delirium - emcrit project•lp •low yield for icu-onset delirium •consider if specific risk...
TRANSCRIPT
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deliriumJosh Farkas MD MSTwitter: @PulmCrit
Blog: www.PulmCrit.orgBook: www.EMCrit.org/IBCC/TOC
Division of Pulmonary & Critical Care MedicineUniversity of Vermont Medical Center
definition
• acute diffuse brain dysfunction
typology epidemiology
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why do we care? causes• CNS catastrophe (CVA, meningitis, seizure)• Medications
• Benzodiazepines, muscle relaxants• Antihistamines• Opioids• Zolpidem • Steroid
• Withdrawal• Metabolic abnormality
• Hypoglycemia• Hypernatremia• Hypercalcemia
• Organ failure• Hepatic encephalopathy• Uremia• Shock• Severe hypercapnia
• Sleep deprivation• Noise• Examinations, lab draws• Uncontrolled pain
Pandharipande 2006 PMID 1639485
evaluation?
Give 10 mg of Haldol and call me in the morning.
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causes• CNS catastrophe (CVA, meningitis, seizure)• Medications
• Benzodiazepines, muscle relaxants• Antihistamines• Opioids• Zolpidem • Steroid
• Withdrawal• Metabolic abnormality
• Hypoglycemia• Hypernatremia• Hypercalcemia
• Organ failure• Hepatic encephalopathy• Uremia• Shock• Severe hypercapnia
• Sleep deprivation• Noise• Examinations, lab draws• Uncontrolled pain
• CNS catastrophe (CVA, meningitis, seizure)• Medications
• Benzodiazepines, muscle relaxants• Antihistamines• Opioids• Zolpidem • Steroid
• Withdrawal• Metabolic abnormality
• Hypoglycemia• Hypernatremia• Hypercalcemia
• Organ failure• Hepatic encephalopathy• Uremia• Shock• Severe hypercapnia
• Sleep deprivation• Noise• Examinations, lab draws• Uncontrolled pain
• Exam• Signs of shock/organ failure?• Focal neuro signs?
• Labs• Fingerstick glucose• Chemistries• ABG/VBG if hypercapnia suspected• Pertinent drug levels (e.g. digoxin, lithium, phenytoin)
• Infectious workup if sepsis suspected• Neuroimaging if…
• Focal signs • CNS trauma• Anticoagulation• Major unexplained change from baseline
• LP• Low yield for ICU-onset delirium• Consider if specific risk factor
• EEG if…• Seizure history• Facial twitching/automatisms• Nystagmoid eye movements
early surveillance vs preventionprevention
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prevention #1: poisonous meds
• benzodiazepines• fluoroquinolones• zolpidem et al.• anticholinergics (diphenhydramine)
opioids & delirium
•Good: titrated to pain
•Bad: calm-down juice
prevention #2: pain strategy
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prevention #3: sleep quality prevention #4: melatonin
OK organs, lights out, it’s time to go to sleep!
-Shilo L et al. 1999 PMID 10334113
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dosage?
• Most patients: 3 mg QHS• Agitated delirium: 6 mg QHS
prevention #5: insomnia plan
Give 10 mg of Haldol and call me in the morning.
insomnia pitfalls
• deleriogenic medications
• delayed therapy
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insomnia pitfalls
• deleriogenic medications
• delayed therapy
insomnia solutions
• nondeleriogenic medications• Quetiapine 25-50 mg• Tradozone 50 mh
• pro-active therapy
prevention #6
• Early mobility• Physical therapy• Daytime stimulation
treatment
• #1 = double down • poisonous meds• pain strategy• sleep quality• melatonin• insomnia plan• mobility, daytime stimulation
treatment
• #2 = treat ALL contributory factors
• CNS catastrophe (CVA, meningitis, seizure)• Medications
• Benzodiazepines, muscle relaxants• Antihistamines• Opioids• Zolpidem • Steroid
• Withdrawal• Metabolic abnormality
• Hypoglycemia• Hypernatremia• Hypercalcemia
• Organ failure• Hepatic encephalopathy• Uremia• Shock• Severe hypercapnia
• Sleep deprivation• Noise• Examinations, lab draws• Uncontrolled pain
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treatment #3
• “antipsychotics”• Sleep disturbance• Dangerous agitation
antipsychotic non-deliriogenic sedatives
• role• Control symptoms• Facilitate sleep
•Avoid deleriogenic sedatives
commonly used antipsychotics
Haloperidol(HALDOL)
Quetiapine(SEROQUEL)
Olanzapine(ZYPREXA)
Route IV preferred
IM possiblePO discouraged
PO only
Rapidly absorbed (within 1 hr)
PO (slowly absorbed)
IV, IMOral disintegrating tablet (ODT)
Half-life ~22 hours ~7 hours ~30 hours
Major advantages Most titratable agent.
Immediately available in most units.
- Shorter half-life makes this a reasonable
drug for insomnia.- High ceiling (800 mg/d)
- No risk of Torsades de Pointes.
Disadvantages Extrapyramidal symptoms
Tardive dyskinesia
PO only Low dose ceiling (30 mg)
Effect on QTc / Torsades Highest Low No risk
Dose - Start with 2-5 mg IV
- Wait 20 min before re-dosing.- If no response to cumulative dose of 10-20 mg try different drug class.
- Insomnia: 25-50 mg QHS
- Vented patients: 50 BID (max 800/d)- Asymmetric dosing to preserve sleep
- Twice strength of haloperidol.
- Delirium in ventilated patient: 5-20 mg QHS
Major roles - Acutely agitated patient.
- Test dose
- Insomnia
- Agitation/delirium on ventilator
-Agitation/delirium on ventilator
-Acutely agitated patient.- Patient with prolonged QTc.
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Lies, all lies
treatment #4
• Refractory agitation?• Severe sundowning?
key points• common & problematic• delirium-preventative measures for ALL patients • poisonous meds• pain strategy• sleep quality• melatonin• insomnia plan• early mobility
• if delirium occurs:• evaluate & treat all causes• symptom control with antipsychotics• ? nocturnal dexmedetomidine
More insanity:Blog: www.PulmCrit.orgiBook: www.emcrit.org/IBCC