a case of delirium

A Case of ICU Delirium

Paula L. Watson, M.D.Assistant Professor

Pulmonary/Critical Care/Sleep MedicineVanderbilt University Medical Center

NIH AG027472-01A1, VA-GRECC,CTSA 1 UL1 RR024975, ASPECT

• 54 year old female prior history of rheumatoid arthritis • Home meds: prednisone 5mg, weekly methotrexate, adalimumab

biweekly• Presented to community hospital with 3 days of cough, fever, myalgias;

required intubation for progressive hypoxia• Bronchoscopy + H1N1 influenza, + candida albicans• Received: tamiflu, vancomycin, ceftazidime, stress dose steriods;

fluconazole added after candida noted in cultures• Barotrauma induced pneumothorax requiring chest tube

• Transferred to academic center ventilator day #3 for management of progressive hypoxia

On arrival:• Temp 99.1, BP 89/56, heart rate 83, respiratory rate 24• Vent settings: TV 300, FiO2 100%, PEEP 20, PIP 30• Admission ABG: 7.40 / 50 / 61; Oxygen saturation 86-92%• sodium 146, potassium 3.9, chloride 111, serum bicarb 30,

BUN 21, creatinine 0.56

Meds:• Tamiflu, doripenem, linezolid, micofungin, stress dose

steriods

Initial Sedation / Analgesic Regimen

• Continuous fentanyl and midazolam

• Clinical bedside sedation scale (Richmond Agitation-Sedation Scale (RASS)

Initial target – 4 (minimally responsive)

• Paralytics administered secondary to ventilator dysynchrony

Richmond Agitation-Sedation Scale(RASS)

+4 Combative+3 Very agitated+2 Agitated+1 Restless

0 Alert /calm-1 Drowsy eye contact >10 sec-2 Light sedation eye contact <10 sec-3 Moderate no eye contact-4 Deep physical stimulation required-5 Unarousable no response even with physical

Sessler, et al. AJRCCM 2002;166:1338-44Ely, et al. JAMA 2003;289:2983-91

Verbal Stimulus

Physical

Stimulus

Neurological Monitoring Neurological Monitoring When Clinical Sedation Scales FailWhen Clinical Sedation Scales Fail

+ 1

0

- 1

- 2

- 3

- 4

- 5

Richmond Agitation-Sedation Scale (RASS)

Burst Suppression is Associated with Increased Mortality

010203040506070

ICU Mortality HospitalMortality

6 MonthMortality

% M

orta

lity

Never Burst-suppressedBurst-suppressed

Watson et al., Crit Care Med 2008;36(12):3171-77

P = 0.02

Bispectral Index Monitor

Target range 50-60 while on paralytics (amnestic)

Hospital Day # 3Improving oxygenation

• Vent settings: TV 300, FiO2 75%, PEEP 14• ABG: 7.40 / 65 /69• sodium 147, potassium 3.7, chloride 102, serum

bicarb 37, BUN 34, creatinine 0.78• Paralytics discontinued previous day

• Rounds:– Sedation target = RASS -4– Actual sedation level = RASS -4– CAM-ICU = unable to assess, patient comatose– Medications (sedatives, analgesics, antipsychotics) =

continuous midazolam, fentanyl

What changes to patient management would you

consider?

Hospital Day # 5• Vent settings: TV 300, FiO2 60%, PEEP 10• ABG: 7.45 / 53 / 71• sodium 143, potassium 4.2, chloride 105, serum

bicarb 35, BUN 22, creatinine 0.56

• Rounds:– Sedation target = RASS -2– Actual sedation level = RASS -2 – CAM-ICU = positive– Medications (sedatives, analgesics, antipsychotics) =

intermittent midazolam, fentanyl

www.icudelirium.org

When CAM+

D drugs, drugs, drugs E eyes, earsL low O2 states (MI, ARDS, PE, CHF, COPD)I infectionR retention (urine), restraintsI ictalU underhydration, undernutritionM metabolic(S) subdural, sleep deprivation

What are the patient’s delirium risk factors?

What changes to patient management would you

consider?

Managing Delirium• Primary prevention preferred

– Avoid or decrease exposure to benzodiazepines• Nonpharmacologic:

– Reorientation– Eye glasses, hearing aids– Provide cognitively stimulating activities– Timely removal of catheters and restraints– Early mobilization

• Pharmacologic:– Stop any offending medications– Consider antipsychotics

• haloperidol (practice guildelines, Crit Care Med 2002)– Consider dexmedetomidine

Which drug for delirium?

86% - haloperidol37% - atypical antipsychotics35% - benzodiazepines13% - propofol8% - opiates5% - dexmedetomidine

Patel et al., Crit Care Med 2009;37:825-32

Fentanyl and midazolam are associated with increased risk of delirium

Pandharipande et al., J Trauma 2008;65(1):34-41

Daily Prevalence of Delirium

• Prevalence of delirium similar prior to starting study drug• Dexmedetomidine resulted in 24.9% ↓ in delirium during

treatment phase (54% dex vs. 76.6% mdz)

Riker, Rocha, JAMA 2009;301(5):489-99

Resolution of Delirium and Coma

0 5 10 15 20Day

0

20

40

60

80

100

Pat

ient

s w

ithou

t Del

irium

or C

oma

(%)

Haloperidol (n=35)Ziprasidone (n=32)Placebo (n=36)

Girard et al., Crit Care Med 2010;38(2)

Main Outcomes

Outcome*Haloperidol

(n=35)Ziprasidone

(n=32)Placebo(n=36) p

Delirium/coma-free days 14 [6-18] 15 [9-18] 13 [2-17] 0.65Ventilator-free days 8 [0-15] 12 [0-19] 12 [0-23] 0.33Length of stayICU 12 [5-16] 10 [4-15] 8 [5-13] 0.70Hospital 14 [10-NA†] 14 [10-NA†] 16 [9-NA†] 0.67

Mortality, % 11 13 17 0.80Extrapyramidal side effectsDaily EPS score 0 [0-0.2] 0 [0-0] 0 [0-0] 0.56

Cognition at dischargeMean T-score 27 [25-31] 28 [24-35] 33 [23-36] 0.50

*Median [interquartile range] except as noted

Girard et al., Crit Care Med 2010;38(2)

Extubation

• CAM-ICU +• During wake and breath trials, patient would

become anxious, agitated, tachypneic, with shallow respiration

• Dexmedetomidine infusion started• Spontaneous breathing trial performed on drug• Patient passed spontaneous breathing trial and

was extubated

Day # 8

• Remains CAM-ICU +• Hallucinations• Husband states that she is not sleeping at

night

When CAM+

D drugs, drugs, drugs E eyes, earsL low O2 states (MI, ARDS, PE, CHF, COPD)I infectionR retention (urine), restraintsI ictalU underhydration, undernutritionM metabolic(S) subdural, sleep deprivation

Animation = Less Delirium

Schweickert et al, Lancet 2009;373:1874-82

Liberationbedside sedation scale

spontanous awakening trialwake up and breath trial

alternative sedative agents (dexmedetomidine)

Animationearly physical therapy