delirium lindsay trantum acnp-bc vumc neuroscience icu
TRANSCRIPT
DELIRIUM
Lindsay Trantum ACNP-BCVUMC Neuroscience ICU
Objectives
• By the end of the presentation……– Identify the key features of delirium– Identify risk factors for delirium– Demonstrate understanding of the treatment plan
for delirium
Delirium = Brain Dysfunction
• Definition: DSM V officially defines delirium as a disturbance of consciousness with inattention accompanied by a change in cognition or perceptual disturbance that develops over a short period of time (hours to days) and fluctuates over time
• “The 6th vital sign”
Subtypes
• Hyperactive– characterized by agitation, restlessness, and
emotional lability
• Hypoactive– decreased responsiveness, withdrawal, and
apathy
• Mixed– Periods of hyperactivity and lethargy
Incidence
• 60%-80% of mechanically ventilated patients• 50%-70% of non-ventilated patients• Hypoactive delirium = 43.5%• Hyperactive delirium = 1.6%• Mixed delirium = 54.1%
(Girard, 2008)
Outcomes
• 3 fold increase in 6 month mortality• 1 in 3 delirium survivors develop permanent
cognitive impairment• Associated with…..– New nursing home placement– Increased length of stay > 8.0 days– Increased mortality– Increased number of days on the ventilator
Outcomes Continued….
• Associated with…….– Depression/PTSD– Increased risk of aspiration– Increased need for re-intubation– Increased hospital cost: national burden $38
billion/year
(Ely, 2004); (Inouye, 1998)
Risk Factors• I WATCH DEATH (many acronyms)– Infection – Withdrawl (Etoh, Sedatives)– Acute Metabolic (renal/liver failure, electrolytes, etc)– Trauma– CNS Pathology– Hypoxia– Deficiencies (B12, thiamine, folate, niacin)– Endocrine (hyper/hypo)– Acute vascular– Toxins– Heavy metals
Pathophysiology
• Multi-factorial and poorly understood• Neurotransmitter imbalance– Dopamine (excess) & acetlycholine (depleation)– Results in neuroexcitability and unpredictable
synapses– GABA, serotonin, endorphins and glutamate
Pathophysiology
• Inflammation– Inflammatory mediators cross blood-brain barrier
and increase vascular permeability– Result = decrease cerebral blood flow (CBF)• Platelets, fibrin, neutrophils obstruct CBF
(Gunther, 2008)
Wake Up and Breathe
• Awakening and Breathing Coordination– Spontaneous Awakening Trial – Spontaneous Breathing Trial
• Choice of Sedation• Delirium Monitoring• Early Mobility and Exercise– Passive Range of Motion to Ambulation
• Family(Girard, 2008)
Monitoring
• Step 1: RASS= Richmond Agitation Sedation Scale– RASS goal– Actual RASS– Minimize Sedation
• Step 2: CAM-ICU = Confusion Assessment Method– Takes approximately 1 minute– Sensitivity/Specificity 95%
Targets 4 Key FeaturesTargets 4 Key FeaturesFeature 1: Acute onset of mental
status changes, or Fluctuating course.
Feature 2: Inattention
AND
AND
Feature 3: Disorganised thinking
Feature 4: Altered level of consciousness
OR
CAM-ICU Worksheet
CAM-ICU Video
• http://www.youtube.com/watch?v=1hSDNOVHMVs
Special Population: Neurologically Impaired
• CAM-ICU has been validated in post-stroke patients
• Should be considered an aid in delirium diagnosis
• Look for non-verbal indicators– Fidgeting, signs of hallucination, waxing and
waning mental status(Mitasova, A., 2012)
Management of Delirium
• Environmental– Early mobility– Maintaining a day/night cycle
• Minimize light/noise• Promoting sleep at night
– Assessing for extubation– Daily sedation interruption– Correct hearing/visual deficits
• Hearing aids• Glasses/magnifying glasses
Management of Delirium
• Pharmacologic Options (intubated)– Sedation choices• Pain relief?–Morphine, fentanyl, hydromorphone
• Sedation?– Dexamedatomidine» Not for patients that need RASS -2 or greater
– Propofol– Avoid benzodiazepines except in ETOH withdrawl
Management of Delirium
• Pharmacologic Options (non-intubated)– Antipsychotics• Haldol 2.5-10mg q2h prn–Monitor daily EKG
• Add Quetiapine 25mg BID and titrate by 25mg q12h• Olanzipine• Dexamedatomidine
– Benzodiazepines• Don’t use unless managing ETOH withdrawl
Delirium Timeline
• Usually seen within the first 24 to 48 hrs• Can last as long as 2 weeks or longer– Be patient
Long-Term Outcomes
• >12 months post-ICU admission (800 pts)– 1/3 Cognitive impairment similar to a moderate
TBI– 1/4 Cognitive impairment similar to mild
Alzheimer’s
(Pandharipande, 2013)
Questions????
Resources
Icudelirium.orgSurgicalcriticalcare.net
Delirium Review Article
References• Girard, Timothy; Pandharipande, Pratik; Ely, Wesley; (2008). Delirium in
the Intensive Care Unit.; Critical Care. 12 (Suppl 3); S3• Gunther, Max, L.; Morandi, Alessandro; Ely, Wesley; (2008)
Pathophysiology of Delirium in the ICU. Critical Care Clinics. 24: 45-6• Inouye, S. et al. (1998). Does delirium contribute to poor hospital
outcomes? A three-site epidemiological study. Journal of General Internal Medicine. 13(4): 234-42.
• Ely, EW et al. (2004). Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA. 14; 291 (14): 1753-62.
• Barr, J. et al. (2013). Clinical Practice Guidelines for the Management of Pain, Agitation and Delirium in Adult Patients in the Intensive Care Unit. Critical Care Medicine. Jan 41(1): 263-306.
• Cheatham, M.D. (Jan 4, 2011); Delirium Management Guidelines. Retrieved from http://www.surgicalcriticalcare.net/Guidelines/delirium_2011.pdf
References
• Girard, et. al (2008) Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised control trial. Lancet: Jan 12;371(9607):126-34
• Pandharipande, PP et al (2013). Long-term cognitive impairment in critical illness. New England Journal of Medicine. Oct 3: 369 (14) 1306-16
• Mitasova, A. et al (2012). Poststroke delirium incidence and outcomes: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Critical Care Medicine. Feb;40(2):484-90.