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ICU DELIRIUM T homas Tobinson , MD Associate Professor, Surgery August 5th, 2009

ICU DELIRIUM T homas Tobinson , MD Associate Professor, Surgery August 5th, 2009. AGS. WHO CARES ABOUT THE BRAIN?. WHY IS DELIRIUM IMPORTANT?. Most common postoperative complication in the elderly. Closely related to adverse outcomes. DELIRIUM.

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ICU DELIRIUM T homas Tobinson , MD Associate Professor, Surgery August 5th, 2009

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  1. ICU DELIRIUMThomas Tobinson, MDAssociate Professor, SurgeryAugust 5th, 2009 AGS

  2. WHO CARES ABOUT THE BRAIN?

  3. WHY IS DELIRIUM IMPORTANT? Most common postoperative complication in the elderly Closely related to adverse outcomes DELIRIUM Potentially preventable, and there is room to improve treatment

  4. WHAT IS DELIRIUM? Delirium is an acute, fluctuating change in mental status, with inattention and altered levels of consciousness CurrOpinCrit Care (2005) 11:360.

  5. DIAGNOSTIC CRITERIA FOR DELIRIUM • Coexisting physiologic disturbance • Acute onset • Disturbance of consciousness • Change in cognition Diagnostic and Statistical Manual of Mental Disorders DSM IV - Fourth Edition (1994).

  6. MULTIFACTORIAL MODEL OF DELIRIUM Predisposing Factors/ Vulnerability Precipitating Factors/ Insults JAMA (1996) 275:852.

  7. MULTIFACTORIAL MODEL OF DELIRIUM Predisposing Factors/ Vulnerability Precipitating Factors/ Insults High Risk DELIRIUM Low Risk JAMA (1996) 275:852.

  8. MULTIFACTORIAL MODEL OF DELIRIUM Predisposing Factors/ Vulnerability Precipitating Factors/ Insults High Risk High Vulnerability Noxious Insult DELIRIUM Low Risk Low Vulnerability Less Noxious Insult JAMA (1996) 275:852.

  9. MULTIFACTORIAL MODEL OF DELIRIUM Predisposing Factors/ Vulnerability Precipitating Factors/ Insults High Risk High Vulnerability Noxious Insult DELIRIUM Low Risk Low Vulnerability Less Noxious Insult JAMA (1996) 275:852.

  10. INCIDENCE OF DELIRIUM 1. Int Psych (2002) 14:301. 2. NEJM(1999) 340:669. 3. Gen Hosp Psych (2002) 24:28. 4. JAGS (2002) 50:850. 5. Ann Surg (2009) 249:173. 6. Am J Surg (2008) 196:864. 7. JAGS (2006) 54:479.

  11. MULTIFACTORIAL MODEL OF DELIRIUM Predisposing Factors/ Vulnerability Precipitating Factors/ Insults High Risk High Vulnerability Noxious Insult DELIRIUM Low Risk Low Vulnerability Less Noxious Insult JAMA (1996) 275:852.

  12. RISK FACTORSFOR DELIRIUM AFTER TRAUMA TRAUMA TIMELINE Pre-existing Patient Factors Injury- specific Factors Emergency Room Findings Operative Variables ICU Variables

  13. PREEXISTING RISK FACTORS Am J Surg (2008) 196:864.

  14. RISK FACTORSFOR DELIRIUM AFTER TRAUMA TRAUMA TIMELINE Pre-existing Patient Factors Injury- specific Factors Emergency Room Findings Operative Variables ICU Variables ↑Age

  15. INJURY-SPECIFIC RISK FACTORS Am J Surg (2008) 196:864.

  16. RISK FACTORS FOR DELIRIUM AFTER TRAUMA TRAUMA TIMELINE Pre-existing Patient Factors Injury- specific Factors Emergency Room Findings Operative Variables ICU Variables ↑Age ↑ISS

  17. EMERGENCY ROOM RISK FACTORS Am J Surg (2008) 196:864.

  18. RISK FACTORS FOR DELIRIUM AFTER TRAUMA TRAUMA TIMELINE Pre-existing Patient Factors Injury- specific Factors Emergency Room Findings Operative Variables ICU Variables ↑Age ↑ISS ↓GCS

  19. OPERATIVE RISK FACTORS Am J Surg (2008) 196:864.

  20. RISK FACTORS FOR DELIRIUM AFTER TRAUMA TRAUMA TIMELINE Pre-existing Patient Factors Injury- specific Factors Emergency Room Findings Operative Variables ICU Variables ↑Age ↑ISS ↑Operations ↑Anesthesia ↓GCS

  21. ICU RISK FACTORS Am J Surg (2008) 196:864.

  22. RISK FACTORS FOR DELIRIUM AFTER TRAUMA TRAUMA TIMELINE Pre-existing Patient Factors Injury- specific Factors Emergency Room Findings Operative Variables ICU Variables ↑Age ↑ISS ↑Operations ↑Anesthesia ↓GCS ↓Hct ↑Transfusion ↑ MOF Score Needed Vent

  23. MULTIFACTORIAL MODEL OF DELIRIUM Predisposing Factors/ Vulnerability Precipitating Factors/ Insults High Risk High Vulnerability Noxious Insult DELIRIUM Low Risk Low Vulnerability Less Noxious Insult JAMA (1996) 275:852.

  24. AGE AND POSTOPERATIVE DELIRIUM 100 80 Incidence of Delirium, % 60 40 20 0 5059 6069 7079 8089 Age, years Ann Surg (2009) 249:173.

  25. PREOPERATIVE RISK FACTORS Ann Surg (2009) 249:173.

  26. INTRAOPERATIVE RISK FACTORS Ann Surg (2009) 249:173.

  27. MULTIFACTORIAL MODEL OF DELIRIUM Predisposing Factors/ Vulnerability Precipitating Factors/ Insults High Risk High Vulnerability Noxious Insult DELIRIUM Low Risk Low Vulnerability Less Noxious Insult JAMA (1996) 275:852.

  28. WHY IS DELIRIUM IMPORTANT? Most common postoperative complication in the elderly Closely related to adverse outcomes DELIRIUM Potentially preventable, and there is room to improve treatment

  29. DELIRIUM AND POOR OUTCOMES • Increased length of hospital stay • Increased hospital cost • Increased need for institutionalization • Increased mortality

  30. OUTCOMES AND DELIRIUM: TRAUMA ICU

  31. OUTCOMES AND DELIRIUM: VA Ann Surg (2009) 249:173.

  32. MORTALITY AND DELIRIUM a n=78 (2 patients lost to 6-month follow-up) Ann Surg (2009) 249:173.

  33. MOTOR SUBTYPES OF DELIRIUM • A spectrum of psychomotor behavior is found in delirium • Delirium motor subtypes: • Hypoactive • Hyperactive • Mixed type J Neuropsychiatry ClinNeurosci(2000) 12:51.

  34. RICHMOND AGITATION-SEDATION SCORE +4 Combative +3 Very agitated +2 Agitated +1 Restless 0 Alert/calm -1 Drowsy -2 Light sedation -3 Moderate sedation -4 Deep sedation -5 Unarousable JAMA (2003) 289:2983. Am J RespCrit Car Med (2002) 166:1228.

  35. MOTOR SUBTYPES OF DELIRIUM +4Combative +3 +2 +1 Restless 0 Alert/calm -1 Drowsy -2 -3 -4 -5 Unarousable HYPERACTIVE HYPOACTIVE JAMA (2003) 289:2983. Am J RespCrit Car Med (2002) 166:1228.

  36. MOTOR SUBTYPES OF DELIRIUM +4 Combative +3 +2 +1 Restless 0 Alert / Calm -1 Drowsy -2 -3 -4 -5 Unarousable MIXED JAMA (2003) 289:2983. Am J RespCrit Car Med (2002) 166:1228.

  37. MOTOR SUBTYPES OF DELIRIUM: INCIDENCE JAGS (2006) 54:479. Ann Surg (2009) 249:173. Am J Surg (2008) 196:864.

  38. MOTOR SUBTYPES OF DELIRIUM: OUTCOMES DVAMC

  39. MOTOR SUBTYPES OF DELIRIUM:ADVERSE EVENTS DVAMC

  40. WHY IS DELIRIUM IMPORTANT? Most common postoperative complication in the elderly Closely related to adverse outcomes DELIRIUM Potentially preventable, and there is room to improve treatment

  41. PREVENTING DELIRIUM IN THE HOSPITALIZED ELDERLY • Hypothesis: Reducing the number of risk factors for delirium will prevent delirium in hospitalized elderly patients • Methods • 852 hospitalized medical patients • Older than 70 years • Compare effectiveness of reducing the risk factors for delirium to standard of care NEJM(1999) 340:669.

  42. MULTICOMPONENT INTERVENTIONSTO PREVENT DELIRIUM NEJM(1999) 340:669.

  43. PREVENTING DELIRIUM IN THE HOSPITALIZED ELDERLY NEJM(1999) 340:669.

  44. PREVENTING DELIRIUM IN THE HOSPITALIZED ELDERLY • Conclusion Implementing supportive protocols to patients at high risk of developing delirium can prevent the occurrences and reduce the duration of delirium NEJM(1999) 340:669.

  45. IDENTIFIABLE CAUSES OF DELIRIUM DELIRIUMS (mnemonic) D E L I R I U M S S rugs (anticholinergics, polypharmacy) motional (depression) ow PO2 states (MI, PE, anemia, CVA) nfection (sepsis) etention of urine or stool ctal states (seizure, post-ictal) ndernutrition/underhydration etabolic (electrolytes, glucose) ubdural (acute CNS processes) ensory (impaired vision or hearing)

  46. MEDICAL EVALUATION OF DELIRIUM H&Pevaluation • Mental status • Neuro exam • History of substance abuse • Vital signs • Review of medications Laboratory tests • CBC • Glucose • Electrolytes • BUN/Cr • UA • O2Saturation ClinMed (2006) 6:303.

  47. IDENTIFIABLE CAUSES OF DELIRIUM 100 80 60 Delirium, % 40 20 0 No identifiable cause Identifiable cause Ann Surg (2009) 249:173.

  48. THE BIPHASIC DISTRIBUTION OF POSTOPERATIVE DELIRIUM 30 No identifiable cause of delirium 25 Delirium due to an identifiable cause Number of subjects 20 15 10 5 0 1 2 3 4 5 6 7 8 9 10 11 12 Postoperativeday Ann Surg (2009) 249:173.

  49. PHARMACOLOGIC TREATMENT: ICU Haloperidol 2 mg q20 min (while agitation persists) OR CritCare Med (2002) 30:119.

  50. PHARMACOLOGIC TREATMENT: ICU • Maintenance dose • 50% of total loading dose is the maintenance dose, divided every 68 hours daily • Continue maintenance dose for 2448 hours before tapering • Tapermaintenance dose by 20%30% daily until off

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