Delirium in the ICU


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Overview of recognition and management of delirium in the ICU

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Delirium in the ICU

  1. 1. Delirium in the ICU <ul><li>from witness to criminal </li></ul>Dr. Andrew Ferguson MEd FRCA FCARCSI DIBICM FCCP
  2. 2. <ul><li>“ The subject of delirium is generally looked upon by the practical physician as one of the most obscure in the chain of morbid phenomena he has to deal with; whilst the frequency of its occurrence under various conditions of the system renders the affection not a little familiar to his eye” </li></ul>Gallway MB (1838). Nature and treatment of delirium. Lond Med Gazette 1: 46–49.
  3. 3. Overview <ul><li>What is delirium ? </li></ul><ul><li>How is it categorised? </li></ul><ul><li>Why does it matter? </li></ul><ul><li>Why does it happen? </li></ul><ul><li>How do we diagnose/monitor it? </li></ul><ul><li>How do we prevent and treat it? </li></ul><ul><li>What does it mean for our patients? </li></ul>
  4. 4. What is Delirium? <ul><li>An acute confusional state with </li></ul><ul><ul><li>Fluctuating mental status </li></ul></ul><ul><ul><li>Disordered attention </li></ul></ul><ul><ul><li>Disorganised thinking OR altered consciousness </li></ul></ul><ul><li>DSM IV definition : “a disturbance of consciousness with inattention accompanied by a change in cognition or perceptual disturbance that develops over a short period (hours to days) and fluctuates with time” </li></ul><ul><li>Synonyms : ICU psychosis, septic encephalopathy, ICU syndrome, acute brain failure, acute confusional state </li></ul>
  5. 5. How is Delirium Categorised? Hyperactive Hypoactive Mixed 1.6% of cases, “ ICU psychosis ”, agitation, restlessness, “picking”, emotional lability 54.1% % of cases 43.5% of cases, “ encephalopathy ”, often unrecognised, withdrawal, flat affect, apathy, lethargy, decreased responsiveness, may be misdiagnosed as depression
  6. 6. Why does delirium matter? <ul><li>Increased reintubation risk (OR=3) </li></ul><ul><li>Increased ICU & hospital stay * (up to 10 days extra) </li></ul><ul><ul><li>Each day in delirium increases risk of longer stay by 20% </li></ul></ul><ul><li>Increased mortality in ICU & out to 6 months** (OR=3) </li></ul><ul><ul><li>Each day spent in delirium increases risk of death by 10% </li></ul></ul><ul><li>Increased ICU & hospital costs *** </li></ul><ul><li>10-24% risk of long-term cognitive impairment </li></ul><ul><li>Increased dementia risk </li></ul><ul><li>Reduced functional status at 3 & 6 months </li></ul>* Ely et al, Intensive Care Med 2001; 27: 1892-1900 ** Ely et al, JAMA 2004; 291: 1753-62 *** Milbrandt et al, CCM 2004; 32: 955-62
  7. 8. Why does delirium happen? <ul><li>Higher cortical dysfunction (on functional neuroimaging) </li></ul><ul><ul><li>Pre-frontal cortex, non-dominant posterior parietal regions, anterior thalamus, basal ganglia, temporal-occipital cortex </li></ul></ul><ul><li>Neurotransmitter dysfunction </li></ul><ul><ul><li>Reduced acetylcholine levels – blockade or deficiency </li></ul></ul><ul><ul><ul><li>Endogenous anticholinergic substances </li></ul></ul></ul><ul><ul><ul><li>Opiates/hypoxia/inflammation </li></ul></ul></ul><ul><ul><li>Serotonin fluctuation </li></ul></ul><ul><ul><li>Dopamine excess </li></ul></ul><ul><ul><li>Glutamate excess (2 o to IFN-  , LPS, hypoxia, hypoglycaemia) </li></ul></ul><ul><li>Predisposition (baseline vulnerability) </li></ul><ul><li>Precipitants (clinical, iatrogenic, organisational risk factors) </li></ul>
  8. 9. Why does delirium happen? Serotonin Acetylcholine Dopamine Opioids & benzo’s 2 o brain infection Decreased cerebral metabolism 1 o intracranial disease Systemic disease Hypoxia Metabolic derangement Withdrawal syndromes Toxins
  9. 10. Risk factors for delirium Van Rompaey Intensive and Critical Care Nursing 2008; 24: 98—107
  10. 11. Age Severity Benzo’s Pun & Ely, Chest 2007; 132: 624–636 Pandharipande et al, Anesthesiology 2006; 104: 21-26
  11. 12. DELIRIUM(S) - causes <ul><li>D Drugs, dementia </li></ul><ul><li>E Eyes & ears (poor vision and hearing) </li></ul><ul><li>L Low O 2 states (CHF, COPD, ARDS, MI, PE) </li></ul><ul><li>I Infection </li></ul><ul><li>R Retention (urine and stool) </li></ul><ul><li>I Ictal states </li></ul><ul><li>U Underhydration/undernutrition </li></ul><ul><li>M Metabolic upset </li></ul><ul><li>(S) Subdural, sleep deprivation </li></ul>
  12. 13. I WATCH DEATH <ul><li>I Infection </li></ul><ul><li>W Withdrawal (alcohol, sedatives, barbiturates etc.) </li></ul><ul><li>A Acute metabolic (acidosis, alkalosis, electrolytes) </li></ul><ul><li>T Trauma (closed head injury, haematoma etc.) </li></ul><ul><li>C CNS pathology (seizures, stroke, encephalitis) </li></ul><ul><li>H Hypoxia </li></ul><ul><li>D Deficiencies (thiamine, niacin, B12, folate) </li></ul><ul><li>E Endocrinopathies (thyroid, glucose, adrenal) </li></ul><ul><li>A Acute vascular (hypertensive crisis, arrhythmia) </li></ul><ul><li>T Toxins/drugs </li></ul><ul><li>H Heavy metals </li></ul>
  13. 14. Diagnosis & monitoring Level of consciousness Content of consciousness
  14. 15. Diagnosis & monitoring <ul><li>Intensive Care Delirium Screening Checklist (ICDSC) </li></ul><ul><ul><li>8 items based on data from preceeding 24 hours </li></ul></ul><ul><ul><li>Score > 4 items = positive for delirium </li></ul></ul><ul><ul><li>Sensitivity 99%, specificity 64%, inter-observer reliability 94% </li></ul></ul><ul><ul><li>Simple </li></ul></ul><ul><li>Confusion Assessment Method for ICU (CAM-ICU) </li></ul><ul><ul><li>4 features </li></ul></ul><ul><ul><li>Altered or fluctuating mental status compared to baseline </li></ul></ul><ul><ul><li>Inattention (Attention Screening Examination – ASE, visual or auditory recollection of letter or images) </li></ul></ul><ul><ul><li>Disorganised thinking – 4 Y/N questions + hold up 2 fingers on each hand </li></ul></ul><ul><ul><li>Altered consciousness – sedation scale e.g. RASS </li></ul></ul><ul><ul><li>Delirium = 1 AND 2 plus 3 OR 4 </li></ul></ul>
  15. 18. ICDSC
  16. 19. CAM-ICU
  17. 20. Treating delirium <ul><li>Non-pharmacological (most studied outside ICU) </li></ul><ul><ul><li>Up to 40% risk reduction achieved </li></ul></ul><ul><ul><li>Repeated reorientation of patients </li></ul></ul><ul><ul><li>Early mobilisation </li></ul></ul><ul><ul><li>Visual and hearing aids (and wax removal!) </li></ul></ul><ul><ul><li>Early catheter, line etc. removal </li></ul></ul><ul><ul><li>Minimise restraints and sedatives </li></ul></ul>
  18. 21. Treating delirium - haloperidol <ul><ul><li>Typical antipsychotic </li></ul></ul><ul><ul><li>2-5 mg iv/po q6H (reduce in elderly) </li></ul></ul><ul><ul><li>Adverse effects – extrapyramidal, prolonged QTc, torsades (3.8%), neuroleptic malignant syndrome </li></ul></ul><ul><ul><li>More effective than lorazepam </li></ul></ul><ul><ul><li>? mortality reduction in ventilated ICU patients </li></ul></ul><ul><ul><li>Dopamine blockade + disinhibition of ACh </li></ul></ul><ul><ul><li>Anti-inflammatory effects </li></ul></ul>Girard & Ely, Handbook of Clinical Neurology 2008; 90: chapter 3
  19. 22. Treating delirium – atypical antipsychotics <ul><ul><li>Olanzepine, quetiapine, risperidone </li></ul></ul><ul><ul><li>Alter multiple neurotransmitters including DA, NA, serotonin, ACh, histamine </li></ul></ul><ul><ul><li>Suggestion of decreased extrapyramidal side-effects compared to haloperidol </li></ul></ul><ul><ul><li>As effective as haloperidol </li></ul></ul>Girard & Ely , Handbook of Clinical Neurology 2008; 90: chapter 3 Skrobik YK, Bergeron N, Dumont M et al . (2004). Olanzapine vs haloperidol: treating delirium in a critical care set- ting. Intensive Care Med 30: 444–449.107: 341–351. Han CS, Kim YK (2004). A double-blind trial of risperidone and haloperidol for the treatment of delirium. Psychosomatics 45: 297–301 Breitbart W, Marotta R, Platt M et al. (1996). A double- blind trial of haloperidol, chlorpromazine, and lorazepam in the treatment of delirium in hospitalized AIDS patients. Am J Psychiatry 153: 231–237.
  20. 23. Internet Resources <ul><li> </li></ul>