This document discusses delirium in the ICU. It begins by defining delirium and describing its fluctuating nature and symptoms. Delirium is then categorized as hyperactive, hypoactive, or mixed. The document explains that delirium increases risks such as longer hospital stays, higher mortality, and long-term cognitive issues. It identifies risk factors and potential causes related to neurotransmitters, predispositions, and precipitants. Methods for diagnosing and monitoring delirium like the ICDSC and CAM-ICU are outlined. Finally, the document reviews treatments including non-pharmacological interventions and pharmacological options like haloperidol and atypical antipsychotics.
Diffusion-weighted imaging or computerized tomography perfusion assessment with clinical mismatch in the triage of wake up and late presenting strokes undergoing neurointervention with Trevo (DAWN) trial methods
Int J Stroke. 2017 Aug;12(6):641-652.
Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct
N Engl J Med. 2018 Jan 4;378(1):11-21.
A multicenter randomized controlled trial of endovascular therapy following imaging evaluation for ischemic stroke (DEFUSE 3)
Int J Stroke. 2017 Oct;12(8):896-905.
Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging
N Engl J Med. 2018 Feb 22;378(8):708-718.
ANESTHETIC CONSIDERATIONS FOR STEREOTACTIC ELECTROENCEPHALOGRAPHY (SEEG) IMP...Anurag Tewari MD
The refractory seizures have significant impact on the quality of life and increase long term neurologic and non-neurologic complications. Implantation of Stereotactic Electroencephalography (SEEG) leads is one of the newer surgical techniques intended to localize seizure foci with higher accuracy than the conventional methods. Most of the commonly utilized anesthetic agents depress EEG waveforms affecting intra operative monitoring during these surgeries. Hence, the anesthetic goals include a stable induction and maintenance with agents which have minimal effect on EEG. This article discusses the peri-operative considerations of multiple anti-epileptic medications, recent advances in anesthetic management, and important post-operative concerns.
Keywords: Anesthesia, epilepsy surgery, intra-operative EEG, intra operative monitoring, refractory seizures, SEEG, seizure foci, stereotactic electroencephalography
Vagal Nerve stimulation
Vagus nerve stimulation (VNS) is a medical treatment that involves delivering electrical impulses to the vagus nerve. It is used as an add-on treatment for certain types of intractable epilepsy and treatment-resistant depression. Frequent side effects include coughing and shortness of breath. Serious side effects may include trouble talking and cardiac arrest.
Diffusion-weighted imaging or computerized tomography perfusion assessment with clinical mismatch in the triage of wake up and late presenting strokes undergoing neurointervention with Trevo (DAWN) trial methods
Int J Stroke. 2017 Aug;12(6):641-652.
Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct
N Engl J Med. 2018 Jan 4;378(1):11-21.
A multicenter randomized controlled trial of endovascular therapy following imaging evaluation for ischemic stroke (DEFUSE 3)
Int J Stroke. 2017 Oct;12(8):896-905.
Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging
N Engl J Med. 2018 Feb 22;378(8):708-718.
ANESTHETIC CONSIDERATIONS FOR STEREOTACTIC ELECTROENCEPHALOGRAPHY (SEEG) IMP...Anurag Tewari MD
The refractory seizures have significant impact on the quality of life and increase long term neurologic and non-neurologic complications. Implantation of Stereotactic Electroencephalography (SEEG) leads is one of the newer surgical techniques intended to localize seizure foci with higher accuracy than the conventional methods. Most of the commonly utilized anesthetic agents depress EEG waveforms affecting intra operative monitoring during these surgeries. Hence, the anesthetic goals include a stable induction and maintenance with agents which have minimal effect on EEG. This article discusses the peri-operative considerations of multiple anti-epileptic medications, recent advances in anesthetic management, and important post-operative concerns.
Keywords: Anesthesia, epilepsy surgery, intra-operative EEG, intra operative monitoring, refractory seizures, SEEG, seizure foci, stereotactic electroencephalography
Vagal Nerve stimulation
Vagus nerve stimulation (VNS) is a medical treatment that involves delivering electrical impulses to the vagus nerve. It is used as an add-on treatment for certain types of intractable epilepsy and treatment-resistant depression. Frequent side effects include coughing and shortness of breath. Serious side effects may include trouble talking and cardiac arrest.
Epilepsy is a common neurological illness. Systematic evaluation and management leads to successful outcomes in most patients with epilepsy. Clinical description along with brain imaging and EEG would lead to accurate diagnosis.
Delirium, also referred to as "acute confusional state" or "acute brain syndrome," is a condition of severe confusion and rapid changes in brain function.
On the occasion of National Epilepsy Day 2014, Dr. ES Krishnamoorthy introduced basic concepts of Epilepsy at the Epilepsy Knowledge Forum in Chennai organised by Neurokrish & Trimed and Sponsored Medall.
Vertigo is a problem commonly encountered in daily clinical practice.So an uniform approach to a patient with Vertigo is essential to identify the underlying aetiology of Vertigo.
1. Delirium in the ICUDelirium in the ICU
from witness to criminalfrom witness to criminal
Dr. Andrew Ferguson
MEd FRCA FCARCSI DIBICM FCCP
2. ““The subject of delirium is generally looked upon by theThe subject of delirium is generally looked upon by the
practical physician as one of the most obscure in the chain ofpractical physician as one of the most obscure in the chain of
morbid phenomena he has to deal with; whilst the frequencymorbid phenomena he has to deal with; whilst the frequency
of its occurrence under various conditions of the systemof its occurrence under various conditions of the system
renders the affection not a little familiar to his eye”renders the affection not a little familiar to his eye”
Gallway MB (1838). Nature and treatment of delirium. Lond Med Gazette 1: 46–49.
3. OverviewOverview
What isWhat is deliriumdelirium??
How is it categorised?How is it categorised?
Why does it matter?Why does it matter?
Why does it happen?Why does it happen?
How do we diagnose/monitor it?How do we diagnose/monitor it?
How do we prevent and treat it?How do we prevent and treat it?
What does it mean for our patients?What does it mean for our patients?
4. What is Delirium?What is Delirium?
AnAn acuteacute confusional stateconfusional state withwith
FluctuatingFluctuating mental statusmental status
DisorderedDisordered attentionattention
DisorganisedDisorganised thinkingthinking OR alteredOR altered consciousnessconsciousness
DSM IV definitionDSM IV definition: “a disturbance of consciousness with: “a disturbance of consciousness with
inattention accompanied by a change in cognition or perceptualinattention accompanied by a change in cognition or perceptual
disturbance that develops over a short period (hours to days) anddisturbance that develops over a short period (hours to days) and
fluctuates with time”fluctuates with time”
SynonymsSynonyms: ICU psychosis, septic encephalopathy, ICU: ICU psychosis, septic encephalopathy, ICU
syndrome, acute brain failure, acute confusional statesyndrome, acute brain failure, acute confusional state
5. How is Delirium Categorised?How is Delirium Categorised?
HyperactiveHyperactive
HypoactiveHypoactive
MixedMixed
1.6% of cases, “ICU psychosis”, agitation,
restlessness, “picking”, emotional lability
1.6% of cases, “ICU psychosis”, agitation,
restlessness, “picking”, emotional lability
54.1% % of cases54.1% % of cases
43.5% of cases, “encephalopathy”, often
unrecognised, withdrawal, flat affect, apathy,
lethargy, decreased responsiveness, may be
misdiagnosed as depression
43.5% of cases, “encephalopathy”, often
unrecognised, withdrawal, flat affect, apathy,
lethargy, decreased responsiveness, may be
misdiagnosed as depression
6. Why does delirium matter?Why does delirium matter?
IncreasedIncreased reintubationreintubation risk (OR=3)risk (OR=3)
IncreasedIncreased ICU & hospital stayICU & hospital stay** (up to 10 days extra)(up to 10 days extra)
Each day in delirium increases risk of longer stay by 20%Each day in delirium increases risk of longer stay by 20%
Increased mortality in ICU & out to 6 months** (OR=3)Increased mortality in ICU & out to 6 months** (OR=3)
Each day spent in delirium increases risk of death by 10%Each day spent in delirium increases risk of death by 10%
IncreasedIncreased ICU & hospital costsICU & hospital costs******
10-24% risk of10-24% risk of long-term cognitive impairmentlong-term cognitive impairment
IncreasedIncreased dementia riskdementia risk
Reduced functional statusReduced functional status at 3 & 6 monthsat 3 & 6 months
* 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
12. DELIRIUM(S) - causesDELIRIUM(S) - causes
DD Drugs, dementiaDrugs, dementia
EE Eyes & ears (poor vision and hearing)Eyes & ears (poor vision and hearing)
LL Low OLow O22 states (CHF, COPD, ARDS, MI, PE)states (CHF, COPD, ARDS, MI, PE)
II InfectionInfection
RR Retention (urine and stool)Retention (urine and stool)
II Ictal statesIctal states
UU Underhydration/undernutritionUnderhydration/undernutrition
MM Metabolic upsetMetabolic upset
(S)(S) Subdural, sleep deprivationSubdural, sleep deprivation
13. I WATCH DEATHI WATCH DEATH
II InfectionInfection
WW Withdrawal (alcohol, sedatives, barbiturates etc.)Withdrawal (alcohol, sedatives, barbiturates etc.)
AA Acute metabolic (acidosis, alkalosis, electrolytes)Acute metabolic (acidosis, alkalosis, electrolytes)
TT Trauma (closed head injury, haematoma etc.)Trauma (closed head injury, haematoma etc.)
CC CNS pathology (seizures, stroke, encephalitis)CNS pathology (seizures, stroke, encephalitis)
HH HypoxiaHypoxia
DD Deficiencies (thiamine, niacin, B12, folate)Deficiencies (thiamine, niacin, B12, folate)
EE Endocrinopathies (thyroid, glucose, adrenal)Endocrinopathies (thyroid, glucose, adrenal)
AA Acute vascular (hypertensive crisis, arrhythmia)Acute vascular (hypertensive crisis, arrhythmia)
TT Toxins/drugsToxins/drugs
HH Heavy metalsHeavy metals
14. Diagnosis & monitoringDiagnosis & monitoring
LevelLevel of consciousnessLevelLevel of consciousness
ContentContent of consciousnessContentContent of consciousness
15. Diagnosis & monitoringDiagnosis & monitoring
• Intensive Care Delirium Screening Checklist (ICDSC)
– 8 items based on data from preceeding 24 hours8 items based on data from preceeding 24 hours
– ScoreScore >> 4 items = positive for delirium4 items = positive for delirium
– Sensitivity 99%, specificity 64%, inter-observer reliability 94%Sensitivity 99%, specificity 64%, inter-observer reliability 94%
– SimpleSimple
• Confusion Assessment Method for ICU (CAM-ICU)
– 4 features4 features
1.1. Altered or fluctuating mental status compared to baselineAltered or fluctuating mental status compared to baseline
2.2. Inattention (Attention Screening Examination – ASE, visual or auditoryInattention (Attention Screening Examination – ASE, visual or auditory
recollection of letter or images)recollection of letter or images)
3.3. Disorganised thinking – 4 Y/N questions + hold up 2 fingers on each handDisorganised thinking – 4 Y/N questions + hold up 2 fingers on each hand
4.4. Altered consciousness – sedation scale e.g. RASSAltered consciousness – sedation scale e.g. RASS
– Delirium = 1 AND 2 plus 3 OR 4Delirium = 1 AND 2 plus 3 OR 4
20. Treating deliriumTreating delirium
• Non-pharmacologicalNon-pharmacological (most studied outside ICU)(most studied outside ICU)
– Up to 40% risk reduction achievedUp to 40% risk reduction achieved
– Repeated reorientation of patientsRepeated reorientation of patients
– Early mobilisationEarly mobilisation
– Visual and hearing aids (and wax removal!)Visual and hearing aids (and wax removal!)
– Early catheter, line etc. removalEarly catheter, line etc. removal
– Minimise restraints and sedativesMinimise restraints and sedatives
21. Treating delirium -Treating delirium - haloperidolhaloperidol
– TypicalTypical antipsychoticantipsychotic
– 2-5 mg iv/po q6H (reduce in elderly)2-5 mg iv/po q6H (reduce in elderly)
– Adverse effectsAdverse effects – extrapyramidal, prolonged– extrapyramidal, prolonged
QTc, torsades (3.8%), neuroleptic malignantQTc, torsades (3.8%), neuroleptic malignant
syndromesyndrome
– More effective than lorazepamMore effective than lorazepam
– ? mortality reduction in ventilated ICU patients? mortality reduction in ventilated ICU patients
– Dopamine blockade + disinhibition of AChDopamine blockade + disinhibition of ACh
– Anti-inflammatory effectsAnti-inflammatory effects
Girard & Ely, Handbook of Clinical Neurology 2008; 90: chapter 3
22. Treating delirium – atypicalTreating delirium – atypical
antipsychoticsantipsychotics
– Olanzepine, quetiapine, risperidoneOlanzepine, quetiapine, risperidone
– Alter multiple neurotransmittersAlter multiple neurotransmitters includingincluding
DA, NA, serotonin, ACh, histamineDA, NA, serotonin, ACh, histamine
– Suggestion of decreased extrapyramidalSuggestion of decreased extrapyramidal
side-effects compared to haloperidolside-effects compared to haloperidol
– As effective as haloperidolAs effective as haloperidol
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.
