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Patients Gone Wild: Agitation and Delirium in the ICU
 

Patients Gone Wild: Agitation and Delirium in the ICU

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    Patients Gone Wild: Agitation and Delirium in the ICU Patients Gone Wild: Agitation and Delirium in the ICU Presentation Transcript

    • CRISMA Critical Care Medicine C·R·I·S·M·A the University of Pittsburgh Patients Gone Wild: Agitation and Delirium in the ICU Eric B. Milbrandt, MD, MPH The CRISMA Laboratory Department of Critical Care Medicine School of Medicine University of Pittsburgh the Clinical Research, Investigation, and Systems Modeling of Acute illness
    • CRISMA Critical Care Medicine Overview C·R·I·S·M·A the University of Pittsburgh What is delirium? Why is it important? Why does it happen? How do we diagnose it? Can we prevent it? When should we treat it? the Clinical Research, Investigation, and Systems Modeling of Acute illness
    • CRISMA Critical Care Medicine Delirium vs. Agitation C·R·I·S·M·A the University of Pittsburgh Latin deliria “out of your furrow” Delirium = acute brain dysfunction Delirium ≠ agitation Agitation: violent motion or stirring; emotional disturbance or excitement Delirium: acute disturbance of consciousness and cognition that fluctuates in severity “Can’t think straight or focus attention” the Clinical Research, Investigation, and Systems Modeling of Acute illness
    • CRISMA Critical Care Medicine Types of Delirium C·R·I·S·M·A the University of Pittsburgh Hyperactive Agitation, combative behavior, pulling lines and tubes Hypoactive Calm, inattentive, ↓ mobility, “spaced out” Far more common, likely due to sedating meds the Clinical Research, Investigation, and Systems Modeling of Acute illness
    • CRISMA Critical Care Medicine Why is Delirium Important? C·R·I·S·M·A the University of Pittsburgh Very common in the ICU 20% to 80% of ICU pts develop delirium Ely et al., JAMA 2001; 286:2703-10 Dubois et al., Intensive Care Med 2001; 27:1297-1304 Associated with Nosocomial pneumonia and failed extubation Cook et al., Ann Intern Med 1998;129:433-40 Namen et al., AJRCCM 2001;163:658-64 ↑LOS, 6-month mortality, cost Ely et al., Intensive Care Med 2001; 27:1982-1900 Ely et al., JAMA 2004; 291:1753-62 Milbrandt et al., CCM 2004; 32:955-62 Prolonged neuropsychological deficits Moller et al, Lancet 1998;351:857 Williams-Russo et al, JAMA 1995;274:44 Scragg et al., Anaesthesia 2001;56:9-14 the Clinical Research, Investigation, and Systems Modeling of Acute illness
    • CRISMA Critical Care Medicine But How Could This Be? C·R·I·S·M·A the University of Pittsburgh Consider hyperactive delirium Pulling lines and tubes Danger to self and others Excess sedation ↑ LOS, time on vent Risk of nosocomial pneumonia, CR-BSI, etc Mortality the Clinical Research, Investigation, and Systems Modeling of Acute illness
    • CRISMA Critical Care Medicine But How Could This Be? C·R·I·S·M·A the University of Pittsburgh Alternatively… Marker of illness severity Rather than causal Another failing organ… the Clinical Research, Investigation, and Systems Modeling of Acute illness
    • CRISMA Critical Care Medicine Why Does It Happen? C·R·I·S·M·A the University of Pittsburgh Baseline Deficits Underlying Age Illness Vision/Hearing Catheters/Restraints Deficits Metabolic Hypoxia Derangements Toxins Pain/Anxiety Medications Sleep Inflammation Deprivation & Thrombosis the Clinical Research, Investigation, and Systems Modeling of Acute illness
    • CRISMA Critical Care Medicine Medications C·R·I·S·M·A the University of Pittsburgh Anticholinergics (tricyclics) Opiates Benzos Antihistimines (Benedryl “sleeper”) H2 blockers Antibiotics Corticosteroids Metoclopramide Muscle relaxants Lidocaine the Clinical Research, Investigation, and Systems Modeling of Acute illness
    • CRISMA Critical Care Medicine Mnemonics C·R·I·S·M·A the University of Pittsburgh IWATCHDEATH Infection Withdrawal Acute metabolic Trauma/pain CNS pathology Hypoxia Deficiencies (B12, thiamine) Endocrinopathies Acute vascular (HTN, shock) Toxins/drugs Heavy Metals the Clinical Research, Investigation, and Systems Modeling of Acute illness
    • CRISMA Critical Care Medicine Mnemonics C·R·I·S·M·A the University of Pittsburgh DELIRIUM Drugs Electrolyte and physiologic abnormalities Lack of drugs Infection Reduced sensory input Intracranial problems Urinary retention and fecal impaction Myocardial problems (MI, CHF, arrhythmia) the Clinical Research, Investigation, and Systems Modeling of Acute illness
    • CRISMA Critical Care Medicine Monitoring And Support C·R·I·S·M·A the University of Pittsburgh Cardiovascular Pulmonary Renal the Clinical Research, Investigation, and Systems Modeling of Acute illness
    • CRISMA Critical Care Medicine Monitoring And Support C·R·I·S·M·A the University of Pittsburgh Brain? the Clinical Research, Investigation, and Systems Modeling of Acute illness
    • CRISMA Critical Care Medicine How Do We Diagnose It? C·R·I·S·M·A the University of Pittsburgh The Spectrum of “Septic Encephalopathy” Normal Delirium Stupor Coma The diagnosis of delirium represents a particular challenge, since traditionally this requires “talking” to a patient Eidelman, JAMA 1996;275:470-473 Papadopoulos, Crit Care Med 2000;28:3019-24 the Clinical Research, Investigation, and Systems Modeling of Acute illness
    • CRISMA Critical Care Medicine How Do We Diagnose It? C·R·I·S·M·A the University of Pittsburgh CAM-ICU (Confusion Assessment Method for the ICU) DSM-IV criteria modified for nonverbal pts Administered by anyone 1-2 minutes Objective, valid, reliable Sensitivity 93-100% & specificity 98-100% Wards: slightly less sensitive than CAM, but easier Interrater reliability κ=0.96 2002 SCCM Sedation & Analgesia Guidelines Vanderbilt ICU Delirium Study Group Int Care Med, JAMA, CCM 2001 the Clinical Research, Investigation, and Systems Modeling of Acute illness
    • Confusion Assessment Method CRISMA Critical Care Medicine C·R·I·S·M·A for the ICU the University of Pittsburgh 2 step process Step 1: Sedation assessment (RASS) the Clinical Research, Investigation, and Systems Modeling of Acute illness
    • CRISMA Critical Care Medicine Richmond Agitation Sedation Scale C·R·I·S·M·A the University of Pittsburgh +4 Combative +3 Very agitated +2 Agitated +1 Restless 0 Alert /calm -1 Drowsy eye contact >10 sec Verbal -2 Light sedation eye contact <10 sec -3 Moderate no eye contact -4 Deep physical stimulation required Physical -5 Unarousable no response even with physical Sessler et al., AJRCCM 2002; 166:1338-1344 the Clinical Research, Investigation, and Systems Modeling of Acute illness
    • Confusion Assessment Method CRISMA Critical Care Medicine C·R·I·S·M·A for the ICU the University of Pittsburgh 2 step process Step 1: Sedation assessment (RASS) Step 2: Assess for 4 CAM-ICU features the Clinical Research, Investigation, and Systems Modeling of Acute illness
    • Confusion Assessment Method CRISMA Critical Care Medicine C·R·I·S·M·A for the ICU the University of Pittsburgh Feature 1: Acute onset of mental status change or a fluctuating course And Feature 2: Inattention Feature 3: Feature 4: Altered Level Or Disorganized Thinking of Consciousness = DELIRIUM the Clinical Research, Investigation, and Systems Modeling of Acute illness
    • CRISMA Critical Care Medicine CAM-ICU C·R·I·S·M·A the University of Pittsburgh Feature 1: acute onset or fluctuating course Evidence of acute change in mental status from baseline? OR Did behavior fluctuate in past 24 hours as evidenced by RASS or GCS? the Clinical Research, Investigation, and Systems Modeling of Acute illness
    • CRISMA Critical Care Medicine CAM-ICU C·R·I·S·M·A the University of Pittsburgh Feature 2: inattention Difficulty focusing attention as evidenced by score <8 on attention screening exam (ASE)? Visual: picture recognition OR Auditory: vigilance “A” random letter test SAVEAHAART the Clinical Research, Investigation, and Systems Modeling of Acute illness
    • CRISMA Critical Care Medicine CAM-ICU C·R·I·S·M·A the University of Pittsburgh Feature 3: disorganized thinking Incorrect answers to 3 or more of 4 questions or inability to follow commands Questions Will a stone float on water? Are there fish in the sea? Does 1 pound weigh more than 2? Can you use a hammer to pound a nail? Commands Hold up this many fingers. the Clinical Research, Investigation, and Systems Modeling of Acute illness
    • CRISMA Critical Care Medicine CAM-ICU C·R·I·S·M·A the University of Pittsburgh Feature 4: altered level of consciousness Is the patients LOC anything other than alert? Hyperactive/agitated Lethargic, stuporous, comatose the Clinical Research, Investigation, and Systems Modeling of Acute illness
    • Confusion Assessment Method CRISMA Critical Care Medicine C·R·I·S·M·A for the ICU the University of Pittsburgh Feature 1: Acute onset of mental status change or a fluctuating course And Feature 2: Inattention Feature 3: Feature 4: Altered Level Or Disorganized Thinking of Consciousness = DELIRIUM the Clinical Research, Investigation, and Systems Modeling of Acute illness
    • CRISMA Critical Care Medicine Can We Prevent It? C·R·I·S·M·A the University of Pittsburgh Baseline Deficits Underlying Age Illness Vision/Hearing Catheters/Restraints Deficits Metabolic Hypoxia Derangements Toxins Pain/Anxiety Medications Sleep Inflammation Deprivation & Thrombosis the Clinical Research, Investigation, and Systems Modeling of Acute illness
    • CRISMA Critical Care Medicine Haloperidol Prophylaxis? C·R·I·S·M·A the University of Pittsburgh 430 elderly hip-surgery patients w/ delirium risk factors Vision worse than 20/70 w/ glasses APACHE>15, MMSE<25, BUN/Cr>17 Haloperidol 1.5 mg/day vs. placebo Preoperatively and up to 3 days post-op Did not reduce incidence Did reduce severity, duration of delirium Hospital LOS ↓ 5.5 days! (among those w/ delirium) Kalisvaart, JAGS 2005;53:1658-1666 the Clinical Research, Investigation, and Systems Modeling of Acute illness
    • CRISMA Critical Care Medicine Other Prevention Approaches C·R·I·S·M·A the University of Pittsburgh Alternative sedative agents Non-GABA drugs Dexmedetomidine, remifentanyl Daily sedation interruption and early PT/OT Pandharipande et al. JAMA 2007 Riker et al. JAMA. 2009 Schweickert et al, Lancet 2009 the Clinical Research, Investigation, and Systems Modeling of Acute illness
    • CRISMA Critical Care Medicine When Should We Treat It? C·R·I·S·M·A the University of Pittsburgh Hyperactive “agitated” delirium Haldol is the drug of choice ICU 5-10 mg IV q20-30 minutes to control delirium then total dose divided q6 Fixed dose of 5-10 mg IV q12h Wards 0.5-2.0 mg IV/IM/PO q12h Goal is to reduce need for drugs which we know can prolong stay (benzos, opiates) Avoid if QTc >500 msec the Clinical Research, Investigation, and Systems Modeling of Acute illness
    • CRISMA Critical Care Medicine When Should We Treat It? C·R·I·S·M·A the University of Pittsburgh Hypoactive delirium??? No one knows what to do Risks of treatment may outweigh benefits Focus should be on reducing modifiable risk factors the Clinical Research, Investigation, and Systems Modeling of Acute illness
    • CRISMA Critical Care Medicine Question C·R·I·S·M·A the University of Pittsburgh Does treating delirium matter? Improve outcomes or just make patients (and caregivers) feel better? the Clinical Research, Investigation, and Systems Modeling of Acute illness
    • CRISMA Critical Care Medicine Haloperidol and Mortality C·R·I·S·M·A the University of Pittsburgh 40% 36.1% 35.5% P=0.001* Mortality (%) 30% 20% 15.4% 10% 7.7% 0% No Haloperidol Low Dose Medium Dose High Dose (0.5-5.0) (5.1-12.5) (>12.5) Mean Daily Dose (mg/day) Milbrandt et al. CCM 2005 the Clinical Research, Investigation, and Systems Modeling of Acute illness
    • CRISMA Critical Care Medicine Quetiapine C·R·I·S·M·A the University of Pittsburgh Prospective multi-center RCT 36 adult ICU pts with delirium (ICDSC≥4) ~80% mechanically ventilated Quetiapine vs. placebo 50 mg q12h orally or per feeding tube Increased q24 if >1 dose haloperidol needed Max 200 mg q24h Until ICU d/c, 10+ days, or ICU team decision Devlin et al. CCM 2009 (Epub ahead of print ) the Clinical Research, Investigation, and Systems Modeling of Acute illness
    • CRISMA Critical Care Medicine Quetiapine C·R·I·S·M·A the University of Pittsburgh Results Shorter time to delirium resolution 1 day vs. 4.5 days, p=0.001 Reduced delirium duration 36 hrs vs. 120 hrs, p=0.006 Less agitation Less time w/ SAS≥5, 6 hrs vs. 36 hrs, p=0.02 Non-significant hospital mortality reduction 11% vs. 17%, p=1.0 Trend to ↑ discharge to home or rehab 89% vs 56%, p=0.06 Devlin et al. CCM 2009 (Epub ahead of print ) the Clinical Research, Investigation, and Systems Modeling of Acute illness
    • CRISMA Critical Care Medicine Conclusions C·R·I·S·M·A the University of Pittsburgh Delirium is common in the ICU Acute brain dysfunction Associated w/ poor outcomes and increased cost National guidelines recommend monitoring & treatment Always start w/ modifiable risk factors before drugs Antipsychotics, non-GABA sedatives, sedation interruption & early PT may prevent or reduce delirium Antipsychotics may improve outcomes, but further study is needed the Clinical Research, Investigation, and Systems Modeling of Acute illness