ABCDE ICU Delirium Bundle
From Diagnosis to Treatment
Timothy D. Girard, MD, MSCI
ICU Delirium and Cognitive Impairment Study Group
Division of Allergy, Pulmonary, & Critical Care Medicine
Center for Health Services Research
Vanderbilt University School of Medicine
VA Tennessee Valley GRECC
Nashville, Tennessee
Disclosures
• Grant monies
– NIH
• Honoraria (for non-promotional presentation)
– Hospira, Inc.
• Research product/procedure/technique
– None
What’s
ahead
1. ABCDEs of critical care
2. Delirium diagnosis
3. Delirium management
1
ABCDEs of Critical Care
A
Awakening trials
B
Breathing trials
C
Coordination
D
Delirium management
E
Exercise & mobility
Awakening – Daily Interruption of Sedatives
Patients Receiving
Mechanical Ventilation (%)
100
Ventilator time reduced by
80
2 days
60
40
Control (n=60)
Adjusted
p<.001
20
Protocol (n=68)
0
0
5
10
15
20
Time (Days)
25
30
Kress JP, et al. N Engl J Med 2000;342:1471-7
Breathing – Spontaneous Breathing Trials
Patients Liberated from
Mechanical Ventilation (%)
100
80
60
40
Intermittent SBTs (n=33)
Daily SBTs (n=31)
Pressure support vent (n=37)
Intermittent mandatory vent (n=29)
20
0
0
2
4
6
8
10
12
14
Weaning Time (Days)
Esteban A, et al. N Engl J Med 1995;332:345-50
Breathing – SBT Protocols
Patients Receiving
Mechanical Ventilation (%)
100
80
Ventilator time reduced by
2 days
60
40
p<.001
Control (n=151)
20
Protocol (n=149)
0
0
5
10
15
20
25
30
Weaning Time (Days)
Ely EW, et al. N Engl J Med 1996;335:1864-9
Days before Weaning Begins
SBTs begin
(Ely 1996)
SBTs begin
(Esteban 1995)
Intubation
Sedation
0
1
2
3
4
Days after Intubation
5
6
7
Patients Successfully Extubated (%)
Duration of Mechanical Ventilation
100
80
SAT+SBT (n=167)
Control (n=168)
60
40
Ventilator time reduced by
3 days
20
0
0
7
14
21
28
Days
Girard TD, et al. Lancet 2008;371:126-34
Patients Discharged from the ICU (%)
ICU Length of Stay
100
80
SAT+SBT (n=167)
p=.01
60
Control (n=168)
40
20
0
0
7
14
21
28
Days
Girard TD, et al. Lancet 2008;371:126-34
Patients Discharged from the Hospital (%)
Hospital Length of Stay
100
80
60
SAT+SBT (n=167)
40
Control (n=168)
20
p=.04
0
0
7
14
21
28
Days
Girard TD, et al. Lancet 2008;371:126-34
One-Year Survival
100
Patients Alive (%)
80
SAT+SBT (n=167)
60
40
Control (n=168)
20
NNT=7
p=.01
0
0
60
120
180
240
300
360
Days
Girard TD, et al. Lancet 2008;371:126-34
Patients with Functional Independence (%)
Return to Functional Independence
80
Early PT/OT (n=49)
60
40
Control (n=55)
20
p=.05
0
0
7
14
21
28
50
100
Hospital Days
Schweickert WD, et al. Lancet 2009;373:1874-82
Secondary Outcomes
Outcome*
Early PT/OT
Control
p
59%
35%
0.02
75 [7.5-95]
55 [0-85]
0.05
31%
49%
0.09
23.5 [7.4-25.6]
21.1 [0-23.8]
0.05
2.0 [0-6.0]
4.0 [2.0-7.0]
0.03
ICU length of stay, days
5.9 [4.5-13.2]
7.9 [6.1-12.9]
0.08
Hospital length of stay, days
13.5 [8.0-23.1]
12.9 [8.9-19.8]
0.93
18%
25%
0.53
Independent functional status
at discharge, %
Barthel Index score at discharge
ICU-acquired paresis at discharge
Ventilator-free days
ICU delirium, days
In-hospital mortality
*Median [IQR] or %
Schweickert WD, et al. Lancet 2009;373:1874-82
2
Delirium Diagnosis
Consciousness
Cognition
di-'lir-E-&m
“a disturbance of consciousness that is
accompanied by a change in cognition that
cannot be better accounted for by a preexisting
or evolving dementia”
– American Psychiatric Association
Riker, ‘09
Girard, ‘08
Pisani, ‘07
Thomason, ‘05
Micek, ‘05
McNicoll, ‘05
Ely, ‘04
McNicoll, ‘03
Ely, ‘01
Medical
ICUs
(40%-80%)
Guenther, ‘09
Lat, ‘09
Plaschke, ‘07
Pandharipande, ‘07
Ouimet, ‘07
Skrobik, ‘04
Bergeron, ‘01
Mixed
ICUs
(10%-40%)
0
20
40
60
Actual Prevalence of Delirium
80
100
Recognition of Delirium in the ICU
MDs recognized 28%
RNs recognized 35%
Spronk PE, et al. Intensive Care Med 2009;35:1276-80
Delirium Subtypes in the ICU
100
80
60
%
40
20
0
Hypoactive
Mixed
Hyperactive
Peterson JF, et al. J Am Geriatr Soc 2006;54:479-84
1
2
Which diagnostic method?
41% - none
37% - clinical assessment
14% - Confusion Assessment Method-ICU
2% - Delirium Rating Scale
2% - Mini Mental State Examination
1% - Delirium Screening Checklist
01%
Patel R, et al. Crit Care Med 2009;37:825-32
Confusion Assessment Method-ICU
Acute onset of changes or
fluctuations in the course
of mental status
Feature 1
and
Inattention 2
Feature
and either
Feature 3
Disorganized thinking
or
Altered level of
consciousness
Feature 4
Ely EW, et al. JAMA 2001; 286:2703-10
Intensive Care
Delirium Screening Checklist (ICDSC)
 Altered level of consciousness
 Inattentiveness
= delirium
 Disorientation
 Hallucination-delusion-psychosis
 Psychomotor agitation or retardation
 Inappropriate speech or mood
 Sleep/wake cycle disturbance
 Symptom fluctuation
≥4
Bergeron N, et al. Intensive Care Med 2001; 27:1297-1304
Nursing Delirium Screening Scale (NuDESC)
Rating
(0, 1, or 2)
Symptoms
Disorientation
Inappropriate behavior
Inappropriate communication
Illusions/hallucinations
Psychomotor retardation
Total score
≥2 = delirium
Gaudreau JD, et al. J Pain Symptom Manage;29:368-75
Validity of ICU Delirium Assessment Tools
Sensitivity
Specificity
100
80
%
60
40
20
0
CAM-ICU
Nu-DESC
DDS
ICDSC*
*Van Eijk MM, et al. Crit Care Med 2009;37:1881-5
Luetz A, et al. Crit Care Med 2010;38:409-18
Brain Road Map
1. Where is the patient going?
Target RASS
2. Where is the patient now?
Current RASS
Current CAM-ICU
3. How did they get there?
Drugs
© Brian Sloan via Flickr
3
Delirium Management
What to THINK When Delirium Is Present
Toxic Situations
CHF, shock, dehydration
Deliriogenic medications
New organ failure, eg, liver, kidney
Hypoxemia
Infection or Immobilization
Nonpharmacologic efforts
Hearing aids, eye glasses, reorientation,
noise reduction, sleep, ambulation
K+ or Electrolyte problems
Control
Protocol
50
40
30
20
10
0
Daily Dose of Benzodiazepines
60
70
ABC Trial - Benzodiazepines
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Study Day
Probability of Delirium (%)
Benzodiazepines and Delirium
100
90
80
70
60
50
No Drug
0-1
1-2
2-3
3-4
4+
Log scale
0-2.7
2.7-7.4
7.4-20
20-55
55+
Original scale
Lorazepam Dose (mg)
Pandharipande PP, et al. Anesthesiology 2006;104:21-6
Days
Duration of Delirium
16
14
12
10
8
6
4
2
0
p=.50
SAT+SBT
Control
Girard TD, et al. Lancet 2008;371:126-34
Effect of Wake Up and Breathe
on Coma
Girard TD, et al. Unpublished data from the ABC Trial.
Effect of Wake Up and Breathe
on Delirium
Girard TD, et al. Unpublished data from the ABC
Daily Risk of Delirium in MENDS
p=0.02
Pandharipande PP, et al. Crit Care
Daily Risk of Delirium in SEDCOM
p<0.001
Riker RR, et al. JAMA 2009;301:489-499
Which drug for delirium?
86% - haloperidol
37% - atypical antipsychotics
35% - benzodiazepines
13% - propofol
8% - opiates
5% - dexmedetomidine
Patel R, et al. Crit Care Med 2009;37:825-32
Patients without Delirium or Coma (%)
Antipsychotics – Delirium and Coma
100
p=0.66
80
60
40
Haloperidol (n=35)
Ziprasidone (n=32)
Placebo (n=36)
20
0
1
5
10
15
20
Day
Girard TD, et al. Crit Care Med 2010;38:428-37
Quetiapine – Resolution of Delirium
Patients with Delirium (%)
100
Quetiapine (n=18)
Placebo (n=18)
80
60
p=0.001
40
20
0
0
2
4
Day
6
8
10
Devlin JW, et al. Crit Care Med 2010;38:419-27
Dexmedetomidine in Agitated Patients
Patients Intubated (%)
100
80
p=.001
60
40
Haloperidol
20
Dexmedetomidine
0
0
2
6
8
Hours
Reade MC, et al. Crit Care 2009;13:R75
MIND-USA
Modifying the Impact of ICU-Associated
Neurological Dysfunction
Reduce immobility
Promote consciousness
Photo by Chris Hartlove for The New York Times
Secondary Outcomes
Outcome*
Early PT/OT
Control
p
59%
35%
0.02
75 [7.5-95]
55 [0-85]
0.05
31%
49%
0.09
Ventilator-free days
23.5 [7.4-25.6]
21.1 [0-23.8]
0.05
ICU delirium, days
2.0 [0-6.0]
4.0 [2.0-7.0]
0.03
ICU length of stay, days
5.9 [4.5-13.2]
7.9 [6.1-12.9]
0.08
Hospital length of stay, days
13.5 [8.0-23.1]
12.9 [8.9-19.8]
0.93
18%
25%
0.53
Independent functional status
at discharge, %
Barthel Index score at discharge
ICU-acquired paresis at discharge
In-hospital mortality
*Median [IQR] or %
Schweickert WD, et al. Lancet 2009;373:1874-82
Looking
back
1. ABCDEs of critical care
2. Delirium diagnosis
3. Delirium management