delirium palpharm14 march2016
TRANSCRIPT
Patama Gomutbutra MD
Case management
Drug induced encephalopathy
Palliative care for pharmacist 14-15th march 2016
Outline
• Case demonstration• Drug induced encephalopathy • Care giver counselling
Case
• Male 68 yo UD DM, HT, Spinal canal stenosis• Consult because alteration of conscious with
occasional jerking movement • Admited to ICU 6 months ago due ruptured
abdominal aorta then off and on infection• later developed ESRD on HD 3 times/weeks
• Current medication (selected) :– Meropenem IV for UTI ESBL– Gabapentin 300 mg PO
Tramadol 1 tab q 8 hrsfor his back pain
– Fluoxetin for his depression– Dilantin 100 mg IV q 8 hrs
because his jerking movement seizure
• Physical exam– Concious: E4VTM5 stuporous , occuasional
spontaneous eye opening but not follow command– Pupil : 3 mm RTLBE– Ocular : roving eyes, no eye deviation, no nystagmus– Movement : equal movement, non-rhythmic jerking
movment of distal hands, stimulus sensitive– Meningeal irritation signs : stiffneck all directions
Kernig’s sing negative– Respiration along ventilator– Reflex : 1+ all, BBK negative both
Goal of care
• “Minimal pain” • Full medication• His family refuse lumbar puncture or any
invasive procedure including CPR
Approach delirum
Appendix 1
D-E-L-I-R-I-U-M nmemonic
• Most of delirium caused by multifactorial– Drugs and dehydration * The most potential reversible – Electrolyte and Endocrine– Low blood flow and Low oxygen (include anemia)– Infection and Inflammation– Retention urine– Impact feces– Uncontroled pain– Mental disorientation
Lawlor PG, Arch Intern Med. 2000 Mar 27;160(6):786.
Drug induced encephalopathy
– Common • Anti-cholinergic (appendix 2)• Dopaminergic • Steroid• Opioid
– Uncommon• Serotoninergic • Antimicrobial• Antiepileptic
Serotoninergic
• serotonin syndrome– limbic : agitation– striatum : tremor , clonus, rigidity : legs> hands– Autonomic instability– GI hypermotility
• Mild anxiety like -> Sever sepsis like• Symptom may develop eariest as 6 hrs• Reverse after 24 hrs discontinue• Antidote:
cyproheptadine via NG 12 mg then 2 mg q 2 hrsmaintanance 8 mg q 6 hrs
Tramadol & Fluoxetinedrug interaction
Antimicrobial drug
• Metronidazole • Cephalosporin *• Carbapenem *• Linezolid• Acyclovir• Isoniazid
* associate with non-convulstive status epilepticus
Antibiotics
• Metronidazole– Dose related : more than 2 g/day– Bilateral symmetrical vasogenic edema
of cerebellar dentate and pons– Reversible : symptom 2 wks to 3 months after
discontinue
Iqbal A. Ann Indian Acad Neurol. 2013 Oct-Dec; 16(4): 569–571.
ReversibleReversible
Antiviral
• Acyclovir– Adjust to renal dose
(Appendix 3)– Reversible symptom after 48-72 hrs after dose
adjusted
Antiepileptic
• Phenytoin– Hypoalbumin
• Valporate– Hypoalbumin– Liver decompensation
• Levetriazetam– Renal impairment
Antiepileptic
• Valporate• Hyperammonia : level >40
– CSF ammonia may high in the normal level serum ammonia
– Inhibit glutamate uptake by astrocyte
• Rx by lactulose to reduce ammonia absorb by intestine.
Care giver advise
• Give them information ‘sens of controllable’– Delirium is not ‘Permanent psychosis’– Tell them basic advise
“D-E-L-I-R-I-U-M”– Reorientation protocol
• Remind patient - time place person• Less confusional environment• Sleep wake adjustment
Take home message
• Drugs and dehydration is the most potential reversible cause of encephalopathy
• Medication involve Ach, DA and Serotonin should be precaution
• Giving information to care giver may be important than medication
Reference
• Comprehensive review with references of drug induce encephalopathy:
http://cdn.intechopen.com/pdfs-wm/35733.pdf
Appendix 1
Appendix 2
PL Detail-Document, Drugs with Anticholinergic Activity. Pharmacist’s Letter/Prescriber’s Letter. December 2011.
Dose adjustment for AcyclovirEncephalitis dose :
CrCl > 50 : 500 mg (10mg/kg) IV q 8 hrs25-50 : 500 mg (10mg/kg) IV q 12 hrs10-25 : 500 mg (10mg/kg) IV q 24 hrs< 10 : 150 mg (5 mg/kg) IV q 24 hrs
give after HD on dialysis dayHD -> 60% decrease dose
Herpes zoster dose:CrCl >25 : 800 mg PO q 4 hrs -5 times a day
10-25 : 800 mg PO q 8 hrs< 10 : 800 mg PO q 12 hrs
Appendix 3