2. What is delirium?
Disturbance of consciousness
Acute change in mental status
Fluctuating course – worse at night
Develops over short time, hours to days
Impaired attention
Disorganised thinking
“ ? 6 th Vital sign “
3.
4. Epidemiology
• Prevalence of delirium in ICU patients was 32.3%
• In specialized ICUs, prevalence may be higher.
• It is 77% in ventilated burn patients
• The incidence of delirium in the ICU ranges from 45% to 87%
• incidence of delirium in ICU is 20% in nonintubated
& 83% in mechanically ventilated patients
5. Why is this important?
common
3 fold higher rate of death by 6 months
Increase time on ventilator (9 vs 4 days)
Increase ICU stay ( 8 vs 5 days)
1.6 fold increase in ICU costs. ( $ 22000 vs 13000)
Longer hospital stays ( 22 Vs 11 days)
Distress to caregivers
Nearly 10x rate cognitive impairment on discharge.
1 in 3 survivors with delirium develop cognitive impairment (
permanent)
6. Delirium
• Synonyms: acute confusional state, organic brain syndrome,
encephalopathy, terminal agitation, terminal restlessness
• Often mistaken for depression, anxiety or dementia
Terminal agitation:
A symptom or sign: thrashing, agitation that may occur in the last days
or hours of life
May be caused by
Pain anxiety dyspnea delirium
7.
8.
9. Delirium is often invisible
The vast majority of delirium in ICU is either hypoactive “quiet” subtype
(35%) or mixed (64%)
Very little (1%) is the pure hyperactive subtype.
Older age is a strong predictor of hypoactive delirium
Hypoactive delirium has worse outcomes
Onset: ICU day 2 (+/- 1.7)
How long: 4.2 (+/- 1.7) days, may be weeks or longer
10. Pathophysiology
• Neuroimaging – 42% ↓CBF, atrophy
• Psychoactive drugs 3-11 fold ↑ delirium
• Related to surgery – multifactorial
• Biomarkers – serum anticholinergic activity
• Neurotransmitters – imbalance in all monoamines, GABA, glutamate and Ach
• Sepsis: blood brain barrier breakdown or damage by metabolic/inflammatory
mediators
16. Diagnostic approach to Delirium
• Delirium is a clinical , bedside diagnosis
• Careful, gentle approach to patient
• Appearance, vital signs
• Focused exams based on history
• consider rectal exam/ catheterization ( if needed)
17. How to diagnose delirium?
Mr. X, a 70-year old with severe COPD, is in the MICU on a ventilator
for respiratory failure. Initially he needed high levels of sedation, but
now sedation has been decreased and Mr. X is awake but agitated,
grimacing, thrashing and trying to sit up in bed. He makes eye
contact, but won’t follow commands
Is Mr. X delirious?
27. Haldol IV recommended by SCCM
• Long half-life (18-54 hours)
• Risk of: QT prolongation, NMS, akathisia
• Monitor QTc BID, follow K, Mg, Ca.
• Beware other drugs that prolong QT (MANY including anti-
arrhythmics, quinolones, erythromycin, methadone)
Pharmacologic Management : Antipsychotics
28. Haloperidol (Haldol)
• Action: CNS depressant and dopamine receptor antagonist
• Side Effects: Prolonged QT interval, Extrapyramidal symptoms, tardive dyskinesia
(long term use)
• IV Dosing:
• Starting dose: Mild agitation 2mg IV,
Moderate to severe agitation 5mg IV
• After 20 min. of 1st dose, if still agitated increase the previous doses by 5mg every
20min until calm.
• Max dose 30 mg in 24 hours
• Once pt is calm, 25% of loading dose should be given Q 6 hours scheduled
• Once pt is delirium free for 24 hours taper off haldol
Pharmacologic Management
29. • Recent double-blind RCT of quetiapine (Seroquil) 50mg BID vs
placebo
• Haldol PRN – study drug increased if any PRN in 24 hours
• 36 ICU patients with delirium
• Shorter time to resolution of delirium (1 vs 4.5 days)
• Reduced duration of delirium (36 vs 120 hours)
• More somnolence with quetiapine, other SEs similar
Atypical Antipsychotics
30. Not typically given IV or IM
• Quetiapine (Seroquil)
• 25mg - 50mg PO
• Risperidone (Risperdal)
• 1 mg - 3 mg PO daily
• Olanzapine (Zyprexa)
• 5mg- 20 mg PO
• 5mg -10 mg IM
Atypical Antipsychotics
(Second Generation)
31. 1. Analgesia
In Pain?
2. Sedation
RASS at target (-1 to 0)
3. Delirium
CAM-ICU positive?
Fentanyl prn
Morphine prn
If not controlled with
2-3 doses/hour, start
Fentanyl
Reassess
Oversedated
Hold sedatives and
analgesics to achieve
RASS target.
Undersedated
1. Benzo prn
2. Propofol
Reassess
1. Underlying cause
2. Non-pharm
management
3. Pharm
management
32. • What is the Daily RASS Goal?
• What is the patient’s RASS now?
• Is the patient on optimal sedation for the RASS goal?
• Combination of sedative and narcotic is synergistic
• Side effects of most agents include:
• Delirium
• Hypotension
• Respiratory depression
Sedation Management
• Increased tolerance with withdrawal
syndromes
• Risk of seizures if stopped abruptly
• Difficulty assessing neurologic status
33. • Inappropriate sedation (over and under) is a frequent problem, causing:
• Increased levels of agitation, delirium
• Sleep fragmentation
• Increased rates of VAP, nosocomial infections, days on mechanical ventilation,
hospital stays, costs
• Self-extubation, reintubation, accidental line removal
• Sedation is rarely discussed in a uniform fashion among health care providers
Sedation and Analgesia: Challenges
34. Benzodiazepines
• Onset
• midazolam<diazepam<lorazepam
• Start with IV push before starting an infusion
• Duration
• diazepam>lorazepam>midazolam> propofol
• (NB midazolam and diazepam highly lipophilic)
• Elimination
• renal failure: active metabolites accumulate for midazolam and diazepam
• cirrhosis: prolongation of metabolism to active metabolites for midazolam &
diazepam
Sedation
35. Opiates
• Consider non-opiate analgesics
• Little amnestic effect
• Active metabolites, lipid deposition (Fentanyl)
• Side effects:
• Respiratory depression
• Hypotension (Morphine > Fentanyl)
• GI (constipation, ileus, gastroparesis, nausea)
• Delirium
• Tolerance followed by withdrawal syndromes
Pain Management
36. • Multidisciplinary process that incorporates expertise from
clinical Psycologist, physicians, nurses, pharmacy, and others
• Uses appropriate quantitative scales to assess and set treatment goals
• Provides etiology-driven treatment (treat pain with analgesics, anxiety with
anxiolytics, etc)
• Avoids over-sedation & under-sedation
• Minimizes the use of sedatives, which can lead to delirium, further agitation,
withdrawal syndromes
• Monitors response to therapeutic interventions
Goal-oriented Management
37. 1. Documentation of RASS Q4 h (all patients)
2. Documentation of CAM-ICU Q8 h (all patients)
3. Discussion of RASS and CAM-ICU by team on daily work
rounds
4. Use Sedation Guideline for sedation and delirium
management
5. Consideration of daily wake-up and daily SBT if appropriate
6. Inclusion of sedation goals on daily goal sheets
Expectations for Our ICU
38. Delirium
• Prevent It Know the risk
• Recognise it assess it
• Revers it reverse the reversible
• Treat it non -Pharmacological antipsycotic
Hinweis der Redaktion
most recent area of the hospital in which delirium is just beginning to be monitored routinely in many centers is the Emergency Department, where the prevalence of delirium among older adults is about 10%.[51] A systematic review of delirium in general medical inpatients showed that estimates of delirium prevalence on admission ranged from 10 to 31%
a multicenter study, the prevalence of delirium in ICU patients was 32.3% [4]. In specialized ICUs, the prevalence of delirium may be higher. For instance, a study showed a prevalence of delirium as high as 77% in ventilated burn patients [5]. The incidence of delirium in the ICU ranges from 45% to 87% [6-8]. The incidence appears to vary according to whether the studied population is composed exclusively of mechanically ventilated patients. As an example, a study found an incidence of delirium of only 20% in nonintubated ICU patients [9], whereas another study found an incidence of 83% in mechanically ventilated patients
USA, the cost of a patient admission with delirium is estimated at between $16k and $64k, suggesting the national burden of delirium may range from $38 bn to $150 bn per year (2008 estimate). In the UK, the cost is estimated as £13k per admission
Terms widely accepted and scientifically supported is ICU Delirium (2012).
decreased cholinergic activity may lead to delirium ,# anticholinergic medication associated with increase in delirium symptoms and that patients with delirium have higher serum anticholinergic activity # overactivity of the dopaminergic system#
chronic alcohol exposure may lead to a decrease in the number of and function of gamma aminobutyric acid receptors and an increase in the N-methyl-D-aspartate receptors.
ensuring that the patient with delirium has adequate oxygenation, hydration, nutrition, and normal levels of metabolites, that drug effects are minimised, constipation treated, pain treated, and so on. Detection and management of mental stress is also very important. involving family members, having recognizable faces at the bedside, having means of orientation available (such as a clock and a calendar) may be sufficient in stabilizing the situation, unnecessary attachments are removed (IVs, catheters, NG tubes) which allows for greater mobility
British professional guidelines by the National Institute for Health and Clinical Excellence advise haloperidol or olanzapine. Benzodiazepines themselves can cause delirium or worsen it, However, if delirium is due to alcohol withdrawal or benzodiazepine withdrawal or if antipsychotics are contraindicated (e.g. in Parkinson's disease or neuroleptic malignant syndrome), then benzodiazepines are recommended.
