Patients Gone Wild: Agitation and Delirium in the ICU
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Transcript of Patients Gone Wild: Agitation and Delirium in the ICU
CRISMA CC·RR·II·SS·MM·AACritical Care Medicine
the University of Pittsburgh
Eric B. Milbrandt, MD, MPH
Patients Gone Wild:
Agitation and Delirium in the ICU
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The CRISMA Laboratory
Department of Critical Care Medicine
School of Medicine
University of Pittsburgh
CRISMA CC·RR·II·SS·MM·AACritical Care Medicine
the University of PittsburghOverview
What is delirium?
Why is it important?
Why does it happen?
How do we diagnose it?
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How do we diagnose it?
Can we prevent it?
When should we treat it?
CRISMA CC·RR·II·SS·MM·AACritical Care Medicine
the University of PittsburghDelirium vs. Agitation
Latin deliria “out of your furrow”
Delirium = acute brain dysfunction
Delirium ≠ agitationAgitation: violent motion or stirring; emotional
disturbance or excitement
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disturbance or excitement
Delirium: acute disturbance of consciousnessand cognition that fluctuates in severity
“Can’t think straight or focus attention”
CRISMA CC·RR·II·SS·MM·AACritical Care Medicine
the University of PittsburghTypes of Delirium
HyperactiveAgitation, combative behavior, pulling lines and tubes
HypoactiveCalm, inattentive, ↓ mobility, “spaced out”
Far more common, likely due to sedating meds
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CRISMA CC·RR·II·SS·MM·AACritical Care Medicine
the University of PittsburghWhy is Delirium Important?
Very common in the ICU20% to 80% of ICU pts develop delirium
Ely et al., JAMA 2001; 286:2703-10
Dubois et al., Intensive Care Med 2001; 27:1297-1304
Associated with Nosocomial pneumonia and failed extubation
Cook et al., Ann Intern Med 1998;129:433-40
Namen et al., AJRCCM 2001;163:658-64
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Namen et al., AJRCCM 2001;163:658-64
↑LOS, 6-month mortality, costEly et al., Intensive Care Med 2001; 27:1982-1900
Ely et al., JAMA 2004; 291:1753-62
Milbrandt et al., CCM 2004; 32:955-62
Prolonged neuropsychological deficitsMoller et al, Lancet 1998;351:857
Williams-Russo et al, JAMA 1995;274:44
Scragg et al., Anaesthesia 2001;56:9-14
CRISMA CC·RR·II·SS·MM·AACritical Care Medicine
the University of PittsburghBut How Could This Be?
Consider hyperactive deliriumPulling lines and tubes
Danger to self and others
Excess sedation
↑ LOS, time on vent
Risk of nosocomial pneumonia, CR-BSI, etc
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Risk of nosocomial pneumonia, CR-BSI, etc
Mortality
CRISMA CC·RR·II·SS·MM·AACritical Care Medicine
the University of PittsburghBut How Could This Be?
Alternatively…Marker of illness severity
Rather than causal
Another failing organ…
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CRISMA CC·RR·II·SS·MM·AACritical Care Medicine
the University of PittsburghWhy Does It Happen?
Age
Baseline Deficits Underlying
Illness
Metabolic DerangementsHypoxia
Catheters/RestraintsVision/Hearing
Deficits
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Derangements
Toxins
Inflammation & Thrombosis
Medications
Hypoxia
Sleep Deprivation
Pain/Anxiety
CRISMA CC·RR·II·SS·MM·AACritical Care Medicine
the University of PittsburghMedications
Anticholinergics (tricyclics)
Opiates
Benzos
Antihistimines (Benedryl “sleeper”)
H2 blockers
Antibiotics
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Antibiotics
Corticosteroids
Metoclopramide
Muscle relaxants
Lidocaine
CRISMA CC·RR·II·SS·MM·AACritical Care Medicine
the University of PittsburghMnemonics
IWATCHDEATHInfectionWithdrawalAcute metabolicTrauma/painCNS pathology
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CNS pathologyHypoxiaDeficiencies (B12, thiamine)EndocrinopathiesAcute vascular (HTN, shock)Toxins/drugsHeavy Metals
CRISMA CC·RR·II·SS·MM·AACritical Care Medicine
the University of PittsburghMnemonics
DELIRIUMDrugs
Electrolyte and physiologic abnormalities
Lack of drugs
Infection
Reduced sensory input
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Reduced sensory input
Intracranial problems
Urinary retention and fecal impaction
Myocardial problems (MI, CHF, arrhythmia)
CRISMA CC·RR·II·SS·MM·AACritical Care Medicine
the University of PittsburghMonitoring And Support
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CardiovascularCardiovascular
PulmonaryPulmonary
RenalRenal
CRISMA CC·RR·II·SS·MM·AACritical Care Medicine
the University of PittsburghMonitoring And Support
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Brain?Brain?
CRISMA CC·RR·II·SS·MM·AACritical Care Medicine
the University of PittsburghHow Do We Diagnose It?
The Spectrum of “Septic Encephalopathy”
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Normal Normal Delirium Stupor ComaDelirium Stupor Coma
Eidelman, JAMA 1996;275:470-473
Papadopoulos, Crit Care Med 2000;28:3019-24
The diagnosis of delirium represents a particular challenge, The diagnosis of delirium represents a particular challenge, since traditionally this requires “talking” to a patientsince traditionally this requires “talking” to a patient
CRISMA CC·RR·II·SS·MM·AACritical Care Medicine
the University of PittsburghHow Do We Diagnose It?
CAM-ICU (Confusion Assessment Method for the ICU)
DSM-IV criteria modified for nonverbal pts
Administered by anyone 1-2 minutes
Objective, valid, reliable
Sensitivity 93-100% & specificity 98-100%Wards: slightly less sensitive than CAM, but easier
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Wards: slightly less sensitive than CAM, but easier
Interrater reliability κ=0.96
2002 SCCM Sedation & Analgesia Guidelines
Vanderbilt ICU Delirium Study Group
Int Care Med, JAMA, CCM 2001
CRISMA CC·RR·II·SS·MM·AACritical Care Medicine
the University of Pittsburgh
Confusion Assessment Methodfor the ICU
2 step process
Step 1:Sedation assessment (RASS)
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CRISMA CC·RR·II·SS·MM·AACritical Care Medicine
the University of PittsburghRichmond Agitation Sedation Scale
+4 +4 CombativeCombative
+3 +3 Very agitatedVery agitated
+2 +2 AgitatedAgitated
+1+1 RestlessRestless
0 Alert /calm0 Alert /calm
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0 Alert /calm0 Alert /calm
--11 Drowsy Drowsy eye contact >10 seceye contact >10 sec
--22 Light sedation Light sedation eye contact <10 seceye contact <10 sec
--33 Moderate Moderate no eye contactno eye contact
--44 Deep Deep physical stimulation requiredphysical stimulation required
--55 UnarousableUnarousable no response even with physicalno response even with physical
Sessler et al., AJRCCM 2002; 166:1338-1344
Verbal
Physical
CRISMA CC·RR·II·SS·MM·AACritical Care Medicine
the University of Pittsburgh
Confusion Assessment Methodfor the ICU
2 step process
Step 1:Sedation assessment (RASS)
Step 2:Assess for 4 CAM-ICU features
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Assess for 4 CAM-ICU features
CRISMA CC·RR·II·SS·MM·AACritical Care Medicine
the University of Pittsburgh
Confusion Assessment Methodfor the ICU
Feature 1: Acute onset of mental status
change or a fluctuating course
Feature 2: Inattention
And
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Feature 3:
Disorganized Thinking
Feature 4: Altered Level
of Consciousness
= DELIRIUM
Or
CRISMA CC·RR·II·SS·MM·AACritical Care Medicine
the University of PittsburghCAM-ICU
Feature 1: acute onset or fluctuating course
Evidence of acute change in mental status from baseline?
ORDid behavior fluctuate in past 24 hours as
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Did behavior fluctuate in past 24 hours as evidenced by RASS or GCS?
CRISMA CC·RR·II·SS·MM·AACritical Care Medicine
the University of PittsburghCAM-ICU
Feature 2: inattention
Difficulty focusing attention as evidenced by score <8 on attention screening exam (ASE)?
Visual: picture recognition
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Visual: picture recognition
OR
Auditory: vigilance “A” random letter test
SAVEAHAART
CRISMA CC·RR·II·SS·MM·AACritical Care Medicine
the University of PittsburghCAM-ICU
Feature 3: disorganized thinking
Incorrect answers to 3 or more of 4 questions or
inability to follow commands
Questions
Will a stone float on water?
Are there fish in the sea?
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Are there fish in the sea?
Does 1 pound weigh more than 2?
Can you use a hammer to pound a nail?
Commands
Hold up this many fingers.
CRISMA CC·RR·II·SS·MM·AACritical Care Medicine
the University of PittsburghCAM-ICU
Feature 4: altered level of consciousness
Is the patients LOC anything other than alert?
Hyperactive/agitated
Lethargic, stuporous, comatose
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Lethargic, stuporous, comatose
CRISMA CC·RR·II·SS·MM·AACritical Care Medicine
the University of Pittsburgh
Confusion Assessment Methodfor the ICU
Feature 1: Acute onset of mental status
change or a fluctuating course
Feature 2: Inattention
And
���� the the CClinical linical RResearch, esearch, IInvestigation, and nvestigation, and SSystems ystems MModeling of odeling of AAcute illness cute illness ����
Feature 3:
Disorganized Thinking
Feature 4: Altered Level
of Consciousness
= DELIRIUM
Or
CRISMA CC·RR·II·SS·MM·AACritical Care Medicine
the University of PittsburghCan We Prevent It?
Age
Baseline Deficits Underlying
Illness
Metabolic DerangementsHypoxia
Catheters/RestraintsVision/Hearing
Deficits
���� the the CClinical linical RResearch, esearch, IInvestigation, and nvestigation, and SSystems ystems MModeling of odeling of AAcute illness cute illness ����
Derangements
Toxins
Inflammation & Thrombosis
Medications
Hypoxia
Sleep Deprivation
Pain/Anxiety
CRISMA CC·RR·II·SS·MM·AACritical Care Medicine
the University of PittsburghHaloperidol Prophylaxis?
430 elderly hip-surgery patients w/ delirium risk
factorsVision worse than 20/70 w/ glasses
APACHE>15, MMSE<25, BUN/Cr>17
Haloperidol 1.5 mg/day vs. placeboPreoperatively and up to 3 days post-op
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Preoperatively and up to 3 days post-op
Did not reduce incidence
Did reduce severity, duration of delirium
Hospital LOS ↓ 5.5 days! (among those w/ delirium)
Kalisvaart, JAGS 2005;53:1658-1666
CRISMA CC·RR·II·SS·MM·AACritical Care Medicine
the University of PittsburghOther Prevention Approaches
Alternative sedative agentsNon-GABA drugs
Dexmedetomidine, remifentanyl
Daily sedation interruption and early PT/OT
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Pandharipande et al. JAMA 2007
Riker et al. JAMA. 2009
Schweickert et al, Lancet 2009
CRISMA CC·RR·II·SS·MM·AACritical Care Medicine
the University of PittsburghWhen Should We Treat It?
Hyperactive “agitated” deliriumHaldol is the drug of choice
ICU
5-10 mg IV q20-30 minutes to control delirium then total dose divided q6
Fixed dose of 5-10 mg IV q12h
Wards
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Wards
0.5-2.0 mg IV/IM/PO q12h
Goal is to reduce need for drugs which we know can
prolong stay (benzos, opiates)
Avoid if QTc >500 msec
CRISMA CC·RR·II·SS·MM·AACritical Care Medicine
the University of PittsburghWhen Should We Treat It?
Hypoactive delirium???No one knows what to do
Risks of treatment may outweigh benefits
Focus should be on reducing modifiable risk
factors
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CRISMA CC·RR·II·SS·MM·AACritical Care Medicine
the University of PittsburghQuestion
Does treating delirium matter?Improve outcomes or just make patients (and
caregivers) feel better?
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CRISMA CC·RR·II·SS·MM·AACritical Care Medicine
the University of PittsburghHaloperidol and Mortality
36.1%
15.4%
35.5%
20%
30%
40%
Mo
rtali
ty (
%) P=0.001*
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7.7%
0%
10%
No Haloperidol Low Dose(0.5-5.0)
Medium Dose(5.1-12.5)
High Dose(>12.5)
Mean Daily Dose (mg/day)
Mo
rtali
ty (
%)
Milbrandt et al. CCM 2005
CRISMA CC·RR·II·SS·MM·AACritical Care Medicine
the University of PittsburghQuetiapine
Prospective multi-center RCT
36 adult ICU pts with delirium (ICDSC≥4)~80% mechanically ventilated
Quetiapine vs. placebo50 mg q12h orally or per feeding tube
Increased q24 if >1 dose haloperidol needed
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Increased q24 if >1 dose haloperidol needed
Max 200 mg q24h
Until ICU d/c, 10+ days, or ICU team decision
Devlin et al. CCM 2009 (Epub ahead of print )
CRISMA CC·RR·II·SS·MM·AACritical Care Medicine
the University of PittsburghQuetiapine
ResultsShorter time to delirium resolution
1 day vs. 4.5 days, p=0.001
Reduced delirium duration
36 hrs vs. 120 hrs, p=0.006
Less agitation
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Less agitation
Less time w/ SAS≥5, 6 hrs vs. 36 hrs, p=0.02
Non-significant hospital mortality reduction
11% vs. 17%, p=1.0
Trend to ↑ discharge to home or rehab
89% vs 56%, p=0.06
Devlin et al. CCM 2009 (Epub ahead of print )
CRISMA CC·RR·II·SS·MM·AACritical Care Medicine
the University of PittsburghConclusions
Delirium is common in the ICU
Acute brain dysfunction
Associated w/ poor outcomes and increased cost
National guidelines recommend monitoring & treatment
Always start w/ modifiable risk factors before drugs
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Always start w/ modifiable risk factors before drugs
Antipsychotics, non-GABA sedatives, sedation interruption & early PT may prevent or reduce delirium
Antipsychotics may improve outcomes, but further study is needed