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Delirium in the Intensive Care Unit (ICU)
This document discusses delirium in the intensive care unit. It begins with a description of the clinical presentations of delirium, including hypoactive, hyperactive, and mixed subtypes. It then covers assessment using the CAM-ICU, predisposing and precipitating risk factors, prevention through non-pharmacological measures like the ABCDEF bundle, and treatment focusing on resolving underlying causes, addressing symptoms, and using a multimodal approach including dexmedetomidine in some cases rather than antipsychotics. The key messages are that delirium is underrecognized, prevention is critical, and a multimodal approach without overusing medication is recommended.
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Overview of delirium, its challenges in ICU, importance of recognizing issues.
Common symptoms include disturbances in consciousness, cognition, and perception, impacting recognition.
Identifies predisposing and precipitating factors like polypharmacy, age, and systemic diseases.
The necessity of screening for delirium in ICU patients, highlighting frequency and long-term impacts.
Introduces assessment tools like RASS and CAM-ICU for early delirium detection.
Challenges such as sedation levels impacting assessment and importance of rigorous checks.
Strategies to prevent delirium include stopping offending medications and non-pharmacological methods.
Review of pharmacological treatments including mixed results for Haldol and Dex, emphasizing caution.
Presentation of studies on delirium duration and patient outcomes, showing varied effectiveness.
Non-pharmacological approaches and the ABCDEF bundle aimed at improving outcomes in ICU.
Impact of rapid reversal on delirium outcomes, emphasizing importance in management strategies.
Summary and essential points on identifying, preventing, and treating delirium in ICU settings.
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Delirium in the Intensive Care Unit (ICU)
- 1. Intensivist: “Houston, WeHave a Problem” Literature: “You Mean You’ve HAD a Problem?” Viren Kaul PCCM Fellow Sinai / EHC @virenkaul
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- 5. What Does it“Look” Like? Hyperactive Delirium 2% Hypoactive Delirium 44% Mixed Delirium 54% Girard,CriticalCare2008. “The Difficult Patient”: Bad terminology, bad outcomes “The Easy to Miss Patient”: Bad recognition, bad outcomes
- 6. Clinical Presentation Girard, CriticalCare 2008. Language Speech Memory Perception Construction
- 7. Predisposing Factors • Polypharmacy •Sensory impairment • Depression • Dehydration • Age / Dementia • Underlying CNS path • Substance abuse • Meds: BZD • Pain • Constipation / Urinary retention • Electrolyte abnormalities • Lack of sensory aids • High number of procedures • Immobility • ICU admission • Emergent surgery • Major medical illness Precipitating Factors
- 8. That’s ALL ourpatients! One can (and I am) arguing that EVERYONE in an ICU should be screened and treated (without meds!)
- 9. The differentials /mimickers: Other causes of encephalopathy / systemic diseases • SDH • Dementia • Seizures • Stroke • Sleep deprivation CNS • Substance / EtOh • Withdrawal • Wernicke’s • Hypoglycemia • Meds: BZD, antichols, etc! Toxic Metabolic • Sepsis • Dementia • UTI • Meningo- encephalitis Infections • Hypoxia • Hypertensive encephalopathy • Shock • Hepatic / renal failure Systemic
- 10. Work up (bemindful, in 2019, most ICUs have this already done for the patient!) – LFTs / Ammonia – TSH – VBG (PaCO2) – Infectious W/U – Pertinent drug levels (e.g. digoxin, lithium, theophylline, AEDs) – Tox W/U, depending on context (e.g. carboxyhemoglobin level) Consider neurotesting: – Unclear story (CT) – CNS trauma (CT) – Anticoagulation on board (CT) – FND (CT/MRI) – GCS very low and unexplained despite initial W/U (CT) – Concern for infection (LP) – Concern for seizures (EEG) IBCC, Josh Farkas @PulmCrit
- 11. The Damage • 50%frequency in ICU pts • Extra 5 days on MV • Extra 8-10 days hLOS • 50% cognitive impairments at D/C • 33% long term impairment!
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- 13. Why Detect Early? Oh,JAMA 2017. Inouye. Annals of IM 1990.
- 14. Assessing Delirium: Simple,Yet Not Simple: Step 1 Do a RASS check: If RASS < -2: Wait and repeat If RASS -2 and above = Perform CAM-ICU
- 15. Assessing Delirium: Simple,Yet Not Simple: Part 2 CAM-ICU score: Sens: 94 – 100% Spec: 90 – 95% High Interrater reliability Oh, JAMA 2017. Inouye. Annals of IM 1990. CAM-ICU Diagnostic Algorithm Acute onset OR fluctuating course Inattention Disorganized thinking ALC
- 16. Original Worksheet by Ely,Vanderbilt 2002. Takes 2 minutes to complete! This is not a sales pitch, it literally takes 2 minutes to perform.
- 17. Challenges to CAM-ICUAssessment: Level of Sedation Adapted from: SCCM. PADIS teaching slides 2018. 4 observational studies (97% CAM-ICU used) 12,699 delirium assessments RASS -2 Positive delirium assessments: 77% RASS 0 to - 1 Positive delirium assessments: 23%
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- 19. Preventing Delirium: StopDoing Stuff! Stop offending meds And don’t use them! Multimodal pain control w/o overdoing Improved sleep quality & stop disturbing them! 5Ps: Pain, Poop, Pee, Pressure, Presence
- 20. Pharmacological Prevention ofDelirium Boogaard, JAMA 2018. Slooter, Handbook of clinical neurology 2017. Su, The Lancet 2016. Haldol REDUCE RCT Risperidone Other antipsychotics Steroids Statins Gabapentin Precedex Su 2016 No diff in delirium or mortality May reduce hallucinations No diff in duration or occurrence of delirium Data Minimal Reduction in delirium 79% vs 32% (Placebo vs Dex) PADIS (2018): No agent advised for PPx Conditional / Low Factor in effect on sleep: I’m keeping an open mind about Dex
- 21. Low Dose NocturnalDex for Prevention of Delirium Skrobik, AJRCCM 2018. Outcome Dex vs Placebo n = 50 Number of patient delirium free 80% vs 54% Leeds Sleep Evaluation Questionnaire No difference
- 22. Melatonin Agonists forPrevention of Delirium in ICU PULMCrit, Josh Farkas. @PulmCrit Study (n) Intervention Rate of Delirium Hatta 2014 (n = 67) 8 mg ramelteon QHS X 1 week 3% vs 32% (p=0.003) Mistraletti 2015 (n = 82) 6 mg melatonin nightly Reduced hydroxyzine use for insomnia Nishikimi 2018 (n = 88) 8 mg ramelteon QHS X duration of ICU stay 24% vs 47% (p=0.048)
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- 24. Pharmacological Treatment ofDelirium SCCM PADIS Guidelines 2018 Reade, JAMA 2016. Drug vs *** Outcomes Result Haldol vs No medication Duration of delirium Duration of MV ICU mortality Not significant (3 RCTs, n = 265) Not significant (2 RCTS, n = 124) Not significant (3 RCTs, n = 265) Atypical antipsychotics vs No medication Duration of delirium Duration of MV ICU LOS ICU mortality Not significant (2 RCTs, n = 102) Not significant (2 RCTS, n = 95) Not significant (3 RCTs, n = 102) Not significant (3 RCTs, n = 102) Dex vs Placebo (DahLIA study) Ventilator free hours ICU LOS hLOS Mean difference 17 hours (1 RCT, n = 74) No difference PADIS (2018): Meds not advised for Rx of Delirium (Conditional, Low Quality) PADIS (2018): Suggest using Dex if agitation/delirium precluding vent liberation (Conditional, Low)
- 26. MIND-USA: Delirium/Coma-Free Days GirardTD, et al. N Engl J Med. 2018;379:2506-2516 0 4 8 10 14 *Adjusted Median Days (95% CI) 62 12 Placebo Haloperidol Ziprasidone OR: 1.04 (0.73-1.48) OR: 0.88 (0.64-1.21) Reference *Adjusted for age, Charlson, baseline frailty, baseline IQCODE, and SOFA and RASS at randomization
- 27. MIND-USA: Hypoactive DeliriumDays Girard TD, et al. N Engl J Med. 2018;379:2506-2516 0 4 8 10 14 Adjusted Median Days (95% CI) 62 12 Placebo Haloperidol Ziprasidone OR: 1.00 (0.68-1.47) OR: 1.10 (0.81-1.48) Reference
- 28. MIND-USA: Hyperactive DeliriumDays Girard TD, et al. N Engl J Med. 2018;379:2506-2516 0 4 8 10 14 Adjusted Median Days (95% CI) 62 12 Placebo Haloperidol Ziprasidone OR: 1.09 (0.70-1.70) OR: 1.18 (0.86-1.61) Reference
- 29. Non-pharmacological Multimodal Treatmentof Delirium SCCM PADIS Guidelines 2018 Study Design / Population Intervention Colombo 2012 Before – After / Mixed ICU Reorientation + environmental / acoustic / visual stimulation Foster 2013 Before – After / Mixed ICU Sedation, sleep wake, sensory stimulation, mobility, music Moon 2015 RCT / Mixed ICU Delirium risk monitoring, cognition / orientation, environment, early therapeutic intervention Hanison 2015 Before – After / Mixed ICU 1st cycle: reduce deliriogenic drugs, daily SV, environmental changes, light exposure, communication aids 2nd cycle: natural light, clocks Rivosecchi 2016 Before – After / Mixed ICU Music, opening blinds, reorientation, cognition, eye/ear protocol Use of these strategies à Reduced occurrence and duration of delirium, ICU LOS, hospital mortality PADIS (2018): Suggest using multimodal non pharmacological interventions (Conditional, Low)
- 30. ABCDEF bundle SCCM /ICU liberation Adapted from SCCM / ICU liberation
- 31. ABCDEF bundle cohort study 2017 n= 6064 Focus on the “F” component Barnes-Daly, CCM 2017.
- 32. Are Outcomes ofDelirium Different if Reversed Rapidly? Patel, AJRCCM 2014. No Delirium Rapidly Reversible Delirium Mixed Delirium Persistent Delirium Days of MV 2.4 2.5 5.1 6.2 ICU LOS 4.0 4.5 9.7 13.1 hLOS 8.1 6.7 26.8 25.4 Prospective cohort. 102 MV pts compared before and after daily interruption of sedation
- 33. Are Outcomes ofDelirium Different if Reversed Rapidly? Patel, AJRCCM 2014. No Delirium Rapidly Reversible Delirium Mixed Delirium Persistent Delirium Days of MV 2.4 2.5 5.1 6.2 ICU LOS 4.0 4.5 9.7 13.1 hLOS 8.1 6.7 26.8 25.4 YES PADIS (2018): When rapidly reversed, sedation related delirium has similar outcomes to no delirium (Conditional, Low Quality)
- 34. Treatment of Delirium:Summary Rx underlying cause • Shock states • Infection • Na • Hyperglycemia • Dysvolemia Address • Pain • Poop: Constipation • Pee: Urinary retention • Presence: Frequent reorientation • Position for comfort Other PADIS components • Mobility • Sleep • Sleep-wake cycle • Reorientation • Tangible contact • Hearing/seeing aids • Less alarms
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- 36. Know what deliriumlook like Hypoactive >> hyperactive Majority of patients in ICU at risk CAM-ICU everyone w/ RASS > -2 Prevent iatrogenesis DELIBRATE PRACTICE Multimodal non pharm Measures for ALL patients Rx: Minimal use of anti-psychotics Use instead: Dex, esp when liberating PADIS / SCCM 5Ps and Meds