

e o

f B

en

zod

iaze

pin

es

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

010

2030

4050

6070

Benzodiazepines

Usual Care+SBTSBT+SAT

0Days

70

20

40

60

80

100P

ati

en

ts D

isc

har

ge

d f

rom

th

e IC

U (

%)

14 21 28

SAT+SBT (n=167)

SBT (n=168)

p=.01

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

reduced ICU stay by 4 days

0Days

70

20

40

60

80

100P

ati

en

ts D

isc

har

ge

d f

rom

th

e H

os

pit

al

(%)

14 21 28

SAT+SBT (n=167)

SBT (n=168)

p=.04


reduced hospital stay by

4 days

Pa

tie

nts

Aliv

e (

%)

00

20

40

60

80

100

60 120 180 240 300 360

Days

Usual Care+SBT (n=168)

SAT+SBT (n=167)

One-Year SurvivalOne-Year Survival

p=.01NNT=7


MENDS trialMENDS trial

MICU/SICU PatientsVentilated & Sedated

ControlLorazepam (GABA)

± Fentanyl

InterventionDexmedetomidine (α2)

± Fentanyl

Pandharipande PP, et al. JAMA 2007;298:2644-53

Incidence of Delirium

Pandharipande et al. Crit Care. 2010 Mar 16;14(2):R38

SEDCOM trial

MICU PatientsVentilated & Sedated

ControlMidazolam (GABA)

± Fentanyl

InterventionDexmedetomidine (α2)

± Fentanyl

Riker, R., et al. JAMA 2009; 301(5): 489-499

**+

*

*

0

10

20

30

40

50

60

70

80

Enrollment 1 2 3 4 5 6

Treatment Day

% P

atie

nts

CA

M-I

CU

Po

sitiv

e

Dexmedetomidine

Midazolam

+P<0.05

*P<0.01

Incidence of Delirium

Riker, R., et al. JAMA 2009; 301(5): 489-499

What about “No Sedation”

Morphine prn 2.5 to 5 mg for comfort

Physician consult if patient seemed uncomfortableHaloperidol prn for delirium

If still uncomfortable: propofol infusion for 6 hours Transitioned back to prn morphine

3 cycles allowed; if failed, propofol infusion with DIS

Strom T, et al. Lancet. 2010;375:475-480.

Strom et al. Lancet 2010; 375:475-80

Study Outcomes

Reduced ICU LOS by 9.7 days (P=0.02)



E Early mobilization•Monitoring instruments•Non pharmacologic management•Pharmacologic treatment

Intensive Care Delirium Screening Checklist

1. Altered level of consciousness

2. Inattention

3. Disorientation

4. Hallucinations

5. Psychomotor agitation or retardation

6. Inappropriate speech

7. Sleep/wake cycle disturbances

8. Symptom fluctuation

Bergeron N, et al. Intensive Care Med. 2001;27:859-864.Ouimet S, et al. Intensive Care Med. 2007;33:1007-1013.

Score 1 point for each component present during shift • Score of 1-3 = Subsyndromal Delirium• Score of ≥ 4 = Delirium

CAM-ICU

1. Acute onset of mental status changes

or a fluctuating course

and

2. Inattention

and

or3. Disorganized Thinking

4. Altered level of consciousness

= Delirium

Ely et al, Ely et al, CCMCCM 2001;29:1370-79 2001;29:1370-79 Ely, E.W., et alEly, E.W., et al.. JAMAJAMA 2001 2001; ; 286: 2703-2710286: 2703-2710

What to THINK if + for delirium

• Toxic SituationsCHF, shock, dehydration

Deliriogenic meds (tight titration, sedative choice)

New organ failure, e.g, liver, kidney

• Hypoxemia; also, consider giving Haloperidol or other antipsychotics

• Infection/sepsis (nosocomial), Immobilization

• Nonpharmacological interventionsHearing aids, glasses, reorient, sleep protocols, music, noise control, ambulation

• K+ or Electrolyte problems

Delirium management

Reorientation & cognitive stimulation1

Hearing aids and/or eye glasses1

Pain management1

Sleep preservation Be a “tight titrator” of sedatives to minimize

exposure Minimize restraint use1

Remove catheters (i.e. urinary, central lines)1

Appropriate sedative choice

1Inouye, et al. NEJM. 1999;340:669-676.

Haloperidol vs Olanzapine Unblinded, no placebo MICU/SICU (mostly surgical) N=67 (45 haloperidol & 22 olanzapine)

Results: Similar clinical improvement Side effects:

Olanzapine--none Haloperidol--EPS

Some mismatch in groups at baseline 1st study glimpsing at these 2 drugs & delirium!

Skrobik YK, et al ICM 2004;30:444-449

MIND Pilot Study

0 5 10 15 20Day

Pat

ient

s w

ithou

t D

eliri

um o

r C

oma

(%)

0

20

40

60

80

100

Haloperidol (n=35)Ziprasidone (n=32)Placebo (n=36)

Girard, et al. Crit Care Med 2010. 38:428-437

Quetiapine vs. Placebo (n=36)

Randomized, double blind, placebo controlled Haloperidol in both groups Quetiapine dose: 50-200mg q12 hrs Study drug given PO

Quetiapine Placebo

Devlin, et al. Crit Care Med 2010; 38: 419-427

N=18 N=18

Delirium + Haloperidol PRN

Quetiapine v. Placebo

Devlin, et al. Crit Care Med 2010; 38: 419-427





Early Mobilization Trial

N=104 mechanically ventilated patients• Early exercise & mobilization with PT/OT

(n=49)• PT & OT decided by primary team (n=55)

Primary endpoint: Number of patients returning to independent functional status at hospital discharge

Secondary endpoints: • Delirium duration• Ventilator-free days

Schweickert WD, et al. Lancet. 2009;373:1874-1882.


24% improvement (1.7-fold better) return to independent functional status at discharge

(NNT=4)

Milestones Achieved ~3 days earlier*

• Standing• Marching• Walking• Transferring

*P < 0.001


Daily Wake-Up + Early Mobility

OutcomeIntervention

(n=49)Control(n=50) P

Functionally independent at discharge 29 (59%) 19 (35%) .02

ICU delirium (days) 2.0 (0.0-6.0) 4.0 (2.0-7.0) .03

Time in ICU with delirium (%) 33% (0-58) 57% (33-69) .02

Hospital delirium (days) 2.0 (0.0-6.0) 4.0 (2.0-8.0) .02

Hospital days with delirium (%) 28% (26) 41% (27) .01

Barthel Index score at discharge 75 (7.5-95) 55 (0-85) .05

ICU-acquired paresis at discharge 15 (31%) 27 (49%) .09

Ventilator-free days 23.5 (7.4-25.6) 21.1 (0.0-23.8) .05

Length of stay in ICU (days) 5.9 (4.5-13.2) 7.9 (6.1-12.9) .08

Length of stay in hospital (days) 13.5 (8.0-23.1) 12.9 (8.9-19.8) .93

Hospital mortality 9 (18%) 14 (25%) .53


Important considerations Safety needs

Close monitoring Intervention based on progressive stepwise continuum:

Readiness Specific disease Strategies to prevent complications Ability to tolerate the activity/movement

Emotional needs Continual reassurance necessary Explain and re-explain circumstances Consider having family at bedside

Comfort needs Look for signs that analgesia or sedatives are needed

Keys to success Utilize existing personnel

• Nurses• Respiratory Therapists• Pharmacists• Physicians• Physical & Occupational Therapy• Speech Therapy

This involves a culture change Team coordination is a MUST Reinforce the goal frequently:

Coordination Collaboration Improvement in patient outcomes Daily team work

Conclusions

Delirium is a significant problem for critically ill patients and a predictor of many negative clinical outcomes.

Reliable and easy tools are available for identification of delirium in the critically ill.

Processes of care are available to minimize incidence of modifiable risk factors.

ABCDE can be incorporated into current practices with minimal additional resources.

Some operational culture change is involved.

Educational Delirium Website

[email protected]

[email protected]

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