Presentation by Dr Hanan Zaghla, Critical Care Department, Cairo University

1. A protochol for
assessment and
managment of
PATIENT WITH
INTE
NSIVE CARE UNIT
PSYCHOSIS
1
ICU PSYCHOSIS

2. A protocol for assessment and
managment of patients with
ICU psychosis
Hanan Zaghla
Critical care department
Cairo University

3. Outline
 DEFINITION
 INCIDENCE
 CAUSES
 PATHOGENESIS
 WHY DO WE NEED GUIDLINES FOR
ICU PSYCHOSIS?
 MANAGMENT STRATEGY
 RECOGNITION
 PREVNENTION
 MANAGMENT
 TAKE HOME MESSAGE

4. ICU Psychosis
Or
ICU Delirium ?
Is it

5. Psychosis or Delirium ?
 Many different terms have been used to describe the
spectrum of cognitive impairment in the ICU,
including ICU psychosis, ICU syndrome, acute
confusional state, septic encephalopathy, and acute
brain failure.
 Recently, the medical literatures indicate that the signs
and symptoms of
ICU psychosis are consistent with delirium
Boltey EM, . J Crit Care. 2019 Mar 01;51:192-197.

6. Delirium is defined as a rapid change in
consciousness (hours to days) characterized by
reduced environmental awareness, decreased
attention and altered cognition.
These clinical features can manifest themselves as
memory deficits, disorientation, hallucinations,
fluctuating levels of alertness, and motor
abnormalities.
. Washington, DC: American Psychiatric Association; 2013
Definition

7. Incidence of delirium
 Delirium is one of the most common of medical
emergencies affecting up to 80% of patients in the intensive
care unit [ICU]) ,
 Annoying fact.......Annoying disease
Marcantonio ER. N Engl J Med 2017;377(15):1456-66.
 Most common psychiatric syndrome found in the general
hospital setting.
 Upto 25% of hospitalized cancer patients
 Upto 51% of postoperative patients
 Patients, who develop delirium in the intensive care until
(ICU), have a two to four fold-increased risk of death
out of the hospital.

8. Why Should We Use Delirium Guidelines
?

9. Risk
factors
`
Environmental
causes
Medical
causes
Causes of delirium
Delirium is the Brain’s way of demonstrating
“acute organ dysfunction”

10. D Drugs
E Eyes, ears, and other sensory deficits
L Low O2 states
I Infection
R Retention (of urine or stool)
I Ictal state
U Underhydraton/undernutrition
M Metabolic causes (DM, Post-operative state,
electrolytes abnormalities)
Illness and Treatment-Related Causes of Delirium
Brummel N, Girard T. . Crit Care Clin 2013; 29(1): 51–65

11. Drug-induced delirium is not uncommon
and the diagnosis is easily missed !!
Analgesics Aspirin, indometacin and opioid analgesics can cause
paranoid psychosis and delirium.
Naproxen and ibuprofen cause impairment of memory
Antidepressants
Anticonvulsants
Antisecretory drugs and mucosal protectants .
Cardiac drugs Digoxin
Class 1A antiarrhythmics
Calcium antagonists,
Angiotensin-converting enzyme (ACE) inhibitors
Amiodarone
Antibiotics e.g. quinolones.

12.  Neuroinflammation.:(IL-1B, TNF-a, ILGF-1) and
metalloproteinases, reactive oxygen species secretion and increment of
the nitrous oxide synthase. → neuronal loss
 Cholinergic Deficiency :acetylcholine acts as a modulator in
sensory and cognitive input
 Neurotransmitter Imbalance:↑ dopamine
↓ acetylcholine
 Chronic Stress ; ↑sympathetic nervous system and ↑ hypothalamic -
hypophyseal-adrenal axis, ↑cytokines levels and results in
chronic hypercortisolism → alteration in the hippocampus function.
Pathophysiology of Delirium
The Lancet Volume 383, Issue 9920, 8–14 March 2014, Pages 911-922

13. RECOGNITION OF DELIRIUM
1-EARLY PREDICTION
The Prediction of Delirium in ICU Patients (PRE-
DELIRIC) model uses 10 predictors :
 AGE
 APACHE II
 Admission group,
 Urgent admission,
 Urea level,
 Morphine use,
 Metabolic acidosis
 Sepsis
 Sedation,
 Coma,
Wassenaar A, et al. Intensive Care Med 2015;41:1048–56.[Article] [PubMed] [PMC]

14. 2.CLINICAL FEATURES
 It may be hyperactive , hypoactive or
mixed delirium
 ↓ awareness of the environment .
 ↓ ability to focus, sustain, or shift attention.
 A change in cognition
 Emotional disturbances
https://www.mayoclinic.org › delirium › symptoms-causes › syc-20371386
Jun 27, 2018
RECOGNITION OF DELIRIUM
Previous studies 32%-66% of cases are
unrecognized by Medical Staff

15. Intensive Care Delirium
Screening Checklist
(ICDSC)
The Confusion Assessment
Method for ICU
(CAM-ICU)
RECOGNITION OF DELIRIUM
Babar A. Khan et al , Crit Care Med. 2017 May; 45(5): 851–857.
Novel ICU delirium detection
strategies - Critical Care Canada ...
.
(Published online 2019 Apr 24. )
3.ASSESSMENT OF DELIRIUM

16. Intensive Care Delirium Screening Checklist
(ICDSC)
1. Altered level of consciousness 1
2. Inattention 1
3. Disorientation 1
4. Hallucinations
5. Psychomotor agitation or retardation 1
6. Inappropriate speech 1
7. Sleep/wake cycle disturbances 1
8. Symptom fluctuation 1
Total score (0‐8)
ICDSC is an 8-item checklist performed by the bedside nurses
giving 1 for each item and if the score is more than 4 ,the attending
physician should be informed for posibility of delirium
TF Kallenbach & LA Amado (2017) ,Southern African Journal of
Anaesthesia and Analgesia,

17. CMAJ Open. 2019 Apr-Jun; 7(2): E294–E299.Published online 2019 Apr 24
CAM – Confusion Assessment Method
Sensitivity (94 to 100%), specificity (90 to 95%)
Requirement for delirium = 1, 2 AND either 3 OR 4
1. Abrupt change?
2. Inattention, can’t focus?
3. Disorganized thinking? Incoherent, illogical?
4. Altered level of consciousness? (Hyper-alert to stupor?)
Decision Tree

18. Once we identify delirium, Now What?
Identify the acute medical problems that could be either
triggering the delirium, or prolonging it!
Clarify pre-morbid functional status, sequence of events
and previous admission cognitive baseline.
Identify all predisposing and precipitating factors
consider the differential diagnosis:
Dementia
Psychiatric Disorders
(ex. schizophrenia)
Depression
Traumatic Head Injury

19.  No recommendation for using a pharmacologic delirium
prevention protocol [administering prophylactic
antipsychotics to the general ICU population] in adult
ICU patients
 Early and aggressive mobilization may reduce the
incidence and duration of delirium, shorten ICU and
hospital LOS, and lower hospital costs.
 There is evidence based delirium prevention strategy .
[“ESCAPE” bundle]
What About Prevention?
Arch Intern Med. 2003;163(8):958-964. doi:10.1001/archinte.163.8.958
Try to Make ICU Less Traumatic for Patients, Families - Medscape - Jul 16 2019.

20. E S C A P E
Early
mobility
Calm
Choise of
sedation
Sleep
managment
Assess
pain and
analgesia
Psychosis
evaluation
Emotional
communicat
ion
ESCAPE bundle
Chin Med J (Engl). 2017 Oct 20; 130(20): 2498–2502..

21. PHARMACOLOGIC MANAGMENT
It is important to remember that:
 Drugs are best given PRN when agitation
becomes a concern or becomes a safety issue
 Medications must be discontinued once the
agitation from the delirium is resolved

22. 1.Benzodiazepines:
 Anxiolytic, amnestic, sedating, hypnotic, and
anticonvulsant effects, but no analgesic activity
 Their amnestic effects extend beyond their sedative effects
 Raise the seizure threshold
 Contraindicated in hepatic encephalopathy
 Could be combined with antipsychotic medication to
lower the doses of antipsychotic or for those with severe
agitation.

23.  A high-potency dopamine- blocking agent is most frequently
used because of its short half-life, few or no anticholinergic
side effects, no active metabolites, and lower sedation.
 Oral or parenteral.
 Safe in hepatic insufficiency
2.Butyrophenones
 Comparisons of haloperidol and other antipsychotics did not find
any antipsychotic to be more effective than another.(e.g
quetapine or respirdone)
World Health Organization (WHO). [cited 29 Nov 2018].
Available from url: https://www.who.int/classifications/icd/en/GRNBOOK.pdf

24. 3.Cholinergics
 Anticholinergic mechanisms may be involved in delirium from
hypoxia, hypoglycemia, thiamine deficiency, traumatic brain
injury, and stroke
 Physostigmine reversed the delirium resulting from
ranitidine , homatropine eyedrops , benztropine , and
meperidine .
T Saito, H Toda, GN Duncan, SS Jellison, T Yu… - bioRxiv, 2019 - biorxiv.org

25. Side effects
 Extrapyramidal side effects, dyskinesia, and neuroleptic
malignant syndrome.
 Lengthen the QT interval.
 lowering of the seizure threshold , elevations in liver enzymes
 Phenothiazines can be associated with sedation, anticholinergic
effects, and α- adrenergic blocking effects that can cause
hypotension
KL Houseknecht et al - The FASEB …, 2019 - fasebj.org

26. 4 .Propofol:
 Such an agent will be a very valuable addition..
 Sedation
 Analgesia
 Reduce delirium incidence
 Easy awakening for assessment
 Minimal respiratory depression
 amnestic effect is less than
benzodiazipines
Propofol Side Effects Drugs.cohttps://www.drugs.com
. Anesthesia › Propofol › Nov 6, 2017

27.  Dose-dependent respiratory depression and hypotension
 Propofol infusion syndrome (PRIS)
propofol infusion syndrome [PRIS]
 worsening metabolic acidosis
Hypertriglyceridemia
 hypotension with increasing vasopressor requirements
 Arrhythmias
 Acute kidney
injury
hyperkalemia
rhabdomyolysis
liver dysfunction
 [usually associated with prolonged administration of high
propofol doses (> 70 μg/kg/min)]
Side effects :
Kam, PC; . (July 2007). "Propofol infusion syndrome". Anaesthesia. 62
(7): 690–701.last edited on 29 January 2019

28.  ⍺2 Agonist-- sedative, analgesic/opioid sparing ,with
sympatholytic properties.
 Patients are more easily arousable and interactive
 The onset of sedation occurs within 15 mins and peak
sedation
occurs within 1 hr of starting an IV infusion .
 Dexmedetomidine is the only sedative approved in the United
States for administration in Intubated ICU patients
 Side effects: Hypotension
5.Dexmedetomidine
Jun 4, 2018 - The North American guidelines proposed strategies to prevent
delirium

29. 2013 guidelines by the Society of Critical
Care Medicine
 Continuous IV infusions of dexmedetomidine is preferred
than benzodiazepine infusions for sedation in in ICU
patients with delirium unrelated to alcohol or
benzodiazepine withdrawal.
 Although dexmedetomidine has only been approved in the
United States for short-term sedation of ICU patients (< 24 hrs),
several studies demonstrate the safety and efficacy of
dexmedetomidine infusions administered for greater than 24 hrs
(up to 28 days) .
Barr J, , et al;guidelines for the management of pain, agitation, and delirium
in adult patients in the intensive care unit. Crit Care Med 2013; 41:263–306

30. Which agent to use ?!
The (PADIS) guidelines 2018;
 Sedation strategies using nonbenzodiazepine sedatives may be
preferred over sedation with benzodiazepines to improve
clinical outcomes in mechanically ventilated adult ICU
patients where agitation is precluding weaning/extubation.
 Suggested using haloperidol or an atypical antipsychotic to
treat delirium in critically ill adults.
Clinical Practice Guidelines for the Prevention and Management of Pain,
Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the
ICU. Crit Care Med 2018; 46:e825–e873

31. Follow-up care
Inpatient (out of icu ) Care:
Carefully assess patients to determine their level of care needs.
Assessment should include
 behavior ( for 24 h).
 daily mental status.
 potential for injury.
 underlying medical and metabolic status.
https://emedicine.medscape.com/article/288890-followup

32. Outpatient (out of hospital) Care
 Following recovery, patient's memories are variable.
 Be sure to educate the patient, family, and primary
caregivers about future risk factors.
 Elderly patients may require 6-8 weeks or longer for full
recovery.
Follow-up care
https://emedicine.medscape.com/article/288890-followup

33. patients should be followed up for psychological
sequelae including cognitive impairment with
Screening for:
a. Dementia
b. Functional psychiatric disorders – post-
traumatic stress disorder
c. Depression
Salluh JIF et al. Outcome of delirium in critically ill patients:systematic review
and meta-analysis. BMJ 2015;350:h2538.
Long-Term Outcomes of ICU delirium

34. Take home message
Delirium is a common medical emergency affecting the
critically ill patient outcome .
Avoidance of risk factors decreases the incidence.
Non pharmacological prevention is essential.
Early detection of the delirium improves the outcome.
Pharmacological treatment by nonbenzodiaipines
(propfol or dexmedotemedine)or antipsychotic is
preferred rather than benzodiazepines.
The patient should be followed up after discharge to
monitor and manage long term complications.

35. REFFERENCES
1. Boltey EM, Iwashyna TJ, Hyzy RC, Watson SR, Ross C, Costa DK. J Crit Care.
2019 Mar 01;51:192-197.
2. Marcantonio ER.. N Engl J Med 2017;377(15):1456-66.
3. Persico I, Cesari M, Morandi A, Haas J, Mazzola P, Zambon A, et al. J Am Geriatr
Soc 2018;66(10):2022-30 https://www.mayoclinic.org -20371386Jun 27, 2018 MAJ
Open. 2019 Apr-Jun; 7(2): E294–E299.
4. Babar A. Khan et al , Crit Care Med. 2017 May; 45(5): 851–857.
5. Devlin JW, Skrobik Y, Gelinas C, et al. Crit Care Med 2018; 46:e825–e873
Medscape - Jul 16 2019.
6. Whitlock EL. et al. K Schomer, J Duby, R Firestone, E Nagle… - Critical Care …,
2019 - Anesthesia & Analgesia 2014;118(4):809-17. World Health Organization
(WHO).. [cited 29 Nov 2018].
7. N Haque, RM Naqvi, M Dasgupta - Canadian Geriatrics Journal, 2019 -
gjonline.ca
8. T Saito, H Toda, GN Duncan, SS Jellison, T Yu… - bioRxiv, 2019 - biorxiv.org
9. KL Houseknecht, M May, M Beauchemin, D Barlow… - The FASEB …, 2019
10.Kam, PC; Cardone D. (July 2007). Anaesthesia. 62 (7): 690–701.last edited on 29
January 2019
11.Louis C, Godet T, Chanques G, Bourguignon N, Morand D, Pereira B, . 2018
12.Barr J, Fraser GL, Puntillo K, et al; American College of Critical Care Medicine,Crit
Care Med 2013; 41:263–306
13.Devlin JW, Skrobik Y, Gelinas C, et al: Crit Care Med 2018; 46:e825–e87
14.Salluh JIF, Wang H, Schneider EB, Nagaraja N, Yenokyan G, Damluji A, et al BMJ
2015;350:h2538.

36. A huge thanks to all my inspiring
professors that have gone above and
beyond to open my mind and my heart