Delirium in ICU Characteristic, Diagnosis and Prevention
-
Upload
hospira2010 -
Category
Documents
-
view
6.620 -
download
13
Transcript of Delirium in ICU Characteristic, Diagnosis and Prevention
![Page 1: Delirium in ICU Characteristic, Diagnosis and Prevention](https://reader033.fdocuments.net/reader033/viewer/2022052523/556b856dd8b42a6c7c8b4e22/html5/thumbnails/1.jpg)
Delirium in ICUCharacteristic, Diagnosis and
Prevention
Marcelo G. Rocha, M.D.Marcelo G. Rocha, M.D.ICU Pav. Pereira Filho
S t C P t AlSanta Casa Porto Alegre RGS Brazil
![Page 2: Delirium in ICU Characteristic, Diagnosis and Prevention](https://reader033.fdocuments.net/reader033/viewer/2022052523/556b856dd8b42a6c7c8b4e22/html5/thumbnails/2.jpg)
OUTLINE OF THE TALK• Definitions
– types/prevalence/importance– risk factors/pathoetiology of deliriumrisk factors/pathoetiology of delirium
• What can we do to prevent delirium:a. Monitoringb. Non pharmacolgical interventionsp gc. Reduction in deliriogenic medications
• Use of Protocols and “less is more”• Use of Protocols and less is more
d. Pharmacological interventionsa Antips choticsa. Antipsychoticsb. Dexmedetomidine
![Page 3: Delirium in ICU Characteristic, Diagnosis and Prevention](https://reader033.fdocuments.net/reader033/viewer/2022052523/556b856dd8b42a6c7c8b4e22/html5/thumbnails/3.jpg)
Definition of DeliriumDefinition of Delirium
• derived from Latin:derived from Latin:– de “away from”– lira “ furrow in field” – ium (Latin for singular)ium (Latin for singular)
![Page 4: Delirium in ICU Characteristic, Diagnosis and Prevention](https://reader033.fdocuments.net/reader033/viewer/2022052523/556b856dd8b42a6c7c8b4e22/html5/thumbnails/4.jpg)
DeliriumDelirium
li i i• Delirium is (1) fluctuation/change in mental status(1) fluctuation/change in mental status (2) inattention
either/or(3) disorganized thinking(3) disorganized thinking (4) altered level of consciousness( )
DSM IV and CAM‐ICU
![Page 5: Delirium in ICU Characteristic, Diagnosis and Prevention](https://reader033.fdocuments.net/reader033/viewer/2022052523/556b856dd8b42a6c7c8b4e22/html5/thumbnails/5.jpg)
Delirium – a brain organ dysfunction
Morandi et al ICM 2008;34:1907‐1915
![Page 6: Delirium in ICU Characteristic, Diagnosis and Prevention](https://reader033.fdocuments.net/reader033/viewer/2022052523/556b856dd8b42a6c7c8b4e22/html5/thumbnails/6.jpg)
Delirium Subtypesyp• Hyperactive delirium ‐agitation restlessness pulling catheters or tubesagitation, restlessness, pulling catheters or tubes, hitting, biting, and emotional lability. (At risk for self‐extubation and subsequent reintubation)q )
• Hypoactive delirium –ypwithdrawal, flat affect, apathy, lethargy and perhaps even unresponsiveness; often unrecognized due to h “ i ” ( i k f i ithese “quiet” symptoms; (At risk for aspiration, pulmonary embolism, decubitus ulcers, and other complications related to immobility)complications related to immobility)
• Mixed ‐ combinationMixed combination
![Page 7: Delirium in ICU Characteristic, Diagnosis and Prevention](https://reader033.fdocuments.net/reader033/viewer/2022052523/556b856dd8b42a6c7c8b4e22/html5/thumbnails/7.jpg)
D li i C iti I i tDelirium versus Cognitive Impairment
• Delirium • Cognitive impairment– rapid onsetfluctuation
– variable to insidious onset– not fluctuating– fluctuation
– clouded consciousness
not fluctuating– no clouding of consciousness– Inattention, disorganized
thought
consciousness– many domains impaired
– not chronic – persistent/chronic (?)
Gordon SM, Intensive Care Med 30:1997‐2008, 2004Jackson JC, Intensive Care Med 30:2009‐2016, 2004
![Page 8: Delirium in ICU Characteristic, Diagnosis and Prevention](https://reader033.fdocuments.net/reader033/viewer/2022052523/556b856dd8b42a6c7c8b4e22/html5/thumbnails/8.jpg)
Prevalence of ICU DeliriumPrevalence of ICU Delirium
• Occurs in up to 80% MICU/SICU MVpatients• 20‐50% of lower severity ICU patients develop20 50% of lower severity ICU patients develop• Hypoactive or mixed forms most common• 65‐70% goes undiagnosed if routine monitoring is not implementedp
Roberts B Aust Crit Care 2005;18:6 8‐9Ely EW. ICM. 2001;27:1892‐1900.Ely EW. JAMA. 2001;286,2703‐2710.Pandharipande. J Trauma. 2008;65:34‐41.Ely EW CCM 2001;29:1370‐1379
Roberts B. Aust Crit Care. 2005;18:6,8‐9.Thomason J. Crit Care. 2005;9:375‐381.
Ely EW. CCM. 2004;32:106‐112.Peterson. JAGS. 2006;54:479‐484.Ely EW. CCM. 2001;29:1370 1379.
Pandharipande. ICM. 2007;33:1726‐1731.Lat I. CCM.2009;37:1898‐1905
Ouimet S. ICM. 2007;33:66‐73.Spronk P. Neth J Med.2009;67:296‐300
Slooter A. CCM.2009. 37 (6):1881‐1885, 2009
![Page 9: Delirium in ICU Characteristic, Diagnosis and Prevention](https://reader033.fdocuments.net/reader033/viewer/2022052523/556b856dd8b42a6c7c8b4e22/html5/thumbnails/9.jpg)
“I i ibl ” O D f ti“Invisible” Organ Dysfunction
• Delirium is not routinely monitored in the ICU 1• Validated tools – ICU‐DSC 2 or CAM‐ICU 3‐4• “ICU Psychosis” traditionally an expected outcome• In non‐ICU settings delirium has been associated withIn non ICU settings, delirium has been associated with prolonged stay, institutionalization, and death 5‐7
4 Ely EW CCM 2001;29,1370‐795 Inouye, Am J Med 1999;106:565‐5736
1 Ely EW CCM 2004;32:106‐1122 Bergeron, ICM 2001;27:859‐64
6 Lawlor, Arch Intern Med 2000;160:786‐7947 McCusker, Arch Intern Med 2002;162:457‐463
g , ;3 Ely EW JAMA 2001;286,2703‐2710
![Page 10: Delirium in ICU Characteristic, Diagnosis and Prevention](https://reader033.fdocuments.net/reader033/viewer/2022052523/556b856dd8b42a6c7c8b4e22/html5/thumbnails/10.jpg)
ICU D li i i li tiICU Delirium ‐ implications3 i hi h i k f d h b 6 h• 3 times higher risk of death by 6 months
• $15k to $25k higher hospital costs• Estimated national $4 to $16 billion associated costs • 5 fewer ventilator free days (days alive and off vent), adjusted P=0.03
• 9 times higher incidence of cognitive impairment at hospital discharge, adj. P=0.002
• Using similar methodology (CAM‐ICU, etc) a Taiwanese cohort found similar mortality data
Ely EW et al, JAMA 2004;291‐1753‐1762y , ;Milbrandt E et al, Crit Care Med 2004;32:955‐962Lin et al, Crit Care Med 2004;32:2254‐59
![Page 11: Delirium in ICU Characteristic, Diagnosis and Prevention](https://reader033.fdocuments.net/reader033/viewer/2022052523/556b856dd8b42a6c7c8b4e22/html5/thumbnails/11.jpg)
Risk factorsModifiable Risk Factor
Preexisting Risk Factors • Sedatives/analgesics• Sleep disturbances
• Dementia• Cognitive dysfunction
• Sleep disturbances• Prolonged immobilization• Poor oxygenation• Cognitive dysfunction
• Age• Severity of illness
• Poor oxygenation• Glucose• Pain• Severity of illness
• Comorbidities• Pain• Infection• Anticholinergic• Anticholinergic Medication
• Electrolyte disturbancesy• Dehydratation
![Page 12: Delirium in ICU Characteristic, Diagnosis and Prevention](https://reader033.fdocuments.net/reader033/viewer/2022052523/556b856dd8b42a6c7c8b4e22/html5/thumbnails/12.jpg)
Risk factors you can’t controlRisk factors you can t control
S i f lAgeEach year increase risk in 2%
Severity of IlnessEach point increase risk in 6%
Pandharipande P et all. Lorazepan is an independent risk factor for transitioning todelirium in ICU patients, Anesthesiology, 2006; 104:21‐26
![Page 13: Delirium in ICU Characteristic, Diagnosis and Prevention](https://reader033.fdocuments.net/reader033/viewer/2022052523/556b856dd8b42a6c7c8b4e22/html5/thumbnails/13.jpg)
Risk factors you can control: medicationRisk factors you can control: medication
Pandharipande P et all. Lorazepan is an independent risk factor for transitioning todelirium in ICU patients, Anesthesiology, 2006; 104:21‐26
![Page 14: Delirium in ICU Characteristic, Diagnosis and Prevention](https://reader033.fdocuments.net/reader033/viewer/2022052523/556b856dd8b42a6c7c8b4e22/html5/thumbnails/14.jpg)
Midazolam and fentanyl as risk factors for delirium
Midazolam Fentanyl
Users
Midazolam
100
Users
Fentanyl
100
UsersNon-Users
ous
6080
p=0.014p=0.031
UsersNon-Users
ous
6080
p=0.007
p=0 936
Day
s D
eliri
o
406
Day
s D
eliri
o
406 p=0.936
%
20
%
20Surgical Trauma
Daily Midazolam Use (Exc Coma Days)
0
Surgical Trauma
Daily Fentanyl Use (Exc Coma Days)
0
Daily Midazolam Use (Exc. Coma Days) Daily Fentanyl Use (Exc. Coma Days)
Pandharipande et al., J Trauma.2008:65;34‐41
![Page 15: Delirium in ICU Characteristic, Diagnosis and Prevention](https://reader033.fdocuments.net/reader033/viewer/2022052523/556b856dd8b42a6c7c8b4e22/html5/thumbnails/15.jpg)
A basic pathoetiological model of deliriumMaldonado J, Crit Care Clin 2008
![Page 16: Delirium in ICU Characteristic, Diagnosis and Prevention](https://reader033.fdocuments.net/reader033/viewer/2022052523/556b856dd8b42a6c7c8b4e22/html5/thumbnails/16.jpg)
Hipoxemia, metabolic derangements Systemic Inflamation
DrugsActivation of primed
microgliaGlobal impairment of cerebral metabolism
Decreased synthesis Neurotransmitter
imbalance, disruptionIncreased cytokines levels in the brain
and release of neurotransmitters
imbalance, disruption of synaptic
communication
deliri mdelirium
![Page 17: Delirium in ICU Characteristic, Diagnosis and Prevention](https://reader033.fdocuments.net/reader033/viewer/2022052523/556b856dd8b42a6c7c8b4e22/html5/thumbnails/17.jpg)
What should we do to preventWhat should we do to prevent delirium in ICU patients?p
1. Monitoring 2. Non pharmacolgical interventions2. Non pharmacolgical interventions3. Reduction in deliriogenic medications4. Pharmacological interventions
DexmedetomidineDexmedetomidineAntipsychotics
![Page 18: Delirium in ICU Characteristic, Diagnosis and Prevention](https://reader033.fdocuments.net/reader033/viewer/2022052523/556b856dd8b42a6c7c8b4e22/html5/thumbnails/18.jpg)
Two Step Approach to Assessing Consciousness
Step 1 Level:Arousal/Sedation Assessment (RASS, SAS)( f i h d )(If pt opens eyes to voice then proceed to Step 2)
Step 2 Content: Delirium Assessment (CAM‐ICU)
![Page 19: Delirium in ICU Characteristic, Diagnosis and Prevention](https://reader033.fdocuments.net/reader033/viewer/2022052523/556b856dd8b42a6c7c8b4e22/html5/thumbnails/19.jpg)
Confusion Assessment MethodCAM‐ICU
1 A t t f t l t t h1. Acute onset of mental status changes or a fluctuating course
and2 I i2. Inattention
andand
or3. Disorganized 4. Altered level of Thinking consciousness
= DeliriumEly, E.W., et al. JAMA; 286, 2703‐2710, 2001. Ely, E.W., et al. Crit Care Med; 29, 1370‐1379, 2001.
![Page 20: Delirium in ICU Characteristic, Diagnosis and Prevention](https://reader033.fdocuments.net/reader033/viewer/2022052523/556b856dd8b42a6c7c8b4e22/html5/thumbnails/20.jpg)
ICU Delirium Screening Checklist8 items based on DSM criteria8 items based on DSM criteria
Normal = 0, 1‐3 = subsyndromal delirium, ≥ 4 = delirium
1. Altered level of consciousness 12. Inattention 13. Disorientation 14 Hallucinations 04. Hallucinations 05. Psychomotor agitation or retardation 16. Inappropriate speech 07. Sleep/wake cycle disturbances 1p/ y8. Symptom fluctuation 1Total score (0 8) 6/8Total score (0‐8) 6/8
Bergeron, et al. ICM. 2001; 27:859
![Page 21: Delirium in ICU Characteristic, Diagnosis and Prevention](https://reader033.fdocuments.net/reader033/viewer/2022052523/556b856dd8b42a6c7c8b4e22/html5/thumbnails/21.jpg)
What should we do to preventWhat should we do to prevent delirium in ICU patients?p
1. Monitoring 2. Non pharmacolgical interventions2. Non pharmacolgical interventions3. Reduction in deliriogenic medications4. Pharmacological interventions
DexmedetomidineDexmedetomidineAntipsychotics
![Page 22: Delirium in ICU Characteristic, Diagnosis and Prevention](https://reader033.fdocuments.net/reader033/viewer/2022052523/556b856dd8b42a6c7c8b4e22/html5/thumbnails/22.jpg)
Daily Wake‐Up + Early MobilityOutcome Intervention
(n=49)Control(n=50)
P
Funcionally independent at discharge (nnt=4) 29 (59%) 19 (35%) .02
ICU delirium (days) 2 (0‐6) 4 (2‐7) .03
Time in ICU with delirium (%) 33% (0‐58) 57% (33‐69) .02
Hospital delirium (days) 2 (0‐6) 4 (2‐8) .02
Hospital days with delirium (%) 28% (26) 41% (27) .01
Barthel Index score at discharge 75 (7.5‐95) 55 (0‐85) .05
ICU‐acquired paresis at discharge 15 (31%) 27 (49%) .09
Ventilator‐free days 23.5 (7.4‐25.6) 21.1 (0 – 23.8) .05
Lenght of stay in ICU (days) 5.9 (4.5‐13.2) 7.9 (6.1‐12.9) .08
LOS hospital (days) 13.5 (8‐23.1) 12.9 (8.9‐19.8) .93
Hospital Mortality 9 (18%) 14 (25%) .53
Schweickert WD – Early physical and occupational therapy in MV, critically ill patients, a RCT, Lancet 2009
![Page 23: Delirium in ICU Characteristic, Diagnosis and Prevention](https://reader033.fdocuments.net/reader033/viewer/2022052523/556b856dd8b42a6c7c8b4e22/html5/thumbnails/23.jpg)
E i t l f tEnvironmental factor
• Extremes in sensory experience (eg. Hypothermia)f h• Deficits in vision or hearing
• Immobility or decreased activityy y• Social isolation• Novel environment• StressStress
![Page 24: Delirium in ICU Characteristic, Diagnosis and Prevention](https://reader033.fdocuments.net/reader033/viewer/2022052523/556b856dd8b42a6c7c8b4e22/html5/thumbnails/24.jpg)
A “bundle” for delirium prevention?
• Family support (all levels, kids, childrens)
bu d e o de u p e e t o
y pp• Allow family at bedside, 24 h/dayO i i i• Orientation improvements– Daylights– Wall clocks
• Hearing aid• Hearing aid• Glasses• Sleep...
![Page 25: Delirium in ICU Characteristic, Diagnosis and Prevention](https://reader033.fdocuments.net/reader033/viewer/2022052523/556b856dd8b42a6c7c8b4e22/html5/thumbnails/25.jpg)
l d d d lSleep deprivation and deliriumD li iSleep Deprivation
D ti l i
Delirium
h• Daytime sleepiness• Lethargy• Irritability
• Lethargy• Agitation
• Irritability• Confusion• Poor short‐term memory
• Confusion• Inattention
Poor short term memory• Sympathetic stimulation• Anger and Frustration
• Sympathetic stimulation• Emotional liabilityg
• Restlessness• Anxiety
• Restlessness• Hallucinations
![Page 26: Delirium in ICU Characteristic, Diagnosis and Prevention](https://reader033.fdocuments.net/reader033/viewer/2022052523/556b856dd8b42a6c7c8b4e22/html5/thumbnails/26.jpg)
Sl P t lSleep Protocol
• Design behavioral protocol to reduce sleep disturbance • Noise reduction at night• Light reduction at night (cover eyes)• Modify timing of patient/staff intervention at nighty g p / g• Avoid unnecssary analgesia and sedation• Ear plugsEar plugs • Pharmacology (melatonin, sedatives)• Back massage relaxation music therapy• Back massage, relaxation, music therapy• Record hours of sleep and discuss during round
![Page 27: Delirium in ICU Characteristic, Diagnosis and Prevention](https://reader033.fdocuments.net/reader033/viewer/2022052523/556b856dd8b42a6c7c8b4e22/html5/thumbnails/27.jpg)
What should we do to preventWhat should we do to prevent delirium in ICU patients?p
1. Monitoring2. Non pharmacolgical interventions2. Non pharmacolgical interventions3. Reduction in deliriogenic medications
‐ sedation protocols and “less is more”4 Pharmacological interventions4. Pharmacological interventions
DexmedetomidinehAntipsychotics
![Page 28: Delirium in ICU Characteristic, Diagnosis and Prevention](https://reader033.fdocuments.net/reader033/viewer/2022052523/556b856dd8b42a6c7c8b4e22/html5/thumbnails/28.jpg)
Sedation Protocols: The EvidenceSedation Protocols: The Evidence
Trial RCT Outcome(s) improved by Protocol
Brook AD, CCM 1999 Yes Ventilator days, ICU and HO LOS, need for tracheostomy
Kress JP, O’Connor NEJM 2000 Yes Ventilator days, ICU LOS
Brattebo G, BMJ 2000 No Ventilator daysBrattebo G, BMJ 2000 No Ventilator days
Chanques G, CCM 2006 No Ventilator days, pain/agitation, infections
Quenot JP, CCM 2007 No Ventilator days, extubation sucess, VAP
Arias‐Rivera S, CCM 2008 No Extubation sucess,
Girart TD, Lancet 2008 (ABC) Yes Ventilator days, HO LOS, survival (nnt=7)
Robinson BR, J Trauma 2008 No Ventilator days, HO LOS
![Page 29: Delirium in ICU Characteristic, Diagnosis and Prevention](https://reader033.fdocuments.net/reader033/viewer/2022052523/556b856dd8b42a6c7c8b4e22/html5/thumbnails/29.jpg)
What should we do to preventWhat should we do to prevent delirium in ICU patients?p
1. Monitoring2. Non pharmacolgical interventions2. Non pharmacolgical interventions3. Reduction in deliriogenic medications
‐ sedation protocols and “less is more”4 Pharmacological interventions4. Pharmacological interventions
Antipsychoticsd dDexmedetomidine
![Page 30: Delirium in ICU Characteristic, Diagnosis and Prevention](https://reader033.fdocuments.net/reader033/viewer/2022052523/556b856dd8b42a6c7c8b4e22/html5/thumbnails/30.jpg)
Risperidone and DeliriumRisperidone and Delirium• Double‐blind randomized trialDouble blind randomized trial • Single dose (1 mg) of risperidone administered after
dicardiac surgery• Reduced the incidence of postoperative deliriump p
– 11.1% (intervention) vs. 31.7% (placebo), P=.009RR=0 35 95% CI=0 16 0 77– RR=0.35, 95% CI=0.16‐0.77
Prakanrattana, et al. Anaesth Intensive Care. 2007;35:714‐719
![Page 31: Delirium in ICU Characteristic, Diagnosis and Prevention](https://reader033.fdocuments.net/reader033/viewer/2022052523/556b856dd8b42a6c7c8b4e22/html5/thumbnails/31.jpg)
Design: Double‐blind, placebo‐controlled
• Quetiapine 50mg PO/NGT twice daily vs Placebo• PRN IV haloperidol protocolized and encouraged in each group• Primary outcome Time to first resolution of delirium (first 12 hour• Primary outcome: Time to first resolution of delirium (first 12 hour period when ICDSC ≤ 3)
Results: Quetiapine added to as‐needed haloperidol results in faster delirium resolution, less agitation, and a greater rate of transfer to
h h bili iCrit Care Med 2010 Vol. 38, No. 2
home or rehabilitation.
![Page 32: Delirium in ICU Characteristic, Diagnosis and Prevention](https://reader033.fdocuments.net/reader033/viewer/2022052523/556b856dd8b42a6c7c8b4e22/html5/thumbnails/32.jpg)
Modyfing the Incidence of Delirium (MIND Trial)
Girard T., Feasibility, efficacy, and safety of antipsychotics for ICU delirium: MIND trial ‐ CCMed 2010
![Page 33: Delirium in ICU Characteristic, Diagnosis and Prevention](https://reader033.fdocuments.net/reader033/viewer/2022052523/556b856dd8b42a6c7c8b4e22/html5/thumbnails/33.jpg)
Dexmedetomidine x Haloperidol
Randomised, open label, parallel‐groups pilot trial, p , p g p p
• 20 ventilated patients with agitated delirium
• Randomized to haloperidol 0.5‐2mg/hr ordexmedetomidine 0.2‐0.7 μg/kg/hr• Dexmedetomidine shorter hours to extubation Dexmedetomidine shorter hours to extubation42 (IQR 23.2‐117.8) vs 20 (IQR 7.3‐24), p=0.016• Dexmedetomidine decreased ICU length of stay6 5 (IQR 4‐9) vs 1 5 (IQR 1‐3) days p=0 0046.5 (IQR 4 9) vs 1.5 (IQR 1 3) days, p=0.004
Reade MC. Critical Care 2009, 13:R75
![Page 34: Delirium in ICU Characteristic, Diagnosis and Prevention](https://reader033.fdocuments.net/reader033/viewer/2022052523/556b856dd8b42a6c7c8b4e22/html5/thumbnails/34.jpg)
Dexmedetomidine x Haloperidol
Randomised, open label, parallel‐groups pilot trial, p , p g p p
• 20 ventilated patients with agitated delirium
• Randomized to haloperidol 0.5‐2mg/hr ordexmedetomidine 0.2‐0.7 μg/kg/hr• Dexmedetomidine shorter hours to extubation Dexmedetomidine shorter hours to extubation42 (IQR 23.2‐117.8) vs 20 (IQR 7.3‐24), p=0.016• Dexmedetomidine decreased ICU length of stay6 5 (IQR 4‐9) vs 1 5 (IQR 1‐3) days p=0 0046.5 (IQR 4 9) vs 1.5 (IQR 1 3) days, p=0.004
Reade MC. Critical Care 2009, 13:R75
![Page 35: Delirium in ICU Characteristic, Diagnosis and Prevention](https://reader033.fdocuments.net/reader033/viewer/2022052523/556b856dd8b42a6c7c8b4e22/html5/thumbnails/35.jpg)
MENDS Study
MICU/SICU V til t d S d tiMICU/SICU Ventilated on SedativesInformed Consent
ControlL (GABA)
InterventionD d idi ( 2)Lorazepam (GABA)
+/- FentanylDexmedetomidine (α2)
+/- Fentanyl
Pandharipande et al JAMA. 2007 Dec 12;298(22):2644-53
![Page 36: Delirium in ICU Characteristic, Diagnosis and Prevention](https://reader033.fdocuments.net/reader033/viewer/2022052523/556b856dd8b42a6c7c8b4e22/html5/thumbnails/36.jpg)
p=.01 p=.09 p=.001
Brain Dysfunction
12
p .01 p .09 p .001
106
84
62
0
DexmedetomidineLorazepam
Delirium/Coma‐Free Days Delirium‐Free Days Coma‐Free Days
Pandharipande PP, et al. JAMA 2007;298:2644‐53
![Page 37: Delirium in ICU Characteristic, Diagnosis and Prevention](https://reader033.fdocuments.net/reader033/viewer/2022052523/556b856dd8b42a6c7c8b4e22/html5/thumbnails/37.jpg)
SEDCOM Trial
MICU PatientsVentilated & Sedated
Control InterventionControlMidazolam (GABA)
± Fentanyl
InterventionDexmedetomidine (α2)
± Fentanyl
ik llRiker R. et all JAMA 2009 301, 5:489
![Page 38: Delirium in ICU Characteristic, Diagnosis and Prevention](https://reader033.fdocuments.net/reader033/viewer/2022052523/556b856dd8b42a6c7c8b4e22/html5/thumbnails/38.jpg)
Daily Incidence of Delirium
Dexmedetomidine Midazolam
54% DEX vs 76.6% MDZ, p<0.001
75.7
70
80
m
Dexmedetomidine Midazolam
*
†
54,660
70
Del
irium
** P < 0.05
40
50
ents
with
*
*
† P < 0.001
20
30
nt o
f Pat
ie *
**
0
10
Perc
en
0Baseline 1 2 3 4 5 6 7 8 Total
Treatment Day
![Page 39: Delirium in ICU Characteristic, Diagnosis and Prevention](https://reader033.fdocuments.net/reader033/viewer/2022052523/556b856dd8b42a6c7c8b4e22/html5/thumbnails/39.jpg)
Daily Delirium ‐ CAM‐ICU Negative at Baseline
Dexmedetomidine Midazolam †55,3
50
60
um_
†
33 340
with
Del
iriu * P < 0.05
† P < 0.001*
33.3
30
ubje
cts
w
10
20
rcen
t of S
0
10
Per
Baseline 1 2 3 4 5 6 7 8 TotalTreatment Day
![Page 40: Delirium in ICU Characteristic, Diagnosis and Prevention](https://reader033.fdocuments.net/reader033/viewer/2022052523/556b856dd8b42a6c7c8b4e22/html5/thumbnails/40.jpg)
Daily Delirium ‐ CAM‐ICU Positive at Baseline
Dexmedetomidine Midazolam †
Daily Delirium CAM ICU Positive at Baseline
94,6
90
100
m *
69,770
80
th D
eliri
um
* * P < 0.05† P < 0.001
50
60
atie
nts
wit
*
*
P < 0.001
30
40
rcen
t of P
a *
**
10
20
Perc *
0Baseline 1 2 3 4 5 6 7 8 Total
![Page 41: Delirium in ICU Characteristic, Diagnosis and Prevention](https://reader033.fdocuments.net/reader033/viewer/2022052523/556b856dd8b42a6c7c8b4e22/html5/thumbnails/41.jpg)
SEDCOM ResultsSEDCOM Results
Dexmedetomidine MidazolamOutcome Dexmedetomidinen=244
Midazolamn=122 P
Ti d ti t t 77 3 (%) 75 1 18Time sedation target 77.3 (%) 75.1 .18
Delirium prevalence 132 (54%) 93 (76%)% <0,001p ( ) ( )
Delirium free‐days 2.5 1.7 .002
Time to extubation 3,7 days 5.6 days .01
ICU LOS 5 9 7 6 24ICU LOS 5,9 7,6 .24
![Page 42: Delirium in ICU Characteristic, Diagnosis and Prevention](https://reader033.fdocuments.net/reader033/viewer/2022052523/556b856dd8b42a6c7c8b4e22/html5/thumbnails/42.jpg)
Summary of MENDS & SEDCOMSummary of MENDS & SEDCOM• Two multicenter, double blind RCTs ofTwo multicenter, double blind RCTs of benzodiazepines vs dexmedetomidine (GABA vs. Alpha 2 agonists) in high severity medical and surgical ICUagonists) in high severity medical and surgical ICU patients:
R d d i id d d ti f d li i /– Reduced incidence and duration of delirium/coma
– Significant or trend towards shorter time to extubation and ICU length of stay
– Other very interesting hypothesis generating findings suchOther very interesting hypothesis generating findings such as reduced infection rates and improved survival in severe sepsisp
![Page 43: Delirium in ICU Characteristic, Diagnosis and Prevention](https://reader033.fdocuments.net/reader033/viewer/2022052523/556b856dd8b42a6c7c8b4e22/html5/thumbnails/43.jpg)
ConclusionsConclusions• Delirium is a frequent disease in the ICU and• Delirium is a frequent disease in the ICU and associated with poor outcomes.
• Delirious is under‐recognized, can be monitored and rapidly identified.rapidly identified.
• New approaches to manage and prevent delirium i dare emerging every day.
• Dexmedetomidine has a place in this new strategies. p g
![Page 44: Delirium in ICU Characteristic, Diagnosis and Prevention](https://reader033.fdocuments.net/reader033/viewer/2022052523/556b856dd8b42a6c7c8b4e22/html5/thumbnails/44.jpg)
Conclusions (6 points for DEX)1. GABA‐agonists increase delirium
( p )g
2. Dexmedetomidine improves outcomes compared to GABA agonistsGABA‐agonists
3. Dexmedetomidine reduces incidence of delirium4. Dexmedetomidine facilitates clearing of delirium5 Dexmedetomidine saves money compared to5. Dexmedetomidine saves money compared to GABAagonists
6. Dexmedetomidine may be better than haloperidol