delirium in the icu · ccpot (see handout) ccpot posi_ve (score >2) treat pain reassess ccpot....
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Delirium in the ICU PamelaL.Smithburger,PharmD,MS,BCPS,BCCCP,FCCP
AssociateProfessor,UniversityofPi@sburghSchoolofPharmacy
Pa2ent Case
• JJis75Yomaleadmi@edtotheMICUon12/10withacuteSOB• Caresforillwifeathome,drives,managesfinances,volunteerswithMealsonWheels
• RVP+InfluenzaA• Sputum+MRSA• Intubated12/116am
Pa2ent Case • PMH
• HTN–Lisinopril20mgdaily• Diabetes-Dietcontrolled• Lowerbackpain-Oxycodone5mgpoq6hrPRNPain(usuallytakes1tabletatbed_memostnights)
• 12/11Medica_onlist• Scheduledmedica_ons
• Chlorhexidine• Famo_dine20mgBIDGastricTube• Heparin5000unitssubqQ8H• Vancomycin1.5gmIVq24hr• Oseltamivir75mgBIDGastricTube
• PRNMedica_ons• Fentanyl50mcgIVQ1HRprnRiker4• Midazolam2mgIVQ2HRprnAGITATION,TargetRiker4• Fentanyl50mcgIVq5minPRNBreakthroughpain(max3dosesin1hr)• Midazolam1mgivq5MINPRNbreakthroughagita_on(max3dosesIN1HR)
Pa2ent case
• 12/11afernoon• Youarriveatthebedsideandthenursereportsthatthepa_enthasnotbeendirectablewithano_ceablechangeinmentalstatus
• Whatshouldyouconsider?
What is going on?
1. Hypercapnia?Nope,arterialbloodgas:7.35/40/25/80
2. Overseda_onwithPRNs?Isthemidazolamdosetoohigh?Isitbeingusedtoofrequently?• NoPRNsweregiven
3.Delirium?
Delirium Assessment 1. Assesslevelofarousal
Rikerscore?AsknursewhathasleadthemtogivetheRikerscoresthattheygaveMustbeaRiker>2tocon_nuewithdeliriumassessment.If<2,furtherassesswhy.
2.Isthepa_entinPain?CCPOT(seehandout)CCPOTPosi_ve(score>2)TreatpainReassessCCPOT.Didscoredecrease?S_llnotdirectable
3.DeliriumAssessmentCAM-ICU(seehandout) CAM-ICUnega_veICDSC(seehandout) ThebedsidenursecompletedanICDSC
CAM-ICU
• Handout• Nega_ve
ICDSC
Score5
• Date/Time
Score1
Score1
Score1
Score0
Score0
Score0
Score1
Score1
Score5
• Consider Riker score over the entire shift • Pt. Riker = 3
ICDSC: Level of Consciousness
LOC
Noscore=Noresponse(Riker=1);reassessin4hrs
Noscore=Responsetointenseandrepeateds_mula_on(loudvoiceandpain)(Riker=2);reassessin4hrs
1=Responsetomildormoderates_mula_on(Riker=3)
0=Normalwakefulness(Riker=4)
1=Exaggeratedresponsetonormals_mula_on(Riker>4)
• Score1foranyofthefollowingabnormali_es: A.Doesnotfollowcommands(i.e.,wiggletoes) B.Easilydistractedbyexternals_muli C.Difficultyinshifingfocus
v Doesthepa_entfollowyouwiththeireyeswhenyoumovetotheoppositesideofthebed?
ICDSC: Inattention
Ina/en0on
0=Notpresent
1=Doesnotfollowcommandsand/oreasilydistractedand/ordoesnotfollowwitheyes
• Score1foranyobviousmistakeinplaceand/orperson
ICDSC: Disorientation
Disorienta0on
0=Notpresent
1=Doesnotrecognizepreviouscaregiversand/orloca_on
Example: Does the patient know they are in the hospital and not elsewhere (i.e. at home)?
• Score1foranyofthefollowingabnormali_es:• Evidenceofhallucina_onsorbehaviorduetoahallucina_on• Delusionsorgrossimpairmentofreality
§ Falsebeliefthatisfixedorunchanging
ICDSC: Hallucinations/delusions
Hallucina0ons/delusions
0=Notpresent
1=Exhibitsbehaviorconsistentwithhallucina_ons/delusionsand/orgrossimpairmentinrealitytes_ng
• Score1foranyofthefollowingabnormali_es:• Hyperac_vity(i.e.pullingatendotrachialtubeorlines)• Hypoactivity (noticeable slowing)
• Adelayedresponsetoques_onsorcommands• Assessifduetorecentanalgesia/seda_on:Score0insteadof1
• Family members can be a good resource for establishing the patient’s baseline!
ICDSC: Agitation/hypoactive
Agita0on/hypoac0ve
0=Notpresent
1=Hyperac_vityrequiringseda_vesorrestraintstopreventharmtoselforothers
1=Clinicallyno_ceablepsychomotorslowing
• Score1foranyofthefollowingabnormali_es:• Inappropriate,disorganized,orincoherentspeech• Inappropriatemoodrelatedtoeventsorsitua_on(Is the patient
apathetic about the situation?)
ICDSC: Inappropriate speech/mood
Inappropriatespeech/mood
0=Notpresent
1=Inappropriate,disorganized,orincoherentspeech
1=Inappropriatedisplayofemo_onorapathyrelatedtocurrentsitua_on
• Sleep/wake cycle disturbance scoring may need to include information reported from the previous shift.
• Patient awake all night
• Sedation ≠ Sleep • Emerging data on DEX potentially allowing non-REM sleep
ICDSC: Sleep/wake cycle disturbance
Sleep/wakecycledisturbance
0=Notpresent
1=Sleeping<4hoursatnightORwakingfrequently(notduetoloudenvironmentorini_atedbystaff)
1=Sleep4hoursormoreduringtheday
Impact of Sleep on Delirium • 97%of1,223ICUphysiciansandnursesagreedthatpoorsleepintheICUisariskfactorfordeliriuminaglobalsurvey
• PADGuidelines“promo_ngsleepinadultICUpa_entsbyop_mizingpa_ents’environments,usingstrategiestocontrollightandnoise,clusteringpa_entcareac_vi_es,anddecreasings_muliatnighttoprotectpa_ent’ssleepcycles”(+1C)asastrategytomanagepain,agita_on,anddelirium
CritCareMed2013;41:263-6AnnAmThoracSoc2016;13(8):1370-7
Impact of Sleep on Delirium
• Systema_creviewofICUstudiesinvolvingsleep-promo_nginterven_onstoimprovedelirium
• 6/10studiesdemonstratedreduc_onsinoccurrencerateofICUdelirium• 4studiesusedsleepbundleswhichalsoresultedinimprovementsindelirium
CritCareMed2106;44:2231-40
• Fluctua_onofanyofthefirst7itemsover24hours(overthecourseofyourshiforfromoneshiftoanother)
ICDSC: Symptom fluctuation
Symptomfluctua0on
0=Notpresent
1=Fluctua_onofthepresenceofanyaboveitemover24hours
Pa2ent Case
• WhythedifferencebetweenCAM-ICUscoresandICDSC??
What to do now?
• STOPandTHINK
“STOP” • “STOP” unnecessary medications • Review sedatives and streamline if possible
• Use minimal amount of sedative and pain medication necessary • Sedation interruption daily • Use of a targeted pain plan
• Optimize sedation medications • Minimize benzodiazepine use • Utilize dexmedetomidine if appropriate
Malik, A. J Clin Nurs 2016 Pohlman AS. http://s3.proce.com/res/pdf/DeliriumAssessment_monograph.pdf
“THINK” • “THINK” about alternative causes of delirium
• Toxic Situations • Dehydration, CHF, shock, new organ failure • Deliriogenic medication use
• Examples: • Anticholinergic medications (Diphenhydramine, promethazine) • Benzodiazepines • Narcotics • Corticosteroids • Sleep agents (ex. Zolpidem)
• Hypoxemia • Infection/Sepsis • Immobilization • Neglected Nonpharmacologic interventions (“MORE Protocol” ) • K+ or electrolyte abnormalities
Malik, A. J Clin Nurs 2016 Pohlman AS. http://s3.proce.com/res/pdf/DeliriumAssessment_monograph.pdf
Delirium Prevention Non-Pharmacologic Protocol
23
Mob
ilityProtoco
l • Ini0atetheProtocol
• Dailyhuddle(PT,RN&RespiratoryTherapist)
• EarlyandRegularAmbula0on M
usicThe
rapy • Playatleast1
hourofrelaxingmusicpershiP
• TurnoffTVifpa0entisunabletoview
Ope
ningand
ClosingBlin
ds
• Openblindsinmorning,closeblindsatnight
• Anglepa0entsinchairstohaveaviewofthewindow
Reorienta0
onand
Cogni0v
eS0
mula0
on
• Askthepa0enthowtheywouldliketobeaddressed
• Reorientpa0enttotheirplanofcareandprogress
• Askcogni0ves0mula0onques0ons:• Whatisyourfavoritesportsteam,movie?Didyouwatchtheirmostrecentone?
Eyean
dEarP
rotocol
• Ifpa0entwearscontactsorglassesandhearingaidsathome,encourageuse
• Inevening,offerthepa0entaneyemaskandearplugstoincreasesleep
Environmental Contributors?
• Didanyoneaskifhewearsglassesorhearingaids?
Family involvement
• Whenasked,hisdaughterdiscloseshehasavery“strong”eyeprescrip_onandcannotseewithouthisglasses
• Hehasalsobeenwearinghearingaidsforthepast20yearsduetoeardamagefromhisworkintheSteelMill.Shehastoshoutathimforhimtobeabletohearherwithouthishearingaids.
• Shedidn’teventhinktobringintheeyeglasses.Shewasafraidthehearingaidswouldgetlostsincetheyareveryexpensive.
• Youencouragehertbringinthehearingaidsandalertnursingleadershipthatthispa_entwillhavehearingaidsbroughtin.
Pharmacologic therapy
An_psycho_csHandout• LancetRespirMed2013;1:515-23• IntensiveCareMed.2004;(30):444-9• CritCareMed.2010;38(2):428-37• CritCareMed.2010;38(2):419-27• Pharmacotherapy.2015;35(8):731-39• JCritCare.2017;41:234-9Receptorhandout
Pa2ent Case
• YoustartJJonolanzapine20mggastricdaily–buthedoesn’thaveoralaccessrightnow.
• CouldtheZydis(orallydisintegra_ngproduct)beusedandabsordedthroughthemoralmucosa?
• Pa_entgainsoralaccess-medica_ongiven• Hedevelopsrigidityandanincreasedtemperatureto38.9C• NMS
Pa2ent Case Op2on 2
• Pa_entgainsoralaccess• Insteadofstar_ngolanzapineyouiden_fysleepasanissue,soyoustartQue_apine50mggastricqhs
• BasesupontheDevlin2010study,que_apine50mggastricBIDwasthestar_ngdose.
Pa2ent Case
• JJimprovesontheque_apine50mggastricqhsandisextubatedon12/13.
• On12/14,JJ’sICDSCscoresarethefollowing:4am:34pm:3
Whatdothesescoresmean?
Subsyndromal delirium
• Ptsthatfallshortofthediagnos_cthresholdfordelirium(ICDSC≥4)• ICUpa_entswithoutdeliriumcomparedtothosewithsubsyndromaldeliriumweremorelikelytobedischargedhome(p=0.0004)andlesslikelytoneedlong-termcare(p<0.0001)
IntensiveCareMed2007;33:1001-13
Pa2ent Case- Subsyndromal Delirium
• Increasenon-pharmacologicpreventa_vemeasurestodecreaseICDSCscore
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