Delirium: The Next Proposed “Never Event.” Is This Realistic?

2,390 views
2,164 views

Published on

0 Comments
2 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
2,390
On SlideShare
0
From Embeds
0
Number of Embeds
5
Actions
Shares
0
Downloads
78
Comments
0
Likes
2
Embeds 0
No embeds

No notes for slide

Delirium: The Next Proposed “Never Event.” Is This Realistic?

  1. 1. Delirium: The Next Proposed “Never Event.” Is This Realistic? Pratik Pandharipande, MD, MSCI Department of Anesthesiology/Critical Care Vanderbilt University School of Medicine, Nashville, TN VA TN Valley Health Care System
  2. 2. Disclosure Research Grant - Hospira Inc Honorarium - Hospira Inc FAER Grant VPSD Award VA Career Development Award
  3. 3. Delirium: A never event? Maybe not yet……BUT • Delirium proposed by CMS as a “Never Event” • “Never Events” are errors in medical care that are clearly identifiable, preventable, and serious in consequences and indicate a problem in the safety of a healthcare facility. • The proposal has given delirium publicity • Increased interest and research in this topic
  4. 4. Histogram showing the number of English articles detected when searching for Delirium and ICU as MeSH or Text Words by year from 1990 through 2007. Articles on Delirium in ICU (MeSH or Text headings in English) 70 60 P-value for trend shift at Number of Articles year 2000 = 0.002 50 40 30 20 10 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year Morandi et al ICM 2008;34:1907-1915
  5. 5. Delirium: A brain organ dysfunction Morandi et al ICM 2008;34:1907-1915
  6. 6. Prevalence of ICU Delirium • Occurs in up to 80% MICU/SICU/TICU ventilated patients develop delirium • 20-50% of lower severity ICU patients develop delirium • Hypoactive or mixed forms most common • 65-70% goes undiagnosed if routine monitoring is not implemented Roberts B. Aust Crit Care. 2005;18:6,8-9. Ely EW. ICM. 2001;27:1892-1900. Thomason J. Crit Care. 2005;9:375-381. Ely EW. JAMA. 2001;286,2703-2710. Ely EW. CCM. 2004;32:106-112. Pandharipande. J Trauma. 2008;65:34-41. Peterson. JAGS. 2006;54:479-484. Ely EW. CCM. 2001;29:1370-1379. Ouimet S. ICM. 2007;33:66-73. Pandharipande. ICM. 2007;33:1726-1731. Spronk P. Neth J Med.2009;67:296-300 Lat I. CCM.2009;37:1898-1905 Slooter A. CCM.2009. 37 (6):1881-1885, 2009
  7. 7. Key Points: ICU Delirium • $15k to $25k higher hospital costs • Longer hospital stays • 3 times higher risk of death by 6 months • Prolonged neuropsychological dysfunction Milbrandt E, et al. Crit Care Med. 2004;32:955-962. Ely EW, et al. JAMA. 2004;291:1753-1762. Ouimet S. ICM. 2007;33:66-73. Lin, et al. Crit Care Med. 2004;32:2254-2259.
  8. 8. Delirium and Long-Term Cognitive 60 Outcomes Cognitive Function at 12 Months P=.005 50 (Predicted Mean T-score) 40 30 20 10 0 0 5 10 15 20 Days of ICU Delirium Girard TD, et al. ATS 2009
  9. 9. Delirium duration and Mortality Pisani M. Am. J. Respir. Crit. Care Med. Sept 2009 (epub)
  10. 10. Subsyndromal Delirium Patients who present some symptoms of delirium, but do not fulfill all criteria for delirium.
  11. 11. Subsyndromal Delirium and Clinical Outcomes No Clinical Delirium Subsyndromal Delirium P-Value ICU Mortality 2.4% 10.6% 15.9% <.001 ICU LOS 2.5 (2.1) 5.2 (4.9) 10.8 (11.3) <.001 Mean (SD) when applicable Ouimet S. Int Care Med. 2007;33:1007-1013.
  12. 12. Pathogenesis of Delirium •Inflammation •Neurotransmitters •Tryptophan metabolites
  13. 13. Risk Factors for Delirium • Aging • Psychoactive medications • Baseline dementia • Sleep deprivation • Psychiatric disorders • Underlying illness – Inflammation – Coagulation • Metabolic disturbances Inouye. JAMA. 1996;275:852-857. Dubois. Intens Care Med. 2001;27:1297-1304. • Hypoxemia Inouye. NEJM. 1999;340:669-676. Jacobi. Crit Care Med. 2002;30:119-141. • Genetic predisposition (?) Milbrandt. Crit Care Med. 2005;33:226-229. Ouimet S. Int Care Med. 2007;33:66-73 Pisani M. Crit Care Med. 2009 Jan;37(1):354-5
  14. 14. Lorazepam and Delirium 100 90 Delirium Risk 80 70 60 50 No drug 0 -1 1 -2 2 -3 3 -4 4+ Log scale 0 - 2.7 2.7 -7.4 7.4 -20 20 -55 55+ Original scale Lorazepam Dose (mg) Pandharipande PP, et al. Anesthesiology. 2006;104:21-26.
  15. 15. Midazolam and Fentanyl (?) as Risk Factors for Delirium Midazolam Fentanyl 100 100 Users Users Non-Users Non-Users 80 80 % Days Delirious % Days Delirious P=.014 P=.007 P=.031 60 60 P=.936 40 40 20 20 0 0 Surgical Trauma Surgical Trauma Daily Midazolam Use (Exc. Coma Days) Daily Fentanyl Use (Exc. Coma Days) Pandharipande, et al. J Trauma. 2008;65:34-41.
  16. 16. Risk factors of Delirium in Burn ICU patients Benzodiazepines 1.0 Odds of delirium 0.8 0.6 0.4 0.2 0.0 0 50 100 150 200 Benzodiazepines in previous 24 hours (midazolam equivalents) Opiates Odds of delirium 1.0 0.8 0.6 0.4 0.2 0.0 0 2000 4000 6000 8000 Opiates in previous 24 hours (fentanyl equivalents) Pandharipande, Agarwal, Cotton et al. ASA 2009
  17. 17. What should we do to “try and make delirium a never event?” • 1. Monitoring • 2. Non pharmacolgical interventions • 3. Reduction in deliriogenic medications • 4. Pharmacological interventions – Dexmedetomidine – Antipsychotics
  18. 18. BRAIN ROAD MAP on ROUNDS 1. Target RASS/ (where going?) (or any valid scale) 2. Actual RASS (where now?) 3. CAM-ICU/ICDSC (content ?) 4. Drugs/toxins/metabolic (how got here?)
  19. 19. Confusion Assessment Method (CAM-ICU) 1. Acute onset of mental status changes or a fluctuating course and 2. Inattention and 3. Altered level of 4. Disorganized thinking or consciousness = Delirium Ely EW, et al. Crit Care Med. 2001;29:1370-1379. Ely EW, et al. JAMA. 2001;286:2703-2710.
  20. 20. 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, et al. ICM. 2001;27:859-864.
  21. 21. Multicomponent preventive protocols Study design Incidence of delirium Duration of Severity of Delirium Delirium Inouye Prospective 9.9% intervention No benefit No benefit matching 15% control Marcantonio RCT 32% intervention 50% No benefit No benefit control Milisen Prospective No benefit 1 day intervention Lower CAM sequential 4 days control score design Lundstrom Clinical Trial No benefit 30.2% intervention Not 59.7% control evaluated Vidan Prospective 11.7% intervention No benefit No benefit cohort trial 18.5% control Inouye S.K,1999 NEJM:669-676 Lundstrom M, 2005 JAGS:622-628 Marcantonio E.R, 2001 JAGS:516-522 Vidan M.T, 2009 JAGS E Pub Milisen K, 2001 JAGS:523-532
  22. 22. Early Mobilization Protocol in Mechanically Ventilated Patients Schweickert et al, Lancet 2009;373:1874-82
  23. 23. Daily Wake-Up + Early Mobility Intervention Control Outcome (n=49) (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 Schweickert WD, et al. Lancet. 2009;373:1874-1882.
  24. 24. Have a Plan: Sedation Protocols and Targeted Sedation
  25. 25. Sedation Protocols: The Evidence Trial RCT Outcome(s) Improved by Protocol Brook et al.1999 Yes Ventilator days, ICU LOS Kress et al. 2000 Yes Ventilator days, ICU LOS Brattebo et al. 2002 No Ventilator days de Lemos et al. 2005 Yes Ventilator days, ICU LOS De Jonghe et al. 2005 No Ventilator days, time to awaken Chanques et al. 2006 No Ventilator days, pain/agitation, infection Quenot et al. 2007 No Ventilator days, extubation success, VAP Arias-Rivera et al. 2008 No Extubation success Bucknall et al. 2008 Yes None Girard et al. 2008 Yes Ventilator days, hospital LOS, survival Robinson et al. 2008 No Ventilator days, hospital LOS Tobar et al. 2008 Yes Oversedation rate
  26. 26. Less is More: Daily Interruption of Sedatives and Wake-Up and Breathe
  27. 27. Benzodiazepines 70 Usual Care + SBT Daily Dose of Benzodiazepines 60 SBT + SAT 50 40 30 20 10 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Study Day
  28. 28. 6000 Opiates Usual Care + SBT SBT + SAT Daily Dose of Opiates 4000 2000 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Study Day
  29. 29. Avoid Benzodiazepines: Alternative Sedatives
  30. 30. MENDS Trial Double-blind, Randomized, Controlled MICU/SICU patients ventilated and sedated Control Intervention lorazepam (GABA) dexmedetomidine (α2) ± fentanyl ± fentanyl Vanderbilt University Medical Center and Washington Hospital Center Pandharipande PP, et al. JAMA. 2007;298:2644-2653.
  31. 31. Risk of Developing Delirium Pandharipande PP, et al. unpublished data
  32. 32. Brain Dysfunction P=.01 P=.09 P=.001 12 10 8 6 4 2 Dexmedetomidine 0 Lorazepam Delirium/Coma-Free Days Delirium-Free Days Coma-Free Days Pandharipande PP, et al. JAMA. 2007;298:2644-2653.
  33. 33. Prevalence of Delirium 54% DEX vs 76.6% MDZ, P<.001 Riker et al. JAMA 2009
  34. 34. Risperidone and Delirium • Double-blind randomized trial (DBRT) • Single dose (1 mg) of risperidone administered after cardiac surgery • Reduced the incidence of postoperative delirium – 11.1% vs.31.7%, P=.009 – RR=0.35, 95% CI=0.16-0.77 Prakanrattana, et al. Anaesth Intensive Care. 2007;35:714-719.
  35. 35. Resolution of Delirium and Coma 100 Patients Without Delirium or Coma (%) 80 60 40 Haloperidol (n=35) Ziprasidone (n=32) 20 Placebo (n=36) 0 1 5 10 15 20 Day Girard TD, et al. Am J Respir Crit Care Med. 2008;177:A817.
  36. 36. Are we making any progress? • Growing awareness about delirium and associated outcomes • Better monitoring instruments for health care providers at bedside • Identification of potential mechanisms and risk factors • Non pharmacological interventions have shown promise in non-ICU cohorts and in ICU cohorts (early mobilization) • Reducing benzodiazepine exposure with alternative sedation paradigms, especially dexmedetomidine has shown improvements in delirium rates and duration

×