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- 1. New Frontiers in Critical Care: Saving the Injured Brain Leanne Boehm, MSN, RN, ACNS-BC ICU Delirium and Cognitive Impairment Study Group Vanderbilt University Medical Center Nashville, TN USA
- 2. Disclosures Educational grant from Hospira Off label drug use No drug is FDA approved for delirium
- 3. Learning Objectives Define delirium and its subtypes Identify delirium outcomes Discuss risk factors for delirium Identify components of an ‘ABCDE’ interdisciplinary bundle of care for the ICU
- 4. Objectives Define delirium and its subtypes Identify delirium outcomes Discuss risk factors for delirium Identify components of an ‘ABCDE’ interdisciplinary bundle of care for the ICU
- 5. What is delirium? Common clinical syndrome that is characterized by: Inattention Acute cognitive dysfunction Thought to be due to disruption of neurotransmission related to: Drug toxicity Inflammation Acute stress responses
- 6. Prevalence of Delirium in the ICU 60–80% MICU/SICU/TICU ventilated patients develop delirium 20–50% of lower severity ICU patients develop delirium Hypoactive or mixed forms most common Majority goes undiagnosed if routine monitoring is not implemented Ouimet S, et al. Intensive Care Med . 2007;33:66-73 Ely EW, et al. JAMA . 2001;286,2703-2710 Pandharipande PP, et al. J Trauma . 2008;65:34-41 Ely EW, et al. Intensive Care Med . 2001;27:1892-1900. Dubois MJ, et al. Intensive Care Med 2001;27:1297-1304 .
- 7. Objectives Define delirium and its subtypes Identify delirium outcomes Discuss risk factors for delirium Identify components of an ‘ABCDE’ interdisciplinary bundle of care for the ICU
- 8. Sequelae of Delirium After Hospital Discharge During the ICU/Hospital Stay - Increased mortality - 3x greater re-intubation rate - Average 10 additional days in hospital - Higher costs of care - Increased mortality - Long-term cognitive impairment - d/c requirement for chronic care facility - Decreased functional status at 6 months Milbrandt EB, et al. Crit Care Med. 2004;32:955-962. Nelson JE, et al. Arch Intern Med. 2006;166:1993-1999. Ely EW, et al. JAMA. 2004;291:1753-1762. Jackson JC, et al. Neuropsychol Rev. 2004;14(2):87-98.
- 9. Risk of death rises 10% per day 1. Ely EW, JAMA 2004;291:1753-62 2. Pisani M, AJRCCM 2009 Sept 10, After adjusting for covariates, each day spent in delirium was associated with 10% increased risk of death at: 6 months 1 year
- 10. Long-term Cognitive Impairment 50% of ICU survivors will have new dementia-like illness Delirium duration is a risk factor for poorer cognitive function (p=0.05) Hopkins, R. O. & Jackson, J. C. (2009) Clin Chest Med 30:143-153 Jackson, J.C., et al. AJRCC , ahead of print
- 11. Objectives Define delirium and its subtypes Identify delirium outcomes Discuss risk factors for delirium Identify components of an ‘ABCDE’ interdisciplinary bundle of care for the ICU
- 12. Patient Factors Increased age Alcohol use Male gender Living alone Smoking Renal disease Depression Vision/Hearing impaired Environment Admission via ED or through transfer Isolation No clock No daylight No visitors Noise Use of physical restraints Sleep deprivation Predisposing Disease Cardiac disease Cognitive impairment (eg, dementia) Pulmonary disease HIV Acute Illness Length of stay Fever Medicine service Lack of nutrition Hypotension Sepsis Metabolic disorders Tubes/catheters Medications: Anticholinergics Corticosteroids - Benzodiazepines Less Modifiable More Modifiable DELIRIUM Inouye SK, et al. JAMA .1996;275:852. Van Rompaey B, et al. Crit Care 2009;13:R77. Skrobik Y. Crit Care Clin . 2009;25(3):585-591. Devlin J, et al. ICM , 2007; 33:929-940.
- 13. Lorazepam & delirium Pandharipande, P.P., et al. Anesthesiology 2006; 124: 21-26 N= 198 MICU pts What’s the chance of being delirious the next day? Covariates controlled: Age Pre-existing cognitive function Severity of illness Co-morbidities Etc.
- 14. Objectives Define delirium and its subtypes Identify delirium outcomes Discuss risk factors for delirium Identify components of an ‘ABCDE’ interdisciplinary bundle of care for the ICU
- 15. ABCDE interdisciplinary bundle ABC A wakening & B reathing C oordination C hoice of sedative D D elirium ID & management E E arly mobilization
- 16. ABCDE interdisciplinary bundle ABC A wakening & B reathing C oordination C hoice of sedative D D elirium ID & management E E arly mobilization Reduce exposure to sedatives Link spontaneous awakening & breathing trials Optimize sedation choice
- 17. Sedation Protocols: The Evidence
- 18. Setting Targets Aim for Cooperative: Calm & Easily Arousable State while minimizing pain, anxiety, or agitation unless contraindicated Easy transition from sleep to wakefulness 1 Can participate in weaning and physical therapy 1 Perform therapeutic maneuvers Allows for cognitive evaluation Adjust depending on patient need Over the course of Illness/Treatment Initial Intubation vs Stabilization Weaning Phase 1 Bekker AY, et al. Neurosurgery 2005;57(1 Suppl 1):1-10
- 19. Daily Awakening Kress JP, et al. NEJM . 2000;342:1471-1477. 0 20 40 60 80 100 Patients Receiving Mechanical Ventilation (%) 0 30 20 10 15 5 25 Control (n=60) Protocol (n=68) (Adjusted P <.001) Time (Days) Reduced Vent time by 2.5 days
- 20. The ABC Trial (both groups get patient targeted sedation) Control Intervention
- 21. Benzodiazepines Study Day Daily Dose of Benzodiazepines 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 0 10 20 30 40 50 60 70 Usual Care+SBT SBT+SAT
- 22. 0 Days 0 20 40 60 80 100 Patients Discharged from the ICU (%) SAT+SBT (n=167) SBT (n=168) p =.01 Girard TD, et al. Lancet 2008;371:126-34 reduced ICU stay by 4 days 7 14 21 28
- 23. 0 Days 0 20 40 60 80 100 Patients Discharged from the Hospital (%) SAT+SBT (n=167) SBT (n=168) p =.04 Girard TD, et al. Lancet 2008;371:126-34 reduced hospital stay by 4 days 7 14 21 28
- 24. One-Year Survival Patients Alive (%) 0 0 20 40 60 80 100 60 120 180 240 300 360 Days Usual Care+SBT (n=168) SAT+SBT (n=167) p =.01 NNT=7 Girard TD, et al. Lancet 2008;371:126-34
- 25. MENDS trial MICU/SICU Patients Ventilated & Sedated Control Lorazepam (GABA) ± Fentanyl Intervention Dexmedetomidine ( α 2) ± Fentanyl Pandharipande PP, et al. JAMA 2007;298:2644-53
- 26. Incidence of Delirium Pandharipande et al. Crit Care. 2010 Mar 16;14(2):R38
- 27. SEDCOM trial MICU Patients Ventilated & Sedated Control Midazolam (GABA) ± Fentanyl Intervention Dexmedetomidine ( α 2) ± Fentanyl Riker, R., et al. JAMA 2009; 301(5): 489-499
- 28. Incidence of Delirium Riker, R., et al. JAMA 2009; 301(5): 489-499
- 29. What about “No Sedation” Physician consult if patient seemed uncomfortable Haloperidol prn for delirium Morphine prn 2.5 to 5 mg for comfort If still uncomfortable: propofol infusion for 6 hours Transitioned back to prn morphine 3 cycles allowed; if failed, propofol infusion with DIS Strom T, et al. Lancet. 2010;375:475-480.
- 30. Strom et al. Lancet 2010; 375:475-80 Study Outcomes Reduced ICU LOS by 9.7 days (P=0.02)
- 31. ABCDE interdisciplinary bundle D D elirium ID & management E E arly mobilization Monitoring instruments Non pharmacologic management Pharmacologic treatment
- 32. Intensive Care Delirium Screening Checklist 1. Altered level of consciousness 2. Inattention 3. Disorientation 4. Hallucinations 5. Psychomotor agitation or retardation 6. Inappropriate speech 7. Sleep/wake cycle disturbances 8. Symptom fluctuation Bergeron N, et al. Intensive Care Med . 2001;27:859-864. Ouimet S, et al. Intensive Care Med. 2007;33:1007-1013. Score 1 point for each component present during shift Score of 1-3 = Subsyndromal Delirium Score of ≥ 4 = Delirium
- 33. CAM-ICU 1. Acute onset of mental status changes or a fluctuating course and 2. Inattention and or = Delirium Ely et al, CCM 2001;29:1370-79 Ely, E.W., et al . JAMA 2001 ; 286: 2703-2710 3. Disorganized Thinking 4. Altered level of consciousness
- 34. What to THINK if + for delirium T oxic Situations CHF, shock, dehydration Deliriogenic meds (tight titration, sedative choice) New organ failure, e.g, liver, kidney H ypoxemia; also, consider giving H aloperidol or other antipsychotics I nfection/sepsis (nosocomial), I mmobilization N onpharmacological interventions Hearing aids, glasses, reorient, sleep protocols, music, noise control, ambulation K + or Electrolyte problems
- 35. D elirium management Reorientation & cognitive stimulation 1 Hearing aids and/or eye glasses 1 Pain management 1 Sleep preservation Be a “tight titrator” of sedatives to minimize exposure Minimize restraint use 1 Remove catheters (i.e. urinary, central lines) 1 Appropriate sedative choice 1 Inouye, et al. NEJM . 1999;340:669-676.
- 36. Haloperidol vs Olanzapine Unblinded, no placebo MICU/SICU (mostly surgical) N=67 (45 haloperidol & 22 olanzapine) Results: Similar clinical improvement Side effects: Olanzapine--none Haloperidol--EPS Some mismatch in groups at baseline 1st study glimpsing at these 2 drugs & delirium! Skrobik YK , et al ICM 2004;30:444-449
- 37. MIND Pilot Study 0 5 10 15 20 Day Patients without Delirium or Coma (%) 0 20 40 60 80 100 Haloperidol (n=35) Ziprasidone (n=32) Placebo (n=36) Girard, et al. Crit Care Med 2010. 38:428-437
- 38. Quetiapine vs. Placebo (n=36) Randomized, double blind, placebo controlled Haloperidol in both groups Quetiapine dose: 50-200mg q12 hrs Study drug given PO Quetiapine Placebo Devlin, et al. Crit Care Med 2010; 38: 419-427 N=18 N=18 Delirium + Haloperidol PRN
- 39. Quetiapine v. Placebo Devlin, et al. Crit Care Med 2010; 38: 419-427
- 40. ABCDE interdisciplinary bundle ABC A wakening & B reathing C oordination C hoice of sedative D D elirium ID & management E E arly mobilization
- 41. Early Mobilization Trial N=104 mechanically ventilated patients Early exercise & mobilization with PT/OT (n=49) PT & OT decided by primary team (n=55) Primary endpoint : Number of patients returning to independent functional status at hospital discharge Secondary endpoints : Delirium duration Ventilator-free days Schweickert WD, et al. Lancet. 2009;373:1874-1882.
- 42. Schweickert WD, et al. Lancet. 2009;373:1874-1882. 24% improvement (1.7-fold better) return to independent functional status at discharge (NNT=4)
- 43. Milestones Achieved ~3 days earlier* Standing Marching Walking Transferring *P < 0.001 Schweickert WD, et al. Lancet . 2009;373:1874-1882.
- 44. Daily Wake-Up + Early Mobility Schweickert WD, et al. Lancet . 2009;373:1874-1882. Outcome Intervention (n=49) Control (n=50) P Functionally independent at discharge 29 (59%) 19 (35%) .02 ICU delirium (days) 2.0 (0.0-6.0) 4.0 (2.0-7.0) .03 Time in ICU with delirium (%) 33% (0-58) 57% (33-69) .02 Hospital delirium (days) 2.0 (0.0-6.0) 4.0 (2.0-8.0) .02 Hospital days with delirium (%) 28% (26) 41% (27) .01 Barthel Index score at discharge 75 (7.5-95) 55 (0-85) .05 ICU-acquired paresis at discharge 15 (31%) 27 (49%) .09 Ventilator-free days 23.5 (7.4-25.6) 21.1 (0.0-23.8) .05 Length of stay in ICU (days) 5.9 (4.5-13.2) 7.9 (6.1-12.9) .08 Length of stay in hospital (days) 13.5 (8.0-23.1) 12.9 (8.9-19.8) .93 Hospital mortality 9 (18%) 14 (25%) .53
- 45. Important considerations Safety needs Close monitoring Intervention based on progressive stepwise continuum: Readiness Specific disease Strategies to prevent complications Ability to tolerate the activity/movement Emotional needs Continual reassurance necessary Explain and re-explain circumstances Consider having family at bedside Comfort needs Look for signs that analgesia or sedatives are needed
- 46. Keys to success Utilize existing personnel Nurses Respiratory Therapists Pharmacists Physicians Physical & Occupational Therapy Speech Therapy This involves a culture change Team coordination is a MUST Reinforce the goal frequently : Coordination Collaboration Improvement in patient outcomes Daily team work
- 47. Conclusions Delirium is a significant problem for critically ill patients and a predictor of many negative clinical outcomes. Reliable and easy tools are available for identification of delirium in the critically ill. Processes of care are available to minimize incidence of modifiable risk factors. ABCDE can be incorporated into current practices with minimal additional resources. Some operational culture change is involved.
- 48. Educational Delirium Website www.ICUdelirium.org [email_address] [email_address]
Editor's Notes
- #6: An acute brain dysfunction
- #7: Up to 75% of delirium missed if a tool is not used…Most delirium is invisible unless you look for it
- #11: Critical care advances have improved ICU survival rates. ICU survivors can go home with potentially preventable limitations they didn’t have before
- #13: Not a lot of great data to describe which are highly associated with delirium Benzos are a strong association
- #14: Ironically, our primary drug used for sedation is the strongest risk factor for developing delirium. Results: This study found 3 significant risk factors for delirium (age, apache [severity of illness], and benzos) - Lorazepam is an independent risk factor for transitioning to delirium - Risk increases with Lorazepam dose -We tend to focus on benzo b/c it’s the one thing that we can modify in our practice
- #18: Improvements in ventilator days, ICU LOS, success of extubation, hospital LOS, etc
- #19: CONSCIOUS SEDATION (Ability to make cognitive evaluation) A sedation goal or endpoint should be established and regularly redefined for each patient. Regular assessment and response to therapy should be systematically documented. Give examples of Insulin, Pressors and how we titrate to endpoint Grade of recommendation = C The use of a validated sedation assessment scale is recommended. Grade of recommendation = B A sedation goal or endpoint should be established and regularly redefined for each patient. Regular assessment and response to therapy should be systematically documented. Grade of recommendation = C
- #25: >70% cognitive impairment at hosp d/c, 3, & 12 months SAT + SBT group had better cognitive functioning at hosp d/c, 3, & 12 months Duration of delirium was a risk factor for poorer cognitive function (p=0.05)
- #26: Investigator initiated- D-RCT, with the investigators holding the FDA IND
- #28: Sedation with dexmedetomidine in SEDCOM was safe (for up to 28 days, which is different than the currently approved 24-hour period) Max Dose: 1.4mcgs/kg/hr
- #29: Dex also reduces delirium compared Midaz
- #30: Study design: Randomized controlled trial in 18-bed university hospital in Denmark Patients requiring MV >24 hours Patients with high ICP on hypothermia protocol or those actively being weaned were excluded Patients randomized 1:1 Sedation group: Sedation with propofol to achieve Ramsay score of 3-4 Morphine prn for pain and Daily interruption of sedation; restart at half dose After 48 hours of propofol, transitioned to midazolam titrated to Ramsay 3-4 with daily interruption of sedation
- #31: ICU LOS 9.7 days shorter in no sedation group (P=___) Sedation linked with longer LOS (HR 1.86, 95% CI 1.05-3.23) No difference in: Accidental removal of ETT (7 vs 6; P =0.69) CT or MRI brain scans (5 vs 8; P =0.43) VAP (6 vs 7; P =0.85) Reintubation within 24 h (7 vs 11; P =0.37)
- #34: Adapted from the popular CAM the CAM-ICU is a validated instrument available for screening delirium in the ICU population. More than 25 different terms have been used to describe the spectrum of cognitive impairment: ICU psychosis, ICU syndrome, acute confusional state, septic encephalopathy, and acute brain failure. This model is based from DSM IV definition of delirium. Delirium is a disturbance of consciousness with inattention accompanied by a change in cognition or perceptual disturbance that develops during a short period and fluctuates over time. We as healthcare professionals need to use standardized terms and definitions when speaking about delirium.
- #36: Reorientation and cognitive stimulation: reorient, calm, and cognitively stimulate patients by conveying the day, date, place, and reason for hospitalization, updating whiteboards with caregiver names, requesting placement of a clock and calendar in the room, and discussing current events, family and friends Hearing aids and/or eye glasses: Determine need for these sensory aids from the surrogate and request that the surrogate provide these whenever possible Pain management: Monitor all patients with a validated pain assessment scale and treat pain Sleep preservation: maintain good sleep hygiene via noise reduction strategies (white noise, earplugs), normal day-night variation in illumination, minimize interruptions during normal sleeping hours via “time out” strategy, maintaining ventilator synchrony, promoting comfort and relaxation (back care, massage, oral care, washing face/hands, and daytime bath) Being a tight titrator, only give what you need to give
- #38: The Modifying the INcidence of Delirium (MIND) Randomized and double blind Multisite - 6 centers 103 MV patients PO/IM delivery of study drug Doses: haloperidol = 5-20mg; ziprasidone 40-160mg
- #42: Assessors blinded to treatment assignment Daily awakening standard
- #44: These milestones occurred in the intervention group an average of three days earlier compared with the control group
- #46: This protocol can be applied to all patients and be adjusted as appropriate per patient. Requires team coordination. Protocol is titrated as appropriate to each patient. The more intense for the more appropriate Crazy ARDS that need paralyzed-still at least get evaluated with ABCDE but won’t get interventions Walky talkies are on the success side All portions have a safety and intensity screen and reviewed for protocol daily.