DELIRIUM

Lindsay Trantum ACNP-BCVUMC Neuroscience ICU

Objectives

• By the end of the presentation……– Identify the key features of delirium– Identify risk factors for delirium– Demonstrate understanding of the treatment plan

for delirium

Delirium = Brain Dysfunction

• Definition: DSM V officially defines delirium as a disturbance of consciousness with inattention accompanied by a change in cognition or perceptual disturbance that develops over a short period of time (hours to days) and fluctuates over time

• “The 6th vital sign”

Subtypes

• Hyperactive– characterized by agitation, restlessness, and

emotional lability

• Hypoactive– decreased responsiveness, withdrawal, and

apathy

• Mixed– Periods of hyperactivity and lethargy

Incidence

• 60%-80% of mechanically ventilated patients• 50%-70% of non-ventilated patients• Hypoactive delirium = 43.5%• Hyperactive delirium = 1.6%• Mixed delirium = 54.1%

(Girard, 2008)

Outcomes

• 3 fold increase in 6 month mortality• 1 in 3 delirium survivors develop permanent

cognitive impairment• Associated with…..– New nursing home placement– Increased length of stay > 8.0 days– Increased mortality– Increased number of days on the ventilator

Outcomes Continued….

• Associated with…….– Depression/PTSD– Increased risk of aspiration– Increased need for re-intubation– Increased hospital cost: national burden $38

billion/year

(Ely, 2004); (Inouye, 1998)

Risk Factors• I WATCH DEATH (many acronyms)– Infection – Withdrawl (Etoh, Sedatives)– Acute Metabolic (renal/liver failure, electrolytes, etc)– Trauma– CNS Pathology– Hypoxia– Deficiencies (B12, thiamine, folate, niacin)– Endocrine (hyper/hypo)– Acute vascular– Toxins– Heavy metals

Pathophysiology

• Multi-factorial and poorly understood• Neurotransmitter imbalance– Dopamine (excess) & acetlycholine (depleation)– Results in neuroexcitability and unpredictable

synapses– GABA, serotonin, endorphins and glutamate

Pathophysiology

• Inflammation– Inflammatory mediators cross blood-brain barrier

and increase vascular permeability– Result = decrease cerebral blood flow (CBF)• Platelets, fibrin, neutrophils obstruct CBF

(Gunther, 2008)

Wake Up and Breathe

• Awakening and Breathing Coordination– Spontaneous Awakening Trial – Spontaneous Breathing Trial

• Choice of Sedation• Delirium Monitoring• Early Mobility and Exercise– Passive Range of Motion to Ambulation

• Family(Girard, 2008)

Monitoring

• Step 1: RASS= Richmond Agitation Sedation Scale– RASS goal– Actual RASS– Minimize Sedation

• Step 2: CAM-ICU = Confusion Assessment Method– Takes approximately 1 minute– Sensitivity/Specificity 95%

Targets 4 Key FeaturesTargets 4 Key FeaturesFeature 1: Acute onset of mental

status changes, or Fluctuating course.

Feature 2: Inattention

AND

AND

Feature 3: Disorganised thinking

Feature 4: Altered level of consciousness

OR

CAM-ICU Worksheet

CAM-ICU Video

• http://www.youtube.com/watch?v=1hSDNOVHMVs

Special Population: Neurologically Impaired

• CAM-ICU has been validated in post-stroke patients

• Should be considered an aid in delirium diagnosis

• Look for non-verbal indicators– Fidgeting, signs of hallucination, waxing and

waning mental status(Mitasova, A., 2012)

Management of Delirium

• Environmental– Early mobility– Maintaining a day/night cycle

• Minimize light/noise• Promoting sleep at night

– Assessing for extubation– Daily sedation interruption– Correct hearing/visual deficits

• Hearing aids• Glasses/magnifying glasses

Management of Delirium

• Pharmacologic Options (intubated)– Sedation choices• Pain relief?–Morphine, fentanyl, hydromorphone

• Sedation?– Dexamedatomidine» Not for patients that need RASS -2 or greater

– Propofol– Avoid benzodiazepines except in ETOH withdrawl

Management of Delirium

• Pharmacologic Options (non-intubated)– Antipsychotics• Haldol 2.5-10mg q2h prn–Monitor daily EKG

• Add Quetiapine 25mg BID and titrate by 25mg q12h• Olanzipine• Dexamedatomidine

– Benzodiazepines• Don’t use unless managing ETOH withdrawl

Delirium Timeline

• Usually seen within the first 24 to 48 hrs• Can last as long as 2 weeks or longer– Be patient

Long-Term Outcomes

• >12 months post-ICU admission (800 pts)– 1/3 Cognitive impairment similar to a moderate

TBI– 1/4 Cognitive impairment similar to mild

Alzheimer’s

(Pandharipande, 2013)

Questions????

Resources

Icudelirium.orgSurgicalcriticalcare.net

Delirium Review Article

References• Girard, Timothy; Pandharipande, Pratik; Ely, Wesley; (2008). Delirium in

the Intensive Care Unit.; Critical Care. 12 (Suppl 3); S3• Gunther, Max, L.; Morandi, Alessandro; Ely, Wesley; (2008)

Pathophysiology of Delirium in the ICU. Critical Care Clinics. 24: 45-6• Inouye, S. et al. (1998). Does delirium contribute to poor hospital

outcomes? A three-site epidemiological study. Journal of General Internal Medicine. 13(4): 234-42.

• Ely, EW et al. (2004). Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA. 14; 291 (14): 1753-62.

• Barr, J. et al. (2013). Clinical Practice Guidelines for the Management of Pain, Agitation and Delirium in Adult Patients in the Intensive Care Unit. Critical Care Medicine. Jan 41(1): 263-306.

• Cheatham, M.D. (Jan 4, 2011); Delirium Management Guidelines. Retrieved from http://www.surgicalcriticalcare.net/Guidelines/delirium_2011.pdf

References

• Girard, et. al (2008) Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised control trial. Lancet: Jan 12;371(9607):126-34

• Pandharipande, PP et al (2013). Long-term cognitive impairment in critical illness. New England Journal of Medicine. Oct 3: 369 (14) 1306-16

• Mitasova, A. et al (2012). Poststroke delirium incidence and outcomes: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Critical Care Medicine. Feb;40(2):484-90.