DELIRIUM

1. DELIRIUM Lindsay Trantum ACNP-BC VUMC Neuroscience ICU

2. 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

3. 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”

4. Subtypes • Hyperactive • characterized by agitation, restlessness, and emotional lability • Hypoactive • decreased responsiveness, withdrawal, and apathy • Mixed • Periods of hyperactivity and lethargy

5. 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)

6. 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

7. 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)

8. 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

9. Pathophysiology • Multi-factorial and poorly understood • Neurotransmitter imbalance • Dopamine (excess) & acetlycholine (depleation) • Results in neuroexcitability and unpredictable synapses • GABA, serotonin, endorphins and glutamate

10. 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)

11. 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)

12. 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%

13. Targets 4 Key Features Feature 1: Acute onset of mental status changes, or Fluctuating course. AND Feature 2: Inattention AND Feature 3: Disorganised thinking OR Feature 4: Altered level of consciousness

14. CAM-ICU Worksheet

15. CAM-ICU Video • http://www.youtube.com/watch?v=1hSDNOVHMVs

16. 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)

17. 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

18. 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

19. 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

20. Delirium Timeline • Usually seen within the first 24 to 48 hrs • Can last as long as 2 weeks or longer • Be patient

21. 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)

22. Questions????

23. Resources Icudelirium.org Surgicalcriticalcare.net

24. Delirium Review Article

25. 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

26. 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.