A case of delirium
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Transcript of A case of delirium
![Page 1: A case of delirium](https://reader034.fdocuments.in/reader034/viewer/2022042700/55858cedd8b42ab2148b53cf/html5/thumbnails/1.jpg)
A Case of ICU Delirium
Paula L. Watson, M.D.Assistant Professor
Pulmonary/Critical Care/Sleep MedicineVanderbilt University Medical Center
NIH AG027472-01A1, VA-GRECC,CTSA 1 UL1 RR024975, ASPECT
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• 54 year old female prior history of rheumatoid arthritis • Home meds: prednisone 5mg, weekly methotrexate, adalimumab
biweekly• Presented to community hospital with 3 days of cough, fever, myalgias;
required intubation for progressive hypoxia• Bronchoscopy + H1N1 influenza, + candida albicans• Received: tamiflu, vancomycin, ceftazidime, stress dose steriods;
fluconazole added after candida noted in cultures• Barotrauma induced pneumothorax requiring chest tube
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• Transferred to academic center ventilator day #3 for management of progressive hypoxia
On arrival:• Temp 99.1, BP 89/56, heart rate 83, respiratory rate 24• Vent settings: TV 300, FiO2 100%, PEEP 20, PIP 30• Admission ABG: 7.40 / 50 / 61; Oxygen saturation 86-92%• sodium 146, potassium 3.9, chloride 111, serum bicarb 30,
BUN 21, creatinine 0.56
Meds:• Tamiflu, doripenem, linezolid, micofungin, stress dose
steriods
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Initial Sedation / Analgesic Regimen
• Continuous fentanyl and midazolam
• Clinical bedside sedation scale (Richmond Agitation-Sedation Scale (RASS)
Initial target – 4 (minimally responsive)
• Paralytics administered secondary to ventilator dysynchrony
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Richmond Agitation-Sedation Scale(RASS)
+4 Combative+3 Very agitated+2 Agitated+1 Restless
0 Alert /calm-1 Drowsy eye contact >10 sec-2 Light sedation eye contact <10 sec-3 Moderate no eye contact-4 Deep physical stimulation required-5 Unarousable no response even with physical
Sessler, et al. AJRCCM 2002;166:1338-44Ely, et al. JAMA 2003;289:2983-91
Verbal Stimulus
Physical
Stimulus
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Neurological Monitoring Neurological Monitoring When Clinical Sedation Scales FailWhen Clinical Sedation Scales Fail
+ 1
0
- 1
- 2
- 3
- 4
- 5
Richmond Agitation-Sedation Scale (RASS)
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Burst Suppression is Associated with Increased Mortality
010203040506070
ICU Mortality HospitalMortality
6 MonthMortality
% M
orta
lity
Never Burst-suppressedBurst-suppressed
Watson et al., Crit Care Med 2008;36(12):3171-77
P = 0.02
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Bispectral Index Monitor
Target range 50-60 while on paralytics (amnestic)
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Hospital Day # 3Improving oxygenation
• Vent settings: TV 300, FiO2 75%, PEEP 14• ABG: 7.40 / 65 /69• sodium 147, potassium 3.7, chloride 102, serum
bicarb 37, BUN 34, creatinine 0.78• Paralytics discontinued previous day
• Rounds:– Sedation target = RASS -4– Actual sedation level = RASS -4– CAM-ICU = unable to assess, patient comatose– Medications (sedatives, analgesics, antipsychotics) =
continuous midazolam, fentanyl
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What changes to patient management would you
consider?
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Hospital Day # 5• Vent settings: TV 300, FiO2 60%, PEEP 10• ABG: 7.45 / 53 / 71• sodium 143, potassium 4.2, chloride 105, serum
bicarb 35, BUN 22, creatinine 0.56
• Rounds:– Sedation target = RASS -2– Actual sedation level = RASS -2 – CAM-ICU = positive– Medications (sedatives, analgesics, antipsychotics) =
intermittent midazolam, fentanyl
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www.icudelirium.org
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When CAM+
D drugs, drugs, drugs E eyes, earsL low O2 states (MI, ARDS, PE, CHF, COPD)I infectionR retention (urine), restraintsI ictalU underhydration, undernutritionM metabolic(S) subdural, sleep deprivation
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What are the patient’s delirium risk factors?
What changes to patient management would you
consider?
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Managing Delirium• Primary prevention preferred
– Avoid or decrease exposure to benzodiazepines• Nonpharmacologic:
– Reorientation– Eye glasses, hearing aids– Provide cognitively stimulating activities– Timely removal of catheters and restraints– Early mobilization
• Pharmacologic:– Stop any offending medications– Consider antipsychotics
• haloperidol (practice guildelines, Crit Care Med 2002)– Consider dexmedetomidine
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Which drug for delirium?
86% - haloperidol37% - atypical antipsychotics35% - benzodiazepines13% - propofol8% - opiates5% - dexmedetomidine
Patel et al., Crit Care Med 2009;37:825-32
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Fentanyl and midazolam are associated with increased risk of delirium
Pandharipande et al., J Trauma 2008;65(1):34-41
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Daily Prevalence of Delirium
• Prevalence of delirium similar prior to starting study drug• Dexmedetomidine resulted in 24.9% ↓ in delirium during
treatment phase (54% dex vs. 76.6% mdz)
Riker, Rocha, JAMA 2009;301(5):489-99
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Resolution of Delirium and Coma
0 5 10 15 20Day
0
20
40
60
80
100
Pat
ient
s w
ithou
t Del
irium
or C
oma
(%)
Haloperidol (n=35)Ziprasidone (n=32)Placebo (n=36)
Girard et al., Crit Care Med 2010;38(2)
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Main Outcomes
Outcome*Haloperidol
(n=35)Ziprasidone
(n=32)Placebo(n=36) p
Delirium/coma-free days 14 [6-18] 15 [9-18] 13 [2-17] 0.65Ventilator-free days 8 [0-15] 12 [0-19] 12 [0-23] 0.33Length of stayICU 12 [5-16] 10 [4-15] 8 [5-13] 0.70Hospital 14 [10-NA†] 14 [10-NA†] 16 [9-NA†] 0.67
Mortality, % 11 13 17 0.80Extrapyramidal side effectsDaily EPS score 0 [0-0.2] 0 [0-0] 0 [0-0] 0.56
Cognition at dischargeMean T-score 27 [25-31] 28 [24-35] 33 [23-36] 0.50
*Median [interquartile range] except as noted
Girard et al., Crit Care Med 2010;38(2)
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Extubation
• CAM-ICU +• During wake and breath trials, patient would
become anxious, agitated, tachypneic, with shallow respiration
• Dexmedetomidine infusion started• Spontaneous breathing trial performed on drug• Patient passed spontaneous breathing trial and
was extubated
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Day # 8
• Remains CAM-ICU +• Hallucinations• Husband states that she is not sleeping at
night
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When CAM+
D drugs, drugs, drugs E eyes, earsL low O2 states (MI, ARDS, PE, CHF, COPD)I infectionR retention (urine), restraintsI ictalU underhydration, undernutritionM metabolic(S) subdural, sleep deprivation
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Animation = Less Delirium
Schweickert et al, Lancet 2009;373:1874-82
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Liberationbedside sedation scale
spontanous awakening trialwake up and breath trial
alternative sedative agents (dexmedetomidine)
Animationearly physical therapy
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