Dr.Peter Papdakos virtual lecture

1. Delirium In Neuro-ICU 2011 PJ Papadakos MD Director CCM University of Rochester Rochester NY.

2. Assessing and Managing Sedation

3. Predisposing and Causative Conditions Anxiety Pain Delirium Interventions Management of predisposing & causative conditions Sedative, analgesic, antipsychotic, medications Calm Alert Free of pain and anxiety Lightly sedated Deeply sedated Unresponsive Pain, anxiety Agitation, vent dyssynchrony Dangerous agitation Spectrum of Distress/Comfort/Sedation ICU Environmental Influences Hospital Acquired Illness Medications Invasive, Medical, & Nursing Interventions Underlying Medical Conditions Acute Medical or Surgical Illness Mechanical Ventilation Agitation Sessler CN, Varney K. Chest. 2008;133(2):552-565.

8. Identifying and Treating Pain

10. Maintaining Patients at the Desired Sedation Goal

11. Sedation-Agitation Scale (SAS) Riker RR, et al. Crit Care Med. 1999;27:1325-1329. Brandl K, et al. Pharmacotherapy. 2001;21:431-436.

12. Richmond Agitation Sedation Scale (RASS) Ely EW, et al. JAMA . 2003;289:2983-2991. Sessler CN, et al. Am J Respir Crit Care Med. 2002;166(10):1338-1344. Verbal Stimulus Physical Stimulus

13. The Importance of Preventing and Identifying Delirium

17. Delirium Duration and Mortality Pisani MA. Am J Respir Crit Care Med . 2009;180:1092-1097. Kaplan-Meier survival curve for 1- year mortality post–ICU admission P < 0.001

18. Confusion Assessment Method (CAM-ICU) or 3. Altered level of consciousness 4. Disorganized thinking = Delirium Ely EW, et al. Crit Care Med . 2001;29:1370-1379. Ely EW, et al. JAMA . 2001;286:2703-2710. 1. Acute onset of mental status changes or a fluctuating course 2. Inattention and and

26. Risk of Delirium With Benzodiazepines Pandharipande P, et al. J Trauma. 2008;65:34-41. Pandharipande P, et al. Anesthesiol. 2006:104:21-26. Lorazepam Dose, mg Delirium Risk

27. Propofol Has Greater Sedation Efficacy Than Continuous Midazolam Walder B, et al. Anesth Analg. 2001;92:975-983. Efficacy of Sedation* Duration of Adequate Sedation * Avg adequate sedation time avg total sedation time n = 18 trials n = 15 trials

28. DEX

29. ?  2A  2C  2A  2A Anxiolysis  2B  2B X  2B X Adapted from Kamibayashi T, Maze M. Anesthesiology . 2000;93:1346-1349. Physiology of   Adrenoceptors  2A

32. MENDS Delirium: All Patients Pandharipande PP, et al . Crit Care . 2010;14:R38.

33. MENDS: Survival in Septic ICU Patients Pandharipande PP, et al . Crit Care . 2010;14:R38.

35. Strategies to Reduce the Duration of Mechanical Ventilation in Patients Receiving Continuous Sedation

38. Number of respondents (%) Barriers to Daily Sedation Interruption (Survey of 904 SCCM members) Clinicians preferring propofol were more likely use daily interruption than those preferring benzodiazepines (55% vs 40% , P < 0.0001) Tanios MA, et al. J Crit Care . 2009;24:66-73. 0 10 20 30 40 50 60 70 Leads to PTSD Leads to cardiac ischemia No benefit Difficult to coordinate with nurse Leads to respiratory compromise Compromises patient comfort Poor nursing acceptance Increased device removal #1 Barrier #2 Barrier #3 Barrier

39. Prevention and Treatment of Delirium in the ICU

43. Use of Atypical Antipsychotic Therapy Is Increasing Ely EW, et al. Crit Care Med. 2004;32:106-112. Patel RP, et al. Crit Care Med. 2009;37:825-832. 0 10 20 30 40 50 60 70 80 90 Atypical anti-psychotics Benzodiazepines Haloperidol Propofol 2001 2007

46. Placebo Quetiapine Proportion of Patients with Delirium Day During Study Drug Administration Log-Rank P = 0.001 Quetiapine added to as-needed haloperidol results in faster delirium resolution, less agitation, and a greater rate of transfer to home or rehabilitation. Devlin JW, et al. Crit Care Med . 2010;38:419-427. Patients with First Resolution of Delirium

47. The Interaction Between Sedation, Critical Illness and Sleep in the ICU