PREVENZIONE E TERAPIA DEL DELIRIUM

NEI REPARTI DI CURA INTENSIVA

Giuseppe Natalini Terapia Intensiva

Fondazione Poliambulanza Brescia

TERAPIA FARMACOLOGICA

Devlin JW. Efficacy and safety of quetiapine in critically ill patients with delirium: A prospective, multicenter, randomized, double-blind, placebo-controlled pilot study Crit Care Med 2010; 38:419-27

Quetiapina

...meglio prevenire...

PREVENZIONE FARMACOLOGICA

Wang W et al. Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery: a randomized controlled trial. Crit Care Med 2012; 40:731-9

Page VJ. Effect of intravenous haloperidol on the duration of delirium and coma in

critically ill patients (Hope-ICU): a randomised, double-blind, placebo-

controlled trial. Lancet Respir Med 2013; 1:515–23

Girard TD. Feasibility, efficacy, and safety of

antipsychotics for intensive care unit delirium: The

MIND randomized, placebo-controlled trial. Crit Care

Med 2010; 38:428-37

...anche la prevenzione farmacologica...

LA SEDAZIONE

van den Boogaard M. Development and validation of PRE-DELIRIC (PREdiction of

DELIRium in ICu patients) delirium prediction model for intensive care patients:

observational multicentre study. BMJ 2012;344:e420

Pandharipande PP. JAMA. 2007; 298:2644-53 Maldonado JR. Psychosomatics 2009; 50:206-17

Riker RR. JAMA 2009; 301:489-99 Shehabi Y. Anesthesiology 2009; 111:1075-84

Rubino AS. Interact Cardiovasc Thorac Surg 2010; 10:58-62

alfa-2 agonisti: buona alternativa (dexmedetomidina, clonidina?)

Dubois MJ. Intensive Care Med 2001; 27:1297-304 Ouimet S. Intensive Care Med 2007; 33:66–73

Pandharipande PP. J Trauma 2008; 65:34-41 Pisani MA. Crit Care Med 2009; 37:177-83

Agarwal V. J Burn Care Res 2010; 31:706-15

oppioidi: solo a dose analgesica

Conclusione: farmaci e delirium

Prevenzione: forse anziani con bassa gravità

Terapia: aloperidolo per trattare episodi acuti (quetiapina?)

Sedativo di prima scelta (per il delirium): dexmedetomidina

Oppioidi: solo per analgesia

PREVENZIONE NON FARMACOLOGICA

Colombo R. A reorientation strategy for reducing delirium in the critically ill. Results of an interventional study. Minerva Anestesiol 2012; 78:1026-33

Strategia di riorientamento

HR 0.50 [95% CI: 0.31-0.89] (p=0.03)

Rispetto del sonno notturno

Van Rompaey B. The effect of earplugs during the night on

the onset of delirium and sleep perception:

randomized controlled trial in intensive care patients.

Crit Care 2012; 16:R73

Schweickert WD. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009; 373:1874-82

Terapia fisica ed occupazionale precoce

Zaal IJ. Intensive care unit environment may affect the course of delirium. Intensive Care Med 2013: 39:481-88

Balas MC. Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle. Crit Care Med 2014; 42:1024-36

Khan BA. Effectiveness of Implementing a Wake Up and Breathe Program on Sedation and Delirium in the ICU. Crit Care Med 2014; 42:791-5

Prevenzione non farmacologica

Nei gruppi di controllo i pazienti erano sottoposti a condizioni di disorientamento e depersonalizzazione, inutilmente immobilizzati nel letto, tenuti inutilmente svegli, senza privacy...

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th edition.2013.

Maldonado JR. Am J Geriatr Psychiatry 2013; 21:1190-222

Girard TD. Associations of markers of inflammation and coagulation with delirium during critical illness. Intensive Care Med 2012; 38:1965-73

Hsieh SJ. The association between Acute Respiratory Distress Syndrome, delirium,

and in-hospital mortality in Intensive Care Unit patients. Am J Respir Crit

Care Med 2015; 191:71-8

Delirium e ARDS

INFIAMMAZIONE E VENTILAZIONE

Pelosi P. The lung and the brain: a dangerous cross-talk. Critical Care 2011, 15:168

Dreyfuss D. Ventilator-induced Lung Injury. Lessons from experimental studies. Am J Respir Crit Care Med 1998; 157:294-323 Slutsky AS. Ventilator-Induced Lung Injury. N Engl J Med 2013;369:2126-36.

Pintado MC et al. Individualized PEEP setting in subjects with ARDS: A randomized controlled pilot study. Respir Care 2013

;58:1416-23

Ranieri MV. Effect of mechanical ventilation on inflammatory mediators in patients with acute respiratory distress

syndrome. JAMA. 1999;282:54-61

Amato MBP. Driving pressure and survival in the Acute Respiratory Distress Syndrome. N Engl J Med 2015; 372:747-55

Ranieri VM. Pressure–time curve predicts minimally injurious ventilatory strategy in an isolated rat lung model. Anesthesiology 2000; 93:1320-8

paziente passivo + flusso inspiratorio costante

SONNO E VENTILAZIONE

Ozsancak A. Sleep and mechanical ventilation. Crit Care Clin 2008; 24:517-31

60% dei pazienti ventilati ha disturbi del sono dovuti alla ventilazione meccanica Bergbom-Engberg I. Assessment of patients’ experience of discomforts during respirator therapy. Crit Care Med 1989; 17:1068–1072

Il problema della PSV

Meza S. Susceptibility to periodic breathing with assisted ventilation during sleep in normal subjects. J Appl Physiol 1998; 85:1929-40

Parthasarathy S. Effect of ventilator mode on sleep quality in critically ill patients. Am J Respir Crit Care Med 2002; 166:1423-9

ACV vs PSV

PSV con basso volume corrente

Cabello B. Sleep quality in mechanically ventilated patients: Comparison of three ventilatory modes. Crit Care Med 2008; 36:1749-55

Toublanc B. Assist-control ventilation vs. low levels of pressure support ventilation on sleep quality in intubated

ICU patients. Intensive Care Med 2007 33:1148-54

insufficienza respiratoria acuta

su cronica

insufficienza respiratoria acuta su cronica

Andrejak C. Does using pressure-controlled ventilation to rest respiratory muscles improve sleep in ICU patients? Respir Med 2013; 107:534-41

impostazione PSV sulla meccanica respiratoria

Fanfulla F. Effects of different ventilator settings on sleep and inspiratory effort in patients with neuromuscular disease. Am J Respir Crit Care Med 2005; 172:619-24

Come migliorare il sonno durante la ventilazione meccanica

1) ventilazione assistita-controllata: prima scelta

- spt malattie polmonari croniche

2) PSV:

- ottimale: scegliere PEEP e supporto su PEEPi e sforzo inspiratorio del paziente (40-80%)

- supporto inspiratorio: volume corrente max 7-8 ml/kg peso ideale, limitare asincronie e apnee

Meza S. Susceptibility to periodic breathing with assisted ventilation during sleep in normal subjects. J Appl Physiol 1998; 85:1929-40 Parthasarathy S. Effect of ventilator mode on sleep quality in critically ill patients. Am J Respir Crit Care Med 2002; 166:1423-9 Fanfulla F. Effects of different ventilator settings on sleep and inspiratory effort in patients with neuromuscular disease. Am J Respir Crit Care Med 2005; 172:619-24 Toublanc B. Assist-control ventilation vs. low levels of pressure support ventilation on sleep quality in intubated ICU patients. Intensive Care Med 2007 33:1148-54 Bosma K. Patient-ventilator interaction and sleep in mechanically ventilated patients: pressure support versus proportional assist ventilation. Crit Care Med 2007;35:1048-54. Cabello B. Sleep quality in mechanically ventilated patients: Comparison of three ventilatory modes. Crit Care Med 2008; 36:1749-55 Andrejak C. Does using pressure-controlled ventilation to rest respiratory muscles improve sleep in ICU patients? Respir Med 2013; 107:534-41

Conclusioni: trattare e prevenire il delirium in Terapia Intensiva

- approccio farmacologico al delirium al momento poco efficace

- efficace la prevenzione non farmacologica (rivoluzione culturale)

- ottimizzare la cura delle cause di delirium: infezioni, ventilazione, ecc.

per curare bene il delirium non bisogna curare il delirium