Diagnosis and Management of
ICU Delirium
June 24, 2010 - July 1, 2010
Dave Miller, MD and Becky Logiudice, MS, RN
Talk Outline
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Why is this important?
What is delirium?
Using CAM-ICU to diagnose ICU delirium
How do I treat delirium?
Goal-oriented sedation
Why is this important?
Perspective from SB
About my delirium memories from the ICU, I have had
few. The time I spent seems like it was in a huge, empty
gray space, sort of like a monstrous underground
parking garage with no cars, only me, floating or
seeming to float, on something. Every once in a while I
would get to an edge of something horrible and once I
remember I thought, "if I just let go, then this horror will
be over…” When I try to write about that time (and I have
tried over and over), words just won't come and in my
line of writing, personal essays, if it doesn't just come
gushing out, I have to stop. And that's where I am now
http://www.icudelirium.org/outcomes.html#reports
Why is this important?
183 ÷ (183+41) = 0.82
Pun B T , Ely E W Chest 2007;132:624-636
Why is this important?
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Common
Increased mortality
Increased LOS
Increased complications
Increased costs
May be associated with increased
dementia and long-term cognitive
impairment
Girard DT et al. Crit Care Med 2010;38(7):epub ahead of print
Pun BT and Ely EW. Chest 2007;132:624-636
What is Delirium?
Answer # 1
You’ll Know it when you see it. . .
What is delirium?
Pun B T , Ely E W Chest 2007;132:624-636
What is delirium?
Answer # 2
Disturbance of consciousness
Inattention
Change in cognition or perceptual disturbance
Develops over hours to days
Fluctuates over time
How do I diagnose delirium?
Case 1
Mr. D, a 70-year old with severe COPD, is in the
MICU on a ventilator for respiratory failure.
Initially he needed high levels of sedation, but
now Propofol has been decreased and Mr. D is
awake but agitated, grimacing, thrashing and
trying to sit up in bed. He makes eye contact,
but won’t follow commands
Is Mr. D delirious?
How do you know?
Assessment of ICU patients
Patient Comfort
Pain
Sedation
Delirium
0 -10 scale
FRACC
Subjective/
physiologic
factors
Sedation
assessment
scale
(RASS, SAS,
MAAS)
CAM-ICU
Assessment tool: CAM-ICU
Assessment tool: CAM-ICU
Richmond Agitation-Sedation Scale (RASS)
RASS
+4 Combative
Combative, violent, immediate danger to staff
+3 Very agitated
Pulls or removes tubes or catheters; aggressive
+2 Agitated
Frequent non-purposeful movement, fights ventilator
+1 Restless
Anxious and apprehensive, but movements not
aggressive or vigorous
0
Alert and calm
-1
Drowsy
Not fully alert but has eye opening to voice and
sustained eye contact (> 10 s)
-2
Light sedation
Briefly awakens to voice with eye opening and eye
contact (< 10 s)
-3
Moderate
sedation
Movement or eye opening to voice but no eye contact
-4
Deep sedation
No response to voice, but movement or eye opening
to physical stimulation
-5
Not arousable
No response to voice or physical stimulation
Assessment tool: CAM-ICU
Attention Screening Examination
Attention Screening Examination
• Auditory
– Squeeze my hand each time I say the letter “A”
– SAVEAHAART
– More than 2 wrong responses = POSTIVE
• Visual (cannot hear or squeeze hands)
– Show 5 pictures, then show 5 repeat and 5 new in
random order
– More than 2 wrong responses = POSITIVE
Assessment tool: CAM-ICU
Assessing for Disorganized Thinking:
Answer 4 simple yes/no questions and follow a 2-step
command:
• E.g.,“Will a stone float on water?”
•“Hold up 2 fingers on one hand, then on the other hand.”
How do I diagnose delirium?
Case 1 revisited
Mr. D, a 70-year old with severe COPD, is in the
MICU on a ventilator for respiratory failure.
Initially he needed high levels of sedation, but
now Propofol has been decreased and Mr. D is
awake but agitated, grimacing, thrashing and
trying to sit up in bed. He makes eye contact,
but won’t follow commands
Is Mr. D delirious?
How do you know?
Case 1 revisited
STEP 1: Mr. D is assessed to be a RASS +2,
which is an acute change from his baseline
STEP 2: He squeezes hands on “A” once out of 5
times (4 errors) so is inattentive
STEP 4: Because his level of consciousness is
altered (RASS +2), STEP 3 does not need to be
assessed.
Mr. D is delirious!
Case 2
• The next day, Mr. D is awake and calm
(RASS 0). He was given several doses of
lorazepam overnight for “agitation.” He
remains intubated, but is following
commands appropriately.
• Is Mr. D delirious now?
STEP 1: He is awake and calm (RASS 0) now, but
fluctuated within the last 24 hours
STEP 2: He scores 6/10 on the Attention
Screening Examination (POSITIVE)
STEP 3: Because his level of consciousness is not
currently altered, he is tested for disorganized
thinking. He scores 3 out of 5 because when
asked “Are there elephants in the sea?” and
“Can you use a hammer to cut wood?” he
answers “YES!” (POSITIVE)
How should we manage Mr. D?
Managing ICU Delirium
1. Look for it
2. Communication between nursing and MDs
3. Identify and treat correctable risk factors
4. Optimize non-pharmacologic interventions
5. Goal-oriented sedation with daily wake-ups
6. Pharmacologic intervention
Managing ICU Delirium
Modify Risk Factors
Host Factor
Acute Illness
Iatrogenic/
Environmental
Age
Sepsis
Metabolic
disturbance
Baseline
comorbidity
Hypoxemia
Lights, noise,
sleep pattern
Baseline cognitive Global severity of
impairment
illness score
Anticholinergic,
sedative and
analgesic meds
Severity of illness and age are
independent risk factors for delirium
Pandharipande et al. Anesthesiology 2006;104:21-26
Lorazepam dose is an independent risk
factor for delirium
Also:
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Other Benzos
Opiates
Propofol
Anticholinergics
H2 blockers
Steroids
Some antibiotics
Psych meds
Pandharipande et al. Anesthesiology 2006;104:21-26
Non-Pharmacologic Management
• Orientation
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Visual and hearing aids
Communicate and re-orient frequently
Familiar objects and people
Consistent nursing staff
TV, news, music during the day
• Environment
– Sleep hygiene: Lights off at night, on during day.
Sleep aids?
– Control excess noise at night
– Ambulate or mobilize early and often
Pun B T , Ely E W Chest 2007;132:624-636
Pharmacologic Management
Antipsychotics
• Little controlled data, but anecdotal and case-series
evidence
– One small recent RCT comparing Haldol vs placebo
found no difference in mortality, LOS, side effects
• Haldol IV recommended by SCCM
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Long half-life (18-54 hours)
Risk of: QT prolongation, NMS, akathisia
Monitor QTc BID, follow K, Mg, Ca.
Beware other drugs that prolong QT (MANY including
anti-arrhythmics, quinolones, erythromycin,
methadone)
Jacobi et al. Crit Care Med 2002;30:119-141
Girard et al. Crit Care Med 2010; 38: 428-37
Pharmacologic Management
Haloperidol (Haldol)
– Action: CNS depressant and dopamine receptor antagonist
– Side Effects: Prolonged QT interval, Extrapyramidal
symptoms, tardive dyskinesia (long term use)
– IV Dosing:
• Starting dose: Mild agitation 2mg IV,
Moderate to severe agitation 5mg IV
• After 20 min. of 1st dose, if still agitated increase the
previous doses by 5mg every 20min until calm.
• Max dose 30 mg in 24 hours
• Once pt is calm, 25% of loading dose should be given Q 6
hours scheduled
• Once pt is delirium free for 24 hours taper off haldol
Atypical Antipsychotics
• Recent double-blind RCT of quetiapine
(Seroquil) 50mg BID vs placebo
• Haldol PRN – study drug increased if any PRN in
24 hours
• 36 ICU patients with delirium
• Shorter time to resolution of delirium (1 vs 4.5
days)
• Reduced duration of delirium (36 vs 120 hours)
• More somnolence with quetiapine, other SEs
similar
Devlin JW et al. Crit Care Med 2010; 38: 419-426
Atypical Antipsychotics
(Second Generation)
Not typically given IV or IM
• Quetiapine (Seroquil)
– 25mg - 50mg PO
• Risperidone (Risperdal)
– 1 mg - 3 mg PO daily
• Olanzapine (Zyprexa)
– 5mg- 20 mg PO
– 5mg -10 mg IM
Fentanyl prn
Morphine prn
1. Analgesia
In Pain?
Reassess
If not controlled with
2-3 doses/hour, start
Fentanyl gtt
2. Sedation
Oversedated
Hold sedatives
and analgesics
to achieve
RASS target.
Restart at 50%
if needed
Reassess
Undersedated
1. Benzo prn
2. Propofol gtt
3. Benzo gtt
RASS at target (-1 to 0)?
3. Delirium
CAM-ICU positive?
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3.
Underlying cause
Non-pharm
management
Pharm
management
Sedation Management
• What is the Daily RASS Goal?
• What is the patient’s RASS now?
• Is the patient on optimal sedation for the RASS goal?
• Combination of sedative and narcotic is synergistic
• Side effects of most agents include:
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Delirium
Hypotension
Respiratory depression
Increased tolerance with withdrawal syndromes
Risk of seizures if stopped abruptly
Difficulty assessing neurologic status
Sedation and Analgesia: Challenges
• Inappropriate sedation (over and under) is a frequent
problem, causing:
– Increased levels of agitation, delirium
– Sleep fragmentation
– Increased rates of VAP, nosocomial infections, days
on mechanical ventilation, hospital stays, costs
– Self-extubation, reintubation, accidental line removal
• Sedation is rarely discussed in a uniform fashion among
health care providers
Sessler CN. Chest 2004;126:1727-1730
Wit M et al. Am J of Crit Care 2003; 12: 343-348.
Sessler CN. Am J Resp CCM 2002; 166:1338-1334
Sedation (short term)
Propofol
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Sedative hypnotic with mild amnestic properties, NO analgesia,
Rapid induction, rapid recovery
Not recommended > 3 days
Side Effects:
– Hypotension 1/3 of all patients, respiratory depression,
bradycardia, arrhythmia, Lipemia, hypertriglycerdemia,
Pancreatitis, Infection Risk
– Propofol Infusion Syndrome: acute refractory bradycardia and
metabolic acidosis, rhabdomyolysis, hyperlipidemia or an
enlarged fatty liver
Dexmedetomidine (Precedex)
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Alpha-2 agonist
Anxiolytic, analgesia, amnesia
No respiratory depression, patient sedate but arousable
Bradycardia, hypo/hypertension
Use < 24h
Sedation
Benzodiazepines
• Onset
– midazolam<diazepam<lorazepam
– Start with IV push before starting an infusion
• Duration
– diazepam>lorazepam>midazolam> propofol
– (NB midazolam and diazepam highly lipophilic)
• Elimination
– renal failure: active metabolites accumulate for
midazolam and diazepam
– cirrhosis: prolongation of metabolism to active
metabolites for midazolam & diazepam
Pain Management
Opiates
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Consider non-opiate analgesics
Little amnestic effect
Active metabolites, lipid deposition (Fentanyl)
Side effects:
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Respiratory depression
Hypotension (Morphine > Fentanyl)
GI (constipation, ileus, gastroparesis, nausea)
Delirium
Tolerance followed by withdrawal syndromes
Goal-oriented Management
• Multidisciplinary process that incorporates expertise
from physicians, nurses, pharmacy, and others
• Uses appropriate quantitative scales to assess and set
treatment goals
• Provides etiology-driven treatment (treat pain with
analgesics, anxiety with anxiolytics, etc)
• Avoids over-sedation & under-sedation
– Minimizes the use of sedatives, which can lead to delirium,
further agitation, withdrawal syndromes
– Monitors response to therapeutic interventions
Kress JP, Hall JB. CCM 2006;2541-2546
Sessler CN. Chest 2004; 1727-1730
Weinert et al. Am J Crti Care 2001; 156-167.
Managing ICU Delirium
1. Look for it
2. Communication between nursing and
MDs
3. Identify and treat correctable risk factors
4. Optimize non-pharmacologic
interventions
5. Goal-oriented sedation with daily wakeups
6. Pharmacologic intervention
Daily Wake-Ups
Kress et al, NEJM 2000:
– 128 vented MICU patients randomized to daily
awakening vs usual care AND midazolam vs propofol
(all patients received morphine)
• Infusions off until following commands or agitated
– Shorter time on vent (4.9 vs 7.3 days)
– Shorter time in ICU (6.4 vs 9.9 days)
– Fewer diagnostic tests for mental status
– No difference in complications or PTSD
– No difference between propofol and midazolam
Kress JP. NEJM 2000. 342:1471-1477
Sessler CN. Crit Care Clin 2009. 25: 489-513
Wake-Up and Breathe
• Multi-center RCT
• 336 vented ICU patients randomized to
spontaneous awakening followed by
spontaneous breathing trial vs usual
sedation with daily SBT
• Safety screens for both SAT and SBT
• SAT passed if patient opened eyes to
verbal stimuli or tolerated being off
sedation for > 4 hours
Girard TD et al. Lancet 2008. 371:126-34
Hooper MH. Crit Care Clin 2009. 25:515-525
Wake-Up and Breathe
• Increased ventilatorfree days (14.7 vs 11.6
days)
• Shorter ICU and
hospital LOS (9.1 and
12.9 days; 14.9 and
19.2 days)
• 14% absolute reduction
in risk of death at 1
year
Girard TD et al. Lancet 2008. 371:126-34
Expectations for Our ICU
(as of July 1, 2010)
1. Documentation of RASS Q4 h (all patients)
2. Documentation of CAM-ICU Q8 h (all patients)
3. Discussion of RASS and CAM-ICU by team on
daily work rounds
4. Use MAH Sedation Guideline for sedation and
delirium management
5. Consideration of daily wake-up and daily SBT
if appropriate
6. Inclusion of sedation goals on daily goal
sheets
Case 3: 57F intubated for ARDS -- Day 10
Feature
1. RASS is 0. Last shift, RASS was +2.
2. SAVEAHAART: 50%
3. Disorganized thinking:
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Will a leaf float on water? Yes
Are elephants in the sea? Yes
Do 2 pounds weigh more than 1? Yes
Can you use a hammer to cut wood? Yes
Fails to hold up 2 fingers
Score: 2 of possible 5 points
4. Altered Level of Consciousness: RASS 0 How should we manage her?
Summary
• Delirium is common and has serious
negative consequences
• May be missed without assessment
• Management is multidisciplinary
– Risk factor modification
– Non-pharmacologic intervention
– Pharmacologic intervention
• Optimize goal-directed sedation and
analgesia
WWW.ICUDELIRIUM.ORG