CAM-ICU Basics

ICU Delirium and Cognitive Impairment Study Group

www.ICUdelirium.orgdelirium@vanderbilt.edu

What is Delirium?

Delirium is a common clinical syndrome characterized by:Inattention

Acute cognitivedysfunction

Pathophysiology: Disruption of neurotransmission (drug action, inflammation, acute stress response)

Delirium: Think rapid onset, inattention, clouding of consciousness (bewildered), fluctuation

Dementia: Think gradual onset, intellectual impairment, memory disturbance, personality/mood change, no conscious clouding

HyperactivePatient may be combative with agitation that may

require sedation (is diagnosed more frequently).

Subtypes of Delirium

HypoactivePatient may be quiet and even peaceful, despite

cognitive impairment. More difficult to assess.

MixedCombination of both types

Why monitor for Delirium?

• 50-80% of ventilated patients develop delirium• 20-50% of lower severity ICU patients develop

delirium• Over 40,000 ventilated patients are delirious

every day• Delirium leads to increased mortality, longer

hospital stay, poorer recovery, higher costs of healthcare, long-term neurocognitive problems.

Ely EW JAMA 2001;286,2703-2710Ely EW CCM 2001;29,1370-79

ICU Delirium: The Canary in the Coal Mine

Under recognized form of organ dysfunction

3-fold increase in mortality at 6 months

Each DAY a patients is delirious = 10% INCREASE in risk of death

Delirium in the ICUClinical Value of RASS/CAM-ICU Measurement

Stimulates thinking of Rx:

– Delirium recognition is a Burglar Alarm for us (early sign of danger)

– Forces us to consider treatable causes earlier– Utilize nonpharmacologic interventions– Do NOT automatically link delirium monitoring with

a specific drug treatment

www.ICUdelirium.org

Educational Delirium Website

A Two Step Approach to Assessing Consciousness

Step 1 Level of Consciousness (arousal): RASS

Step 2 Content of Consciousness (delirium): CAM-ICU

Step 1: LOC Assessment

Assess for arousal

Step 1: Arousal Assessment (RASS)

+3

+2

+1

0

- 1

- 2

- 3

- 4

- 5

Richmond Agitation-Sedation Scale (RASS)

Step 2: Content Assessment

Assess for Delirium

Confusion Assessment Method for the ICU (CAM-ICU)

Feature 1: Acute change or fluctuating course of mental

status

And

Feature 2: Inattention

And

Feature 3: Altered level of consciousness

Feature 4: Disorganized Thinking

Or

Inouye, et. al. Ann Intern Med 1990; 113:941-948.1Ely, et. al. CCM 2001; 29:1370-1379.4Ely, et. al. JAMA 2001; 286:2703-2710.5

Feature 1: Alteration/Fluctuation in Mental Status

Is the pt different than his/her baseline mental status?

OR

Has the patient had any fluctuation in mental status in the past 24 hours (eg fluctuating RASS, GCS, previous delirium assessments, etc)

Present: If either question is YES.

Feature 1: Alteration/Fluctuation in Mental Status

Common Questions: • What if you do not know the patient’s baseline?

– Assume normal unless you have red flags that make you suspicious

– Red Flag: patient came from institution• What about dementia?

– Ask family “What could she/he do prior to this illness?”

Feature 2: Inattention

Screening for Attention– two options

Letter “A” test Letters: S A V E A H A A R T (or numbers)Say 10 letters (or numbers) and instruct the patient to

squeeze on the letter “A” (or on a certain number) PicturesSimilar test with pictures (instructions are in picture packets)

Feature 2: Inattention

1. Attempt Letters first.

2. If pt is able to perform the Letter test you are sure of the results, you are done with Inattention test.

3. If pt is unable to perform the Letter test or you are unsure of the results, use the Pictures.

If you perform both tests, use the Pictures result to determine if inattention is present.

Inattention Present : If >2 errors

Feature 2: Inattention

• What if the patient only squeezes once and then falls back to “sleep”? or What if the patient is too hyperactive/combative to participate in squeezing?– Remember what you are assessing—Attention – This patient is inattentive

• If you have to explain the directions more than twice, start to be suspicious for inattention

If either Feature 1 or 2 are absent,

Stop

Overall CAM-ICU is Negative

If Features 1 and 2 are present,

Proceed

to Feature 3

Feature 3: Alt Level of Consciousness

Any LOC other than Alert.

Present: If the Actual RASS score is anything other than “0” (zero).

You have already done this assessment. It was the first thing you did when you

walked in the room!

Feature 4: Disorganized Thinking

Yes/No Questions (Use either Set A or Set B) :

Set A Set B

1. Will a stone float on water? 1. Will a leaf float on water?2. Are there fish in the sea? 2. Are there elephants in the sea?3. Does one pound weigh more than 3. Do two pounds weigh two pounds? more than one pound?

4. Can you use a hammer to pound a nail? 4. Can you use a hammer to cut wood?

Note: Use whatever form of communication that works (nodding, hand squeezing, blinking, etc).

Feature 4: Disorganized Thinking

Command

Say to patient: “Hold up this many fingers” (Examiner holds two fingers in front of patient) “Now do the same thing with the other hand” (Not repeating the number of fingers).

• Patient gets credit only if able to successfully complete the entire command

Feature 4: Disorganized Thinking

Present: If there is >1 error for the combined questions + command.

• Notes: – If pt is unable to move both arms, for the second

part of the command ask patient “Add one more finger”.

– If patient is unable to move arms at all (quadriplegic), then feature 4 is present if patient misses more than 1 question.

Confusion Assessment Method for the ICU (CAM-ICU)

Feature 1: Acute change or fluctuating course of mental

status

And

Feature 2: Inattention

And

Feature 3: Altered level of consciousness

Feature 4: Disorganized Thinking

Or

Inouye, et. al. Ann Intern Med 1990; 113:941-948.1Ely, et. al. CCM 2001; 29:1370-1379.4Ely, et. al. JAMA 2001; 286:2703-2710.5

Case Studies

Case #1: Mr. Icy

45 y/o man, lawyer with no previous memory or attention problem

Dx: DKA, IntubatedIn the past 24hrs the RASS scores have been -3 to +1. Step 1: Arousal AssessmentCurrently: Awake and moving around restless in bed, but

not aggressive. RASS = +1

What do we do next?

Step 2: CAM-ICU

- Feature 1:

Is he at his MS baseline?

Fluctuation?

- Feature 2:

Letters = 4 errors

- Feature 3:

RASS = +1

- Feature 4

Pos Neg

Feature 1

Feature 2

Feature 3

Feature 4

Case #1: Mr. Icy

Step 2: CAM-ICU

- Feature 1:

Is he at his MS baseline?

Fluctuation?

Other RASS Scores: -3 +1

- Feature 2:

Letters = 4 errors

- Feature 3:

RASS = +1

- Feature 4

Pos Neg

Feature 1

X

Feature 2

X

Feature 3

X

Feature 4

Is this patient

delirious??

Case #1: Mr. Icy

Case #2 Mrs. Dapple75 y/o femaleDx: Severe pneumonia requiring prolonged mechanical

ventilation and difficulty weaningIn past 24 hours: RASS scores -3 to -1

Step 1: Arousal AssessmentEyes closed, but awakens to voice; maintains eye contact for

>10 secondsRASS = -1

What do we do next?

Step 2: CAM-ICU- Feature 1:

Is she at her MS baseline?

Fluctuation?

- Feature 2:

Letters = 1 error

- Feature 3

- Feature 4

Pos Neg

Feature 1

Feature 2

Feature 3

Feature 4

Case #2 Mrs. Dapple

Step 2: CAM-ICU- Feature 1:

Is he at his MS baseline?

Fluctuation?

RASS Variance: 2

- Feature 2:

Letters = 1 error

- Feature 3

- Feature 4

Pos Neg

Feature 1

X

Feature 2

X

Feature 3

Feature 4

Is this patient

delirious??

Case #2 Mrs. Dapple

Case # 3 Miss Universe

Miss Universe was successfully extubated from the Vent at 0800. All sedation and analgesia had been stopped earlier in the AM. Yesterday evening and last night she had periods of agitation with a documented RASS range of -1 to +3.

Step 1: Arousal Assessment Pt alert and calm. RASS = 0

What do we do next?

Step 2: CAM-ICU

- Feature 1:

Is she at her MS baseline?

Fluctuation?

- Feature 2:

Letters = 3 errors, but you aren’t sure

Pictures = 4 errors

- Feature 3:

RASS = 0

- Feature 4

Pos Neg

Feature 1

Feature 2

Feature 3

Feature 4

Case #3: Miss Universe

Step 2: CAM-ICU

- Feature 1: Is she at her MS baseline? Fluctuation? RASS Variance = 4- Feature 2: Letters = 3 errors, but you

aren’t sure. Pictures = 4 errors- Feature 3: RASS = 0- Feature 4

Pos Neg

Feature 1

X

Feature 2

X

Feature 3

X

Feature 4

Case #3: Miss Universe

Do you need to

do Feature 4??

Step 2: CAM-ICU

- Feature 1: Is she at her MS baseline? Fluctuation?- Feature 2: Letters = 3 errors, but you aren’t

sure. Pictures = 4 errors- Feature 3: RASS = 0- Feature 4: Answered half the questions wrong Unable to perform 2-step command 3 errors

Pos Neg

Feature 1

Feature 2

Feature 3

Feature 4

Case #3: Miss Universe

Step 2: CAM-ICU

- Feature 1: Is she at her MS baseline? Fluctuation?- Feature 2: Letters = 3 errors, but you aren’t

sure. Pictures = 4 errors- Feature 3: RASS = 0- Feature 4: Answered half the questions wrong Unable to perform 2-step command 3 errors

Pos Neg

Feature 1

X

Feature 2

X

Feature 3

X

Feature 4

X

Case #3: Miss Universe

Is this patient

delirious??

What if Miss Universe had gotten all 4 of her

questions right?

Step 2: CAM-ICU

- Feature 1: Is she at her MS baseline? Fluctuation?- Feature 2: Letters = 3 errors, but you aren’t

sure. Pictures = 4 errors- Feature 3: RASS = 0- Feature 4: Answered all 4 questions correct Unable to perform 2-step command 1 error

Pos Neg

Feature 1

X

Feature 2

X

Feature 3

X

Feature 4

X

Case #3: Miss Universe

Is this patient

delirious??

Case # 4 Mr. Bubble

Mr. Bubble works as a traveling salesman, and has been fully independent until admission. He is admitted with acute pancreatitis. His sedatives were turned off 30 minutes ago for a Spontaneous Awakening Trial (SAT).

Step 1: Arousal Assessment Eyes closed, moves head to verbal stimulation, no eye

contactRASS = -3

What do we do next?

Step 2: CAM-ICU

- Feature 1: Is he at his MS baseline? Fluctuation?- Feature 2: Letters= no squeeze for any letters - Feature 3: RASS = -3- Feature 4:

Pos Neg

Feature 1

Feature 2

Feature 3

Feature 4

Case #4: Mr. Bubble

Step 2: CAM-ICU

- Feature 1: Is he at his MS baseline? Fluctuation?- Feature 2: Letters= no squeeze for any letters - Feature 3: RASS = -3- Feature 4:

Pos Neg

Feature 1

X

Feature 2

X

Feature 3

X

Feature 4

Case #4: Mr. Bubble

Is this patient

delirious??

Confusion Assessment Method for the ICU (CAM-ICU)

Feature 1: Acute change or fluctuating course of mental

status

And

Feature 2: Inattention

And

Feature 3: Altered level of consciousness

Feature 4: Disorganized Thinking

Or

Inouye, et. al. Ann Intern Med 1990; 113:941-948.1Ely, et. al. CCM 2001; 29:1370-1379.4Ely, et. al. JAMA 2001; 286:2703-2710.5

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

Nonpharmacologic Interventions

• Environmental changes (e.g. noise reduction)

• Sensory aids (e.g. hearing aids, glasses)• Reorientation and stimulation• Sleep preservation & enhancement• Exercise and mobility

RASS (N/D & reason if not done)

CAM-ICU Feature 1(MS change or fluctuation)

Absent Present

CAM-ICU Feature 2(Inattention)

Absent Present

CAM-ICU Feature 3(Altered LOC)

Absent Present

CAM-ICU Feature 4(Disorganized thinking)

Absent Present

Overall CAM-ICU1 + 2 + [3 or 4] = CAM-ICU+

Negative Positive UTA (RASS -4/-5 only) Not done: ________

Brain Road Map for Rounds(Script for Interdisciplinary Communication)

Skipping any of these steps could leave the clinical team wanting more information!

Investigate (Ask these questions) Report (only takes 10 seconds)

Where is the patient going? Target sedation score (RASS, SAS, etc)

Where is the patient now?Actual sedation score (RASS, SAS, etc)Delirium assessment (CAM-ICU, ICDSC, etc)

How did they get there? Drug exposures

Case Study - Day 1Female, age 61

Hx: hypertension

CC: altered mental status, pneumonia

Dx: Septic shock, ARDS, acute renal failure

Vent settings: A/C rate 16, TV 400, PEEP 14, FiO2 70%

Infusions: Levophed 8 mcg/min, vasopressin 0.4 units/min, insulin gtt, IVF

Assessment: Target RASS -3, actual RASS +1 to +2, displaying vent asynchrony, CAM-ICU positive, bilateral rhonchi, pulses present

Drugs: Receiving intermittent boluses of fentanyl and midazolam

What next?

Review your Road MapReport:

Action:What do you do now?

Where is the patient going? Target sedation score: RASS -3

Where is the patient now?Actual sedation score: RASS +1 to +2Delirium: CAM-ICU positive

How did they get there? Drug exposures: Intermittent fentanyl & midazolam

Case Study – Day 3

Vent settings: AC rate 16, TV 400, PEEP 6, FiO2 40%

Infusions: propofol 40 mcg/kg/hr, Levophed 4 mcg/min, vasopressin 0.4 units/min, insulin gtt, IVF

Drugs: Intermittent fentanyl for analgesia

Assessment: Target RASS -1, actual RASS -3, CAM-ICU positive, not breathing over vent set rate, bilateral rhonchi, pulses present, moving extremities spontaneously

What next?

Review your Road MapReport:

Action:What do you do now?

Where is the patient going? Target sedation score: RASS -1

Where is the patient now?Actual sedation score: RASS -3Delirium: CAM-ICU positive

How did they get there?Drug exposures: Propofol infusion 40 mcg/kg/min & intermittent fentanyl for pain

Case Study – Day 5Vent settings: Pressure support 5, PEEP 5, 40% and tolerating spontaneous breathing trial

Infusions: Levophed/vasopressin off, insulin gtt, IVF, propofol off

Septic shock resolved, passed SAT/SBT

Assessment: Target RASS 0, actual RASS 0, CAM-ICU positive, lungs clear, moves all extremities

What next?

Review your Road MapReport:

Action:What do you do now?

Where is the patient going? Target sedation score: RASS 0

Where is the patient now?Actual sedation score: RASS 0Delirium: CAM-ICU positive

How did they get there? Drug exposures: No sedatives/analgesics in the past 24h

Questions?

www.ICUdelirium.org

delirium@vanderbilt.edu