delirium in intensive care unit

Annoying facts.. Annoying disease

most common psychiatric

syndrome found in the general

hospital setting.

Upto 40% of hospitalized AIDS

patients

Upto 25% of hospitalized cancer

patients

Upto 51% of postoperative patients

up to 80% of mechanically

ventilated adult ICU patients

and up to 80% of patients with

terminal illnesses

Usually followed treatment paths...

Sister, you give some fortwin-phenergan

You call the duty doctor

What should I do.. Sister?..tell the patient to be calm…

We are more tempted to label it as an annoyance.....from the patient

And hesitant to accept that…actually we are more confused than the patient…!!! [ in managing icu psychosis ]

limbs, heart or gall

bladder…medically or

surgically…but don’t ignore this

organ….Getting mentally disturbed….or Getting physically disturbed….which is more common among us as a normal human being or as a doctor…..?

it’s a problem anybody in this world can develop, when diseased, traumatized, with all psychological defenses breached…

….…. Primarily its a problem for

In a busy ICU, for the nursing staff

it’s a KATRINA

A reduced clarity of awareness

of the environment with reduced

ability to focus, sustain, or shift

attention.

A change in cognition (such as

Memory deficit, disOrientation,

Language disturbance) or

the development of a perceptual

disturbance

tends to fluctuate during the course

Other symptoms commonly associated with delirium include..

emotional disturbances (i.e., fear, anxiety, anger, depression, apathy, euphoria)

attention deficits,

disordered sleep-wake cycle

Don’t miss the introverts

Hyperactive delirium is more often associated with hallucinations and delusions, while

hypoactive delirium is more often characterized by confusion and sedation, and is often misdiagnosed in ICU patients.

Before the storm…

Some patients manifest subclinical

delirium or prodromal symptoms

such as restlessness,anxiety,

irritability, distractibility, or sleep

disturbance in the days before the

onset of overt delirium.

The duration of symptoms range

from less than 1 week to more than

2 months

To reach the other end

safely is difficult…

majority of patients recover fully,

delirium may progress to stupor,

coma, seizures, or death,

particularly if untreated.

Full recovery is less likely in the

elderly,

Persistent cognitive deficits are

also quite common in elderly

Risk factors

,.

Risk Factors

preexisting dementia/cognitive impairment,

history of hypertension and/or alcoholism, and a

high severity of illness at admission

severe sepsis or shock;

on mechanical ventilation;

receiving parenteral sedative and opioidmedications

Coma is an independent risk factor

Benzodiazepine use may be a risk factor

Age 65 years or older.

Current hip fracture

Notorious.....

Surgeries : particularly cardiotomy, hip

surgery, or a transplant

Burns

dialysis

central nervous system lesions

Dont disturb the equillibrium...further

Ohh…I lost it….I mean my acetyl choline

reserve…e.g. aging

Don’t drain my reserve with your naughty

drugs

Dementia

Male

Visual impairment

See.... that crooked fellow tied me, when I

was in ICU

The use of re-straints, including endotracheal

tubes ‘restraints, intravenous lines, bladder

catheters, and intermittent pneumatic leg

compression devices, casts, and traction

devices all have been associated with an

increased incidence of delirium

Sleep deprivation

may lead to the development of both

psychosis and delirium.

Studies have found that the average amount

of sleep in patients in an intensive care unit

(ICU) is limited to 1 hour and 51 minutes per

24-hour period

Work..tension..many find it difficult to sleep @ home…then what about patients in ICUs?They have few complete sleep

cycles, numerous awakenings due to environmental disruptions (noise, light, and physical stimulation), and infrequent REM sleep

Sleep deprivation impairs tissue repair and cellular immune function, and may affect the healing response

In critically ill patients, sleep deprivation may contribute to the development of delirium and increased levels of physiologic stress

Risk Factors

Four baseline risk factors are positively and significantly associated with the development of delirium in the ICU: preexisting dementia, history of hypertension and/or alcoholism, and a high severity of illness at admission :

patients with a baseline history of cognitive impairment, severe sepsis or shock; on mechanical ventilation; receiving parenteralsedative and opioid medications

Coma is an independent risk factor

Benzodiazepine use may be a risk factor

Impact of Delirium on ICU Patient

Outcomes

need to stay longer in hospital or in critical

care

have an increased incidence of dementia

have more hospital-acquired complications,

such as falls and pressure sores

have a very high rate of death during the

months following discharge; especially first 6

months

Increased cost of care

Impact of Delirium on

Outcomes In postoperative patients, delirium is a

harbinger of limited recovery and poor long-

term outcome ; particularly after orthopedic

surgery

Seizures may occur in delirium, particularly

among patients with alcohol or sedative-

hypnotic withdrawal, head trauma,

hypoglycemia, strokes, or extensive burns

An can change

his/her life Early detection and treatment of

delirium may in turn

allow for a patient to be conscious, yet cooperative enough to potentially participate in ventilator weaning trials

and early mobilization efforts.

SUBTYPES

.

Delirium due to Drug and/or

Alcohol Withdrawal.

manifests as a hyperactive type of delirium

Withdrawal symptoms may result from abrupt discontinuation of:

1) drugs that patients were taking chronically;

2) sedatives or opioids administered as part of routine ICU care; or

3) chronic ethanol use.

Opioid Withdrawal....

sweating, piloerection, mydriasis,

lacrimation, rhinorrhea, vomiting, diarrhea,

abdominal cramping, tachycardia,

hypertension, fever, tachypnea, yawning,

restlessness, irritability, myalgias, increased

sensitivity to pain, and anxiety

The onset of symptoms can occur < 12 hrs

following discontinuation of opioids, or be

precipitated by either the administration of

Benzodiazepine withdrawal

Prolonged benzodiazepine use in ICU patients may lead to withdrawal symptoms when the drug is abruptly discontinued

manifesting as anxiety, agitation, tremors, headaches, sweating, insomnia, nausea, vomiting, myoclonus, muscle cramps, hyperactive delirium, and occasionally seizures

flumazenil may induce symptoms of benzodiazepine withdrawal

Don’t

leave me

Even dexmedetomidine....

Adult ICU patients receiving dexmedetomidine infusions for up to 7 days have developed withdrawal symptoms, most commonly nausea, vomiting, and agitation, within 24–48 hrs of discontinuing dexmedetomidine

the incidence of withdrawal following discontinuation of dexmedetomidine was 4.9% vs. 8.2% in midazolam-treated patients

Alcohol Withdrawal Syndrome

[AWS]Between 8% and 31% of hospitalized

patients with ethanol dependence, especially surgical and trauma patients, will go on to develop (AWS)

generalized tonic-clonic seizures, delirium tremens (DTs), (agitation, delirium, and seizures) and hyperadrenergic symptoms (hypertension, tachycardia, arrhythmias)

may exhibit prolonged ventilator dependence and extended ICU stays as a result of persistent delirium

So dont miss....

Signs and symptoms of opioid and sedative

withdrawal in critically ill patients may be

overlooked or attributed to other causes,

such as alcohol or illicit drug withdrawal.

opioids and/or sedatives administered for

prolonged periods (i.e., days) should be

weaned over several days in order to reduce

the risk of drug withdrawal.

PREVENTION

.

Approaches in prevention

nonpharmacologic (e.g., early mobilization),

pharmacologic, and

combined pharmacologic/nonpharmacologicapproaches.

Trials say....

no recommendation for using a pharmacologic delirium preventionprotocol [administering prophylactic antipsychotics to the general ICU population] in adult ICU patients

Early and aggressive mobilization may reduce the incidence and duration of delirium, shorten ICU and hospital LOS, and lower hospital costs.

Dear..You want GOOD KNIGHT ?

nurses should select time periods to promote sleep by avoiding routine ICU care activities (such as the daily bath), turning down the lights, and reducing ambient noise during these periods

In three studies suggesting scheduled rest periods, the periods most likely to be uninterrupted in the ICU were 2–4 AM, 12–5 AM and around 3 AM

GOOD NIGHT.......dear

Control daytime light exposure,

use eye patches or ear plugs to limit the aversive effects of noise and light

cluster patient care activities,

and decrease stimuli at night to protect patients' sleep cycles

no recommendation for using specific modes of mechanical ventilation to promote sleep in adult ICU patients

SEDATION AND

DELIRIUM

.

To catch the thief, you… he has to

be responsivepatients should be able to

sufficiently interact and communicate

Optimal pain management and a light level of sedation are essential for this to occur.

Light and deep

Sedatives can be titrated to maintain either

light (i.e., patient is arousable and able to

purposefully follow simple commands) or

deep sedation (i.e., patient is unresponsive

to painful stimuli).

Multiple studies have demonstrated the

negative consequences of prolonged, deep

sedation, and the benefits of maintaining

lighter sedation levels in adult ICU patients

Light light light...

Maintaining light levels of sedation increases

the physiologic stress response, but is not

associated with an increased incidence of

myocardial ischemia (B).

So the recommendation is that sedative

medications be titrated to maintain a light

rather than deep level of sedation in adult

ICU patients, unless clinically

contraindicated

daily sedation interruption or a light target

level of sedation

Don’t knock him/her out....if possible

Check patient’s ability to purposefully respond to commands (i.e., a combination of any three of the following actions) upon request open eyes, maintain eye contact, squeeze hand, stick out tongue, and wiggle toes

is essential, for assessing patients’ readiness to wean and extubate, for performing delirium assessments, and for implementing early mobility efforts.

Analgesia-first sedation

in mechanically ventilated adult ICU patients

high frequency of pain and discomfort as primary causes of agitation; patients should receive adequate and preemptivetreatment for pain

is associated with longer ventilator-free time

Analgesia-first sedation

But opiates can interfere with respiratory drive, reduce gastric motility, and complicate the provision of enteral nutrition

Possible pain recurrence and withdrawal upon analgesic discontinuation

may require supplementation with other traditional sedative agents

Other points

Restraints themselves can increase agitation

and should be considered only when other

means of control are not effective or

appropriate

The justification for initiating restraints and

continuing use of restraints should be

documented

Education of nursing staff on each shift

regarding the clinical features and course of

delirium

behavioral problems may make us to

overlook underlying general medical

DELIRIUM

MONITORING SCALES

AND SEDATION

SCALES

.

Routine monitoring of delirium in

adult ICU patients is feasible in

clinical practice

ICU patients at moderate to high risk for delirium (e.g.,) should be routinely monitored, at least once per nursing shift, for the development of delirium using a valid and reliable delirium assessment tool.

The Confusion Assessment Method for the ICU (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) are the most valid and reliable delirium monitoring tools in adult ICU patients

Monitoring depth of sedation

The use of sedation scales,

sedation protocols designed to minimize

sedative use, and

the use of nonbenzodiazepine medications

are associated with improved ICU patient

outcomes, and decreased incidences of

delirium and long-term cognitive dysfunction


The Richmond Agitation-Sedation Scale (RASS) and Sedation-Agitation Scale (SAS) are the most valid and reliable sedation assessment tools for measuring quality and depth of sedation in adult ICU patients

objective measures of brain function (e.g., AEPs, BIS, NI, PSI, or SE) be used as an adjunct to subjective sedation assessments in adult ICU patients who are receiving neuromuscular blocking agents


EEG monitoring if known or suspected

seizures, to titrate electrosuppressive

medication to achieve burst suppression in

adult ICU patients with elevated ICP

Useful in ICU patients either with known

seizure activity or who are at risk for seizures

(e.g., traumatic brain injury, intracerebral

hemorrhage, CVA)

EEG changes in delirium: generalized

TREATMENT

.

PSYCHIATRIC MANAGEMENT

Coordinate with other physicians caring for

the patient

Identify the etiology

Initiate interventions for acute conditions

Provide other disorder-specific treatment

Assess and monitor psychiatric status

Educate patient and family regarding the

illness

Provide postdelirium management

PSYCHIATRIC MANAGEMENT

.

ENVIRONMENTAL AND

SUPPORTIVE

INTERVENTIONS

understimulation is also dangerous;

gprovide a regular amount of

modest stimulation (vocal, visual,

tactile) to the patient with delirium..

ENVIRONMENTAL AND

SUPPORTIVE

INTERVENTIONS [nice]introducing cognitively stimulating

activities

Address dehydration

optimise oxygen saturation

Address infection

avoid unnecessary catheterisation

mobilise soon after surgery

dentures, ensuring they fit properly

Any medication or agent known to

cause delirium or to have high

anticholinergic potential should be

SOMATIC INTERVENTIONS

There is no published evidence that

treatment with haloperidol reduces the

duration of delirium in adult ICU patients

Atypical antipsychotics may reduce the

duration of delirium in adult ICU patients

No recommendations for administering

rivastigmine to reduce the duration of

delirium in ICU patients (–1B).

Benzodiazepines are considered the

mainstay in alcohol withdrawal

PHARMACOLO

GY

.

Benzodiazepines

anxiolytic, amnestic, sedating, hypnotic, and anticonvulsant effects, but no analgesic activity

Their amnestic effects extend beyond their sedative effects

Lorazepam > midazolam > diazepam.

when there is a need for a medication that

can raise the seizure threshold (unlike

antipsychotics, which lower the seizure

threshold)

contraindicated in delirium from hepatic

encephalopathy

DOUBLE EDGED

Benzodiazepines can exacerbate symptoms

of delirium

when used alone for general cases of

delirium shown to be ineffective

Combining a benzodiazepine with an

antipsychotic medication for patients who

can only tolerate lower doses of

antipsychotic medications or who have

prominent anxiety or agitation.

In hepatic insufficiency: if bzd is needed, use

lorazepam, oxazepam, and temazepam

Side effects

behavioral disinhibition, amnesia, ataxia,

respiratory depression, physical

dependence, rebound insomnia, withdrawal

reactions, and delirium

Be vigilant : Elderly patients, respiratory

depression , systemic hypotension, hepatic

dysfunction

Parenteral formulations of lorazepam :

propylene glycol toxicity in ICU patients

Butyrophenones

Haloperidol, a high-potency dopamine-

blocking agent is most frequently used

because of its short half-life, few or no

anticholinergic side effects, no active

metabolites, and lower likelihood of causing

sedation.

orally or intramuscularly,

fewer extrapyramidal side effects when

administered intravenously.

Pharmakokinetics safe in hepatic

insufficiency

Haloperidol

Optimal dose range : initial doses of

haloperidol in the range of 1–2 mg every 2–4

hours as needed have been used, and even

lower starting doses (e.g., 0.25–0.50 mg

every 4 hours as needed) are suggested for

elderly patients.

Initiating haloperidol with a bolus dose of 10

mg followed by continuous intravenous

infusion of 5–10 mg/hour has been

suggested

Dosing patterncombination of antipsychotics and

benzodiazepines is more efficacious

Started with 3 mg i.v. of haloperidol followed

immediately by 0.5–1.0 mg i.v. of lorazepam.

if little or no improvement is observed within

20 minutes, an additional

dose of 5 mg i.v. of haloperidol and 0.5–2.0

mg i.v. of lorazepam can be given

Cholinergics

anticholinergic mechanisms may be involved

in delirium from hypoxia, hypoglycemia,

thiamine deficiency, traumatic brain injury,

and stroke

Physostigmine reversed the delirium

resulting from ranitidine , homatropine

eyedrops , benztropine , and meperidine .

Iv /im 0.16 to 2.00 mg and continuous

intravenous infusions of 3 mg/hour

Other drugs

Consider giving short-term (usually for 1

week or less) haloperidol or olanzapine

[NICE –guidelines 2010]

Phenothiazines : prototype- Chlorpromazine

Side effects in generalextrapyramidal side effects, tardive

dyskinesia, and neuroleptic malignant

syndrome.

Lengthen the QT interval

lowering of the seizure threshold,

galactorrhea, elevations in liver enzyme

levels

Phenothiazines can be associated with

sedation, anticholinergic effects, and α-

adrenergic blocking effects that can cause

hypotension

Wait....wait...

Dont use antipsychotics in patients at

significant risk for torsades de pointes (i.e.,

patients with baseline prolongation of QT

interval, patients receiving concomitant

medications known to prolong the QT

interval, or patients with a history of this

arrhythmia)

Haloperidol, Ziprasidone, risperidone [four

out of 1,100 patients]

QuesTThe ECG should be monitored in patients

receiving antipsychotic medications for

delirium, and a QTc interval longer than 450

msec or more than 25% over baseline may

warrant a cardiology consultation and

consideration of discontinuation of the

antipsychotic medication.

serum levels of magnesium and potassium

Milk

My name is Propofol and I love GABAA, glycine, nicotinic, and M1 muscarinicreceptors

sedative, hypnotic, anxiolytic, amnestic, antiemetic, and anticonvulsant properties

amnestic effects at light sedation levels are less than that of benzodiazepines

Rapid onset and offset

useful in patients requiring frequent awakenings for neurologic assessments and it may facilitate daily sedation interruption protocols

Spoilt Milk

dose-dependent respiratory depression and hypotension

propofol infusion syndrome (PRIS) propofol infusion syndrome [PRIS]

worsening metabolic acidosis

Hypertriglyceridemia

hypotension with increasing vasopressor requirements

Arrhythmias

Acute kidney injury

hyperkalemia

rhabdomyolysis

liver dysfunction

[usually associated with prolonged administration of high

propofol doses (> 70 μg/kg/min)]

Such an agent will

be a very valuable

addition...

Sedation

Analgesia

Reduce delirium incidence

Easy awakening for assessment

Minimal respiratory depression

Dexmedetomidine

⍺2 Agonist-- sedative, analgesic/opioidsparing [reduce opioid requirements in critically ill patients], and sympatholyticproperties

Patients are more easily arousable and interactive

The onset of sedation occurs within 15 minsand peak sedation occurs within 1 hr of starting an IV infusion of dexmedetomidine

1 mcg/kg loading dose, administered over 10 minutes, followed by a maintenance infusion of 0.2–1.0 mcg/kg/hour.

Dexmedetomidine

metabolized by the liver -- hepatic dysfunction: prolonged emergence, require lower dexmedetomidine doses

Although dexmedetomidine has only been approved in the United States for short-term sedation of ICU patients (< 24 hrs) at a maximal dose of 0.7 μg/kg/hr (up to 1.0 μg/kg/h for procedural sedation), several studies demonstrate the safety and efficacy of dexmedetomidine infusions administered for greater than 24 hrs (up to 28 days) and at higher doses (up to 1.5 μg/kg/hr)

2013 guidelines by the Society of

Critical Care Medicine

in adult ICU patients with delirium unrelated

to alcohol or benzodiazepine withdrawal,

continuous IV infusions of dexmedetomidine

rather than benzodiazepine infusions be

administered for sedation in order to reduce

the duration of delirium in these patients

benzodiazepines may be a risk factor for the

development of delirium in the ICU.

Zhang et al. Critical Care 2013,

17:R47

The limited data suggested that the

efficacious way to prevent postoperative

delirium included dexmedetomidine

sedation, multicomponent interventions and

antipsychotics comprising haloperidol,

olanzapine and risperidone

Jose´ R. Maldonado, M.D.,

(Psychosomatics 2009; 50:206 –217)

Dexmedetomidine and the Reduction of

Postoperative Delirium after Cardiac Surgery

“…suggest that postoperative sedation with

dexmedetomidine was associated with

significantly lower rates of postoperative

delirium and lower care costs”

Bad habits of this good friend..

hypotension and bradycardia

IV loading doses can cause either hypotension or hypertension

Because dexmedetomidine does not significantly affect respiratory drive, it is the only sedative approved in the United States for administration in nonintubated ICU patients, and infusions can be continued as needed following extubation

[but beware of upper airway obstruction]

Which agent to use

Sedation strategies using nonbenzodiazepine sedatives (either propofol or dexmedetomidine) may be preferred over sedation with benzodiazepines (either midazolam or lorazepam) to improve clinical outcomes in mechanically ventilated adult ICU patients

The clinical significance of the comparative deliriogenic effects .... one high-quality trial indicating benzodiazepines pose higher risks than dexmedetomidine

Technology has reached its peak ;

still in some situations....

benzodiazepines remain important for

managing agitation in ICU patients,

especially for treating anxiety, seizures, and

alcohol or benzodiazepine withdrawal.

Benzodiazepines are also important when

deep sedation, amnesia, or combination

therapy to reduce the use of other sedative

agents is required

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Special situations

When delirium is comorbid with

other psychiatric disorders, the

delirium should be treated first

and the treatments for these

other disorders, such as

antidepressant or anxiolytic

medications, should be minimized

or not begun until the delirium is

resolved

It can be difficult to distinguish

between delirium and dementia

and some people may have both

Special situations

Use antipsychotic drugs with

caution or not at all for people

with conditions such as

Parkinson's disease

FINAL STATEMENTS

a

ICU CARE BUNDLE-PAD

a

References

2013 guidelines by the Society of

Critical Care Medicine

American Psychiatric Association

steering committee on practice

guidelines For the Treatment of patients

with Delirium [APA Practice

Guidelines],1999

Delirium Diagnosis, prevention and

management,Issued: July 2010; NICE

clinical guideline 103,

guidance.nice.org.uk/cg103

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