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Transcript of Delirium in Critically Ill Mechanically Ventilated ... · PDF fileDelirium in Critically Ill...

CCCF

November 11, 2013

Delirium in Critically Ill Mechanically Ventilated Patients Enrolled in the

SLEAP Multicenter Randomized Trial

Geeta Mehta MD, FRCPC

And The SLEAP Investigators

For the Canadian Critical Care Trials Group

Disclosures

I have no disclosures

Funding: Canadian Institutes of Health

Research

Background

Delirium is common in critically ill patients

Delirium is associated with worse outcomes

Prolonged durations of MV, and lengths of stay

Patient and ICU risk factors

Sedation minimization may reduce delirium

All patients managed

with an RN driven

analgesia/sedation protocol

Daily interruption Sedation/analgesia

No daily interruption

randomized

SLEAP - Sedation Lightening and Evaluation of A Protocol

JAMA 2012

Eligibility

Inclusion criteria 18 years MV and anticipated need for MV 48 hours ICU team has decided to initiate continuous opioid

and/or benzodiazepine infusion(s)

Exclusion criteria Admission after cardiac arrest Traumatic Brain Injury Receiving Neuromuscular blockers Withdrawal or limitation of life support Previous enrolment in SLEAP Enrolment in confounding trial Lack of informed consent

Primary Outcome

Duration of MV: from intubation to extubation or tracheostomy mask, for 48 hours

Secondary outcomes

Delirium Intensive Care Delirium Screening Checklist

Both groups

Nurse-implemented algorithm for management of analgesia and sedation Analgesia: morphine, fentanyl or hydromorphone

Sedation: midazolam or lorazepam

Sedation Scale: SAS or RASS

Ventilator Weaning protocol

Intensive Care Delirium Screening Checklist

Sedation-agitation scale

7 Dangerous Pulling ET, trying to remove catheters, climbing bed agitation rail, striking staff, thrashing

6 Very agitated Not calm, despite verbal reminding; requires physical restraints, biting ET tube

5 Agitated Mildly agitated, attempting to sit up, calms with verbal instructions

4 Calm and cooperative Calm, awakens easily, follows commands

3 Sedated Difficult to arouse, awakens to verbal stimuli or gentle shaking but drifts off again, follows simple commands

2 Very sedated Arouses to physical stimuli but does not communicate nor follow commands, may move spontaneously

1 Unarousable Minimal or no response to noxious stimuli, does not communicate nor follow commands

Riker RR et al. Crit Care Med 1999;27:1325

Richmond Agitation Sedation Scale

+4 Combative Overtly combative, violent, immediate danger to staff

+3 Very agitated Pulls or removes tube(s) or catheter(s); aggressive

+2 Agitated Frequent non-purposeful movement, fights ventilator

+1 Restless Anxious but movements not aggressive, vigorous

0 Alert and Calm Difficult to arouse, awakens to verbal stimuli or gentle shaking but drifts off again, follows simple commands

-1 Drowsy Not fully alert, but has sustained awakening (eye- opening/eye contact) to voice ( 10 seconds)

-2 Light Sedation Briefly awakens with eye contact to voice (< 10 seconds)

-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 Unarousable No response to voice or physical stimulation

Sessler CN et al. AJRCCM 2002;166:1338

Daily interruption group

Bedside nurses interrupted opioid and benzodiazepine infusions daily

Assessed hourly for wakefulness: SAS 4-7 (RASS -1 to +4) and able to perform at least 3 of:

1) eye opening 2) tracking 3) hand squeezing 4) toe moving

If infusions no longer required (patient free of discomfort and agitation, SAS 2-5, or RASS -4 to +1), oral or bolus IV therapy used

If infusions required, resumed at half prior dose(s), titrated to achieve target level of light sedation

Intensive Care Delirium Screening Checklist

Bergeron et al. ICM 2001;27:859

Altered level of consciousness (A-E) If A or B do not complete patient evaluation for the period Inattention Disorientation Hallucination - delusion psychosis Psychomotor agitation or retardation Inappropriate speech or mood Sleep/wake cycle disturbance Symptom fluctuation TOTAL SCORE (0-8)

1. Altered level of consciousness:

A) No response

B) Need for vigorous stimulation to obtain any response signifies severe alteration in LOC

precluding evaluation

If coma (A) or stupor (B) there is no further evaluation during that period.

C) Drowsiness or requirement of a mild to moderate stimulation for a response implies an

altered level of consciousness and scores 1 point.

D) Wakefulness/sleeping state that is easily aroused - considered normal, scores no point.

E) Hypervigilance is rated as an abnormal level of consciousness and scores 1 point.

2. Inattention: Difficulty in following a conversation or instructions. Easily distracted by

external stimuli. Difficulty in shifting focuses.

3. Disorientation: Any obvious mistake in time, place or person

4. Hallucination, delusion or psychosis: The unequivocal manifestation of hallucination or of

behaviour probably due to hallucination or delusion. Gross impairment in reality testing.

5. Psychomotor agitation or retardation: Hyperactivity requiring additional sedatives or

restraints to control potential danger. Hypo-activity or noticeable psychomotor slowing.

6. Inappropriate speech or mood: Inappropriate, disorganised or incoherent speech.

Inappropriate display of emotion related to events or situation.

7. Sleep/wake cycle disturbance: Sleeping < 4 hrs or waking frequently at night. Sleeping

most of the day.

8. Symptom fluctuation: Fluctuation of any item or symptom over 24 hours

423 Patients

214 PS+DI, 209 PS

3 No Delirium data

420 Assessed

226 (53.8%)

ICDSC 4 163 (38.8%)

ICDSC

Baseline Characteristics

Variable Ever Delirium

N=226

Never Delirium

N=163

P

value

Age (yrs) 57 (46,68) 60 (50,71)

Female (%) 38.9% 53.4% .005

APACHE II 23 (18,27) 24 (19,29)

SOFA day 1 6 (4,9) 7 (4,9)

Type of admission (%)

Medical

Surgical

Trauma

78.8%

16.8%

4.4%

89.0%

8.6%

2.4%

.03

Baseline Characteristics

Ever Delirium

N=226

Never

Delirium

N=163

P

value

Admission Diagnosis (N)

Bacterial/viral pneumonia

Sepsis

Other respiratory disease

Aspiration pneumonia

COPD

18.6%

19.5%

10.2%

3.5%

2.2%

24.5%

18.4%

10.4%

4.3%

4.9%

Pre-ICU Conditions

Cigarette smoking

Ethanol use

Psychiatric

Neurological

31.5%

34.6%

16.8%

15.0%

16.2%

20.9%

18.4%

19.6%

.002

.02

Outcomes

Kaplan-Meier Curves - Time to Successful Extubation

Patients remaining intubated

0.2

0.4

0.6

0.8

1.0

0 5 10 15 20 25 28

Successful Extubation in First 28 days of study

Time, daysNo. of patients at risk

Delirium

Non-delirium

226

163

177

96

108

41

71

17

51

8

34

5

29

3

Delirium

Non-Delirium

P < 0.0001

0

5

10

15

20

25

Delirium

Neverdelirium

MV ICU LOS Hospital

LOS

Duration of Mechanical Ventilation and

Lengths of Stay

Days

P

Other outcomes

Ever delirium

N=226

Never delirium

N=163

P

value

Device removal

Gastric tube

ETT

Urinary catheter

C-line or A-line

31 (13.7%)

14 (6.2%)

14 (6.2%)

22 (9.7%)

15 (9.2%)

7 (4.3%)

4 (2.4%)

5 (3.1%)

.17

.41

.08

.01

Head CT or MR, N (%) 41 (18.5%) 19 (11.8%) .07

Lumbar puncture, N (%) 11 (4.9%) 2 (1.2%) .049

Physical restraint, N (%)

Study days, median (IQR)

195 (86.3%)

5 (2,9)

125 (76.7%)

2 (1,6)

.01

Medication administration

Ever delirium

N=226

Never delirium

N=163

P

value

Midazolam equivalents (mg)

Dose/pt/day

Infusion, days

104 (356)

5 (3,9)

57 (123)

3 (2,6)

SAS and workload

Ever delirium

N=226

Never delirium

N=163

P

value

SAS score, mean

3.41

3.32

.14

RN VAS score, mean

4.2

3.7

Coma

Ev