Delirium in the ICU PamelaL.Smithburger,PharmD,MS,BCPS,BCCCP,FCCP

AssociateProfessor,UniversityofPi@sburghSchoolofPharmacy

Pa2ent Case

•  JJis75Yomaleadmi@edtotheMICUon12/10withacuteSOB• Caresforillwifeathome,drives,managesfinances,volunteerswithMealsonWheels

• RVP+InfluenzaA•  Sputum+MRSA•  Intubated12/116am

Pa2ent Case •  PMH

•  HTN–Lisinopril20mgdaily•  Diabetes-Dietcontrolled•  Lowerbackpain-Oxycodone5mgpoq6hrPRNPain(usuallytakes1tabletatbed_memostnights)

•  12/11Medica_onlist•  Scheduledmedica_ons

•  Chlorhexidine•  Famo_dine20mgBIDGastricTube•  Heparin5000unitssubqQ8H•  Vancomycin1.5gmIVq24hr•  Oseltamivir75mgBIDGastricTube

•  PRNMedica_ons•  Fentanyl50mcgIVQ1HRprnRiker4•  Midazolam2mgIVQ2HRprnAGITATION,TargetRiker4•  Fentanyl50mcgIVq5minPRNBreakthroughpain(max3dosesin1hr)•  Midazolam1mgivq5MINPRNbreakthroughagita_on(max3dosesIN1HR)

Pa2ent case

•  12/11afernoon•  Youarriveatthebedsideandthenursereportsthatthepa_enthasnotbeendirectablewithano_ceablechangeinmentalstatus

• Whatshouldyouconsider?

What is going on?

1.  Hypercapnia?Nope,arterialbloodgas:7.35/40/25/80

2.  Overseda_onwithPRNs?Isthemidazolamdosetoohigh?Isitbeingusedtoofrequently?•  NoPRNsweregiven

3.Delirium?

Delirium Assessment 1.  Assesslevelofarousal

Rikerscore?AsknursewhathasleadthemtogivetheRikerscoresthattheygaveMustbeaRiker>2tocon_nuewithdeliriumassessment.If<2,furtherassesswhy.

2.Isthepa_entinPain?CCPOT(seehandout)CCPOTPosi_ve(score>2)TreatpainReassessCCPOT.Didscoredecrease?S_llnotdirectable

3.DeliriumAssessmentCAM-ICU(seehandout) CAM-ICUnega_veICDSC(seehandout) ThebedsidenursecompletedanICDSC

CAM-ICU

• Handout• Nega_ve

ICDSC

Score5

•  Date/Time

Score1

Score1

Score1

Score0

Score0

Score0

Score1

Score1

Score5

•  Consider Riker score over the entire shift •  Pt. Riker = 3

ICDSC: Level of Consciousness

LOC

Noscore=Noresponse(Riker=1);reassessin4hrs

Noscore=Responsetointenseandrepeateds_mula_on(loudvoiceandpain)(Riker=2);reassessin4hrs

1=Responsetomildormoderates_mula_on(Riker=3)

0=Normalwakefulness(Riker=4)

1=Exaggeratedresponsetonormals_mula_on(Riker>4)

•  Score1foranyofthefollowingabnormali_es: A.Doesnotfollowcommands(i.e.,wiggletoes) B.Easilydistractedbyexternals_muli C.Difficultyinshifingfocus

v  Doesthepa_entfollowyouwiththeireyeswhenyoumovetotheoppositesideofthebed?

ICDSC: Inattention

Ina/en0on

0=Notpresent

1=Doesnotfollowcommandsand/oreasilydistractedand/ordoesnotfollowwitheyes

•  Score1foranyobviousmistakeinplaceand/orperson

ICDSC: Disorientation

Disorienta0on

0=Notpresent

1=Doesnotrecognizepreviouscaregiversand/orloca_on

Example: Does the patient know they are in the hospital and not elsewhere (i.e. at home)?

•  Score1foranyofthefollowingabnormali_es:•  Evidenceofhallucina_onsorbehaviorduetoahallucina_on•  Delusionsorgrossimpairmentofreality

§  Falsebeliefthatisfixedorunchanging

ICDSC: Hallucinations/delusions

Hallucina0ons/delusions

0=Notpresent

1=Exhibitsbehaviorconsistentwithhallucina_ons/delusionsand/orgrossimpairmentinrealitytes_ng

•  Score1foranyofthefollowingabnormali_es:•  Hyperac_vity(i.e.pullingatendotrachialtubeorlines)•  Hypoactivity (noticeable slowing)

•  Adelayedresponsetoques_onsorcommands•  Assessifduetorecentanalgesia/seda_on:Score0insteadof1

• Family members can be a good resource for establishing the patient’s baseline!

ICDSC: Agitation/hypoactive

Agita0on/hypoac0ve

0=Notpresent

1=Hyperac_vityrequiringseda_vesorrestraintstopreventharmtoselforothers

1=Clinicallyno_ceablepsychomotorslowing

•  Score1foranyofthefollowingabnormali_es:•  Inappropriate,disorganized,orincoherentspeech•  Inappropriatemoodrelatedtoeventsorsitua_on(Is the patient

apathetic about the situation?)

ICDSC: Inappropriate speech/mood

Inappropriatespeech/mood

0=Notpresent

1=Inappropriate,disorganized,orincoherentspeech

1=Inappropriatedisplayofemo_onorapathyrelatedtocurrentsitua_on

• Sleep/wake cycle disturbance scoring may need to include information reported from the previous shift.

• Patient awake all night

• Sedation ≠ Sleep • Emerging data on DEX potentially allowing non-REM sleep

ICDSC: Sleep/wake cycle disturbance

Sleep/wakecycledisturbance

0=Notpresent

1=Sleeping<4hoursatnightORwakingfrequently(notduetoloudenvironmentorini_atedbystaff)

1=Sleep4hoursormoreduringtheday

Impact of Sleep on Delirium •  97%of1,223ICUphysiciansandnursesagreedthatpoorsleepintheICUisariskfactorfordeliriuminaglobalsurvey

• PADGuidelines“promo_ngsleepinadultICUpa_entsbyop_mizingpa_ents’environments,usingstrategiestocontrollightandnoise,clusteringpa_entcareac_vi_es,anddecreasings_muliatnighttoprotectpa_ent’ssleepcycles”(+1C)asastrategytomanagepain,agita_on,anddelirium

CritCareMed2013;41:263-6AnnAmThoracSoc2016;13(8):1370-7

Impact of Sleep on Delirium

•  Systema_creviewofICUstudiesinvolvingsleep-promo_nginterven_onstoimprovedelirium

•  6/10studiesdemonstratedreduc_onsinoccurrencerateofICUdelirium•  4studiesusedsleepbundleswhichalsoresultedinimprovementsindelirium

CritCareMed2106;44:2231-40

•  Fluctua_onofanyofthefirst7itemsover24hours(overthecourseofyourshiforfromoneshiftoanother)

ICDSC: Symptom fluctuation

Symptomfluctua0on

0=Notpresent

1=Fluctua_onofthepresenceofanyaboveitemover24hours

Pa2ent Case

• WhythedifferencebetweenCAM-ICUscoresandICDSC??

What to do now?

•  STOPandTHINK

“STOP” • “STOP” unnecessary medications • Review sedatives and streamline if possible

• Use minimal amount of sedative and pain medication necessary • Sedation interruption daily • Use of a targeted pain plan

• Optimize sedation medications • Minimize benzodiazepine use • Utilize dexmedetomidine if appropriate

Malik, A. J Clin Nurs 2016 Pohlman AS. http://s3.proce.com/res/pdf/DeliriumAssessment_monograph.pdf

“THINK” • “THINK” about alternative causes of delirium

•  Toxic Situations •  Dehydration, CHF, shock, new organ failure •  Deliriogenic medication use

•  Examples: •  Anticholinergic medications (Diphenhydramine, promethazine) •  Benzodiazepines •  Narcotics •  Corticosteroids •  Sleep agents (ex. Zolpidem)

•  Hypoxemia •  Infection/Sepsis •  Immobilization •  Neglected Nonpharmacologic interventions (“MORE Protocol” ) •  K+ or electrolyte abnormalities

Malik, A. J Clin Nurs 2016 Pohlman AS. http://s3.proce.com/res/pdf/DeliriumAssessment_monograph.pdf

Delirium Prevention Non-Pharmacologic Protocol

23

Mob

ilityProtoco

l • Ini0atetheProtocol

• Dailyhuddle(PT,RN&RespiratoryTherapist)

• EarlyandRegularAmbula0on M

usicThe

rapy • Playatleast1

hourofrelaxingmusicpershiP

• TurnoffTVifpa0entisunabletoview

Ope

ningand

ClosingBlin

ds

• Openblindsinmorning,closeblindsatnight

• Anglepa0entsinchairstohaveaviewofthewindow

Reorienta0

onand

Cogni0v

eS0

mula0

on

• Askthepa0enthowtheywouldliketobeaddressed

• Reorientpa0enttotheirplanofcareandprogress

• Askcogni0ves0mula0onques0ons:• Whatisyourfavoritesportsteam,movie?Didyouwatchtheirmostrecentone?

Eyean

dEarP

rotocol

• Ifpa0entwearscontactsorglassesandhearingaidsathome,encourageuse

• Inevening,offerthepa0entaneyemaskandearplugstoincreasesleep

Environmental Contributors?

• Didanyoneaskifhewearsglassesorhearingaids?

Family involvement

• Whenasked,hisdaughterdiscloseshehasavery“strong”eyeprescrip_onandcannotseewithouthisglasses

•  Hehasalsobeenwearinghearingaidsforthepast20yearsduetoeardamagefromhisworkintheSteelMill.Shehastoshoutathimforhimtobeabletohearherwithouthishearingaids.

•  Shedidn’teventhinktobringintheeyeglasses.Shewasafraidthehearingaidswouldgetlostsincetheyareveryexpensive.

•  Youencouragehertbringinthehearingaidsandalertnursingleadershipthatthispa_entwillhavehearingaidsbroughtin.

Pharmacologic therapy

An_psycho_csHandout•  LancetRespirMed2013;1:515-23•  IntensiveCareMed.2004;(30):444-9• CritCareMed.2010;38(2):428-37• CritCareMed.2010;38(2):419-27• Pharmacotherapy.2015;35(8):731-39•  JCritCare.2017;41:234-9Receptorhandout

Pa2ent Case

•  YoustartJJonolanzapine20mggastricdaily–buthedoesn’thaveoralaccessrightnow.

• CouldtheZydis(orallydisintegra_ngproduct)beusedandabsordedthroughthemoralmucosa?

• Pa_entgainsoralaccess-medica_ongiven• Hedevelopsrigidityandanincreasedtemperatureto38.9C• NMS

Pa2ent Case Op2on 2

• Pa_entgainsoralaccess•  Insteadofstar_ngolanzapineyouiden_fysleepasanissue,soyoustartQue_apine50mggastricqhs

• BasesupontheDevlin2010study,que_apine50mggastricBIDwasthestar_ngdose.

Pa2ent Case

•  JJimprovesontheque_apine50mggastricqhsandisextubatedon12/13.

• On12/14,JJ’sICDSCscoresarethefollowing:4am:34pm:3

Whatdothesescoresmean?

Subsyndromal delirium

• Ptsthatfallshortofthediagnos_cthresholdfordelirium(ICDSC≥4)•  ICUpa_entswithoutdeliriumcomparedtothosewithsubsyndromaldeliriumweremorelikelytobedischargedhome(p=0.0004)andlesslikelytoneedlong-termcare(p<0.0001)

IntensiveCareMed2007;33:1001-13

Pa2ent Case- Subsyndromal Delirium

•  Increasenon-pharmacologicpreventa_vemeasurestodecreaseICDSCscore