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Intensive Care Training Program Radboud University Medical Centre
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Intensive Care Training Program Radboud University Medical Centre Nijmegen Prediction and prevention of delirium
Transcript of Intensive Care Training Program Radboud University Medical Centre
Intensive Care Training ProgramRadboud University Medical Centre Nijmegen
Prediction and prevention of delirium
• Acute mental disorder: develops over hours/days and fluctuates during
the day
• Disturbed consciousness: decreased ability to concentrate
• Cogni2ve changes (memory disturbances, disorienta9on, language
problems)
DSM-‐IV criteria = gold standard
Delirium
• 30-‐50% of all ICU pa9ents develop symptoms of delirium
• Delirium increases ICU mortality
• Delirium independent predictor for mortality
• Delirium increases hospital length-‐of-‐stay
• Delirium increases ICU costs with 39% and hospital costs with
31% depending on severity
Delirium
Delirium screening with CAM-ICU
0
25
50
75
100
Sensitivity Specificity PPV NPV
%
Total population (N=181) Hypoactive (N=36) Hyperactive (N=7) Mixed type (N=32)
van Eijk MM. Am J Respir Crit Care Med 2011;184:340-344
Delirium (n=411)
Non-‐delirium (n=1202)
p-‐value (corrected for
APACHE-‐II score)
Associa2on of delirium with outcome*
Dura9on of MV (days) 4,6 [1-‐11] 0,3 [0-‐1] <0,0001 O.R. 7,0(95%CI 4,7-‐10,5)
Reintuba9on 10% 0,5% <0,0001
Accidental removal of ET and catheters 23,1% 0,6% <0,0001
LOS-‐ICU (days) 6 [2-‐13] 1 [1-‐2] <0,0001 O.R. 8,6 (95%CI 5,8-‐12,7)
LOS-‐hospital (days) 20 [10-‐39] 7 [5-‐14] <0,0001 O.R. 2,1(95%CI 1,5-‐3,0)
Hospital mortality (%) 73 (17,8%) 40 (3,3%) <0,0001 O.R. 2,1(95%CI 1,2-‐3,5)
van den Boogaard et al., 2011 IJNS
Short term consequences
* mul9variate logis9c regression analysis with covariates: delirium, admission category, history of pulmonary disease, reintuba9on and sepsis.
van den Boogaard. Crit Care Med 2012;40:12-118
van den Boogaard et al., 2012 CCM
Long term consequences
N = 225Age > 60
Cardiac surgery
MM
SE
Saczynski JS. N Engl J Med 2012;367:30-39
Prevention
• Inefficient in all patients
• less effective
• labour intensive
• side-effects
Prediction model necessary to identify high risk patients
• Developed and validated in a total of 3056 pa9ents in 5 centra in
NL (UMCN, UMCU, MCL, OLVG and Gelre zkh)
• PRE-‐DELIRIC consists of 10 predictors: age, APACHE-‐II, coma,
admission category, infec2on, metabolic acidosis, use of morphine,
seda2ves , plasma urea and emergency admission
• Predic9on of delirium in 24 hours
• High predic9ve value (AUC 0,85)
• Predic9ve value medical personnel is low (AUC 0,56)van den Boogaard et al., 2012 BMJ
Iden9fy high risk pa9ents with PRE-‐DELIRIC
van den Boogaard. BMJ 2012;344:E420
• No differences in studies using Donezepil, Gabapen9n, Ci9coline
• Haloperidol preven9on in hip surgery: decreases dura9on, delirium less severe, shorter admission dura9on
• Haloperidol preven9on in surgical and medical ICU-‐pa9ents: ↓incidence 23-‐15% and ↑delirium free days 5,7-‐ 6,2 days (no risk-‐stra9fica9on)
• Most experience with haloperidol
• First choice in most guidelines -‐ dose dependent side effects
Choice of agent
Haloperidol prevention
Wei Wang. Crit Care Med 2012;40:731-739
Critically ill elderly after non-cardiac surgery0.5 mg bolus + 0.1 mg/hr for 12 hours
Wei Wang. Crit Care Med 2012;40:731-739
Wei Wang. Crit Care Med 2012;40:731-739
• PRE-‐DELIRIC ≥ 50% or history of demen9a or alcohol abuse
• Haloperidol 3x1 mg
• Preven9on stops with ICU discharge or occurrence delirium
• No preven9on if:
• Already delirium
• Haloperidol contraindicated
Delirium preven9on program
• Controle 2008-‐2009
• Interven9on 2010-‐2011
• End-‐points
• Delirium incidence
• Delirium free days without coma in 28 days
• 28-‐day mortality
• Accidental removal ET/catheters
• Dura9on of MV
• Reintuba9on
• ICU readmission
• LOS-‐ICU and hospital
Primary measure
Secondary measure
Control (N=299) Interven9on (N=177) Difference
Age 64±14 63±14 P=0,64
Sex (Male,%) 181 (61%) 115 (65%) P=0,20
APACHE-‐II score 20±7 19±6 P=0,06
PRE-‐DELIRIC score 73±22 75±19 P=0,50
Other risks-‐ alcohol abuse-‐ demen9a
41 (14%)5 (2%)
20 (11%)2 (2%)
P=0,37
Sepsis (%) 64 (21%) 53 (30%) P=0,02Admission category :-‐ surgical-‐ medical-‐ trauma -‐ neurology/neurosurgery
75 (25%)143 (48%)32 (11%)49 (16%)
33 (19%)106 (60%)18 (10%)20 (11%)
P=0,78
Emergency admission 261 (87%) 152 (86%) P=0,52
Control (N=299) Interven9on (N=177) Difference
PRE-‐DELIRIC score 73±22 75±19 P=0,50
Delirium incidence (N,%) 225 (75%) 115 (65%) P=0,01
Delirium-‐free-‐days without coma in 28 days (median, IQR)
13 [3-‐27] 20 [8-‐27] P=0.003
Dura9on mechanical ven9la9on in hrs [median, IQR]
118 [39-‐250] 90 [36-‐229] P=0.24
Re-‐intuba9ons (N,%) 25 (8%) 15 (9%) P=0.51
Unplanned removal of tubes(N,%)
-‐endotracheal tube-‐ Gastric tube-‐ CVC/arterial-‐katheter
58 (19%)
8 (3%)26 (9%)24 (8%)
21 (12%)
4 (2%)14 (8%)1 (<1%)
P=0.02
ICU re-‐admissions (N,%) 55 (18%) 20 (11%) P=0.03
Controle (N=299) Interven9on (N=177) Difference
LOS-‐IC [median, IQR] 7 [3-‐13] 6 [3-‐12] P=0,65
LOS-‐ziekenhuis [median, IQR] 21 [11-‐41] 20 [11-‐31] P=0,16
28-‐day mortality 38 (12.5%) 6 (6.3%) P=0.03
Number Needed to Treat: 16
Survival duration
Control (N=299)
Interven9on -‐not-‐treated
(N=59)
Interven9on (N=177)
PRE-‐DELIRIC score 73±22 77±17 75±19
Age 64±14 62±15 63±14
APACHE-‐II 20±7 20±6 19±6
Sepsis (N,%) 64 (21%) 16 (27%) 53 (30%)
Delirium incidence (N,%) 225 (75%) 53 (90%) 115 (65%)
Delirium-‐free days without coma in 28 days (median, IQR) 13 [3-‐27] 14 [1-‐22] 20 [8-‐27]
28-‐days mortality 36 (12,5%) 7 (11,9%) 13 (7,3%)
Interven9on(N=177)
Haloperidol dose changed:-‐ Drowsiness-‐ Rigidity-‐ Suspicion NMS-‐ Parkinsonism
13 (3%)2 (2%)
1 (0,2%) 1 (0,2%)
Haloperidol stopped: -‐ Increase QTc-‐ Seda9ve effect-‐ Renal failure
11 (2%) 3 (0,6%) 1 (0,2%)
