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Delirium in Intensive Care Unit

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important points regarding ICU psychosis, role of dexmedetomidine in it's treatment, mortality associated with delirium, symptomatic and definitive management

Publicado en: Salud y medicina
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Delirium in Intensive Care Unit

  1. 1. 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
  2. 2. 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 ]
  3. 3. 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…
  4. 4. 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
  5. 5. Other symptoms commonly associated with delirium include.. emotional disturbances (i.e., fear, anxiety, anger, depression, apathy, euphoria) attention deficits, disordered sleep-wake cycle
  6. 6. 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.
  7. 7. 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
  8. 8. 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
  9. 9. Risk factors ,.
  10. 10. 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 opioid medications Coma is an independent risk factor Benzodiazepine use may be a risk factor Age 65 years or older. Current hip fracture
  11. 11. Notorious..... Surgeries : particularly cardiotomy, hip surgery, or a transplant Burns dialysis central nervous system lesions
  12. 12. 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
  13. 13. 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
  14. 14. 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
  15. 15. 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
  16. 16. 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 parenteral sedative and opioid medications Coma is an independent risk factor Benzodiazepine use may be a risk factor
  17. 17. 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 parenteral sedative and opioid medications Coma is an independent risk factor Benzodiazepine use may be a risk factor
  18. 18. 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
  19. 19. 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
  20. 20. 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.
  21. 21. SUBTYPES .
  22. 22. 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.
  23. 23. 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
  24. 24. 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
  25. 25. 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
  26. 26. 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
  27. 27. 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.
  28. 28. PREVENTION .
  29. 29. Approaches in prevention nonpharmacologic (e.g., early mobilization), pharmacologic, and combined pharmacologic/nonpharmacologic approaches.
  30. 30. Trials say.... no recommendation for using a pharmacologic delirium prevention protocol [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.
  31. 31. 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
  32. 32. 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
  33. 33. SEDATION AND DELIRIUM .
  34. 34. To catch the thief, you… he has to be responsive patients should be able to sufficiently interact and communicate Optimal pain management and a light level of sedation are essential for this to occur.
  35. 35. 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
  36. 36. 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
  37. 37. 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.
  38. 38. 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 preemptive treatment for pain is associated with longer ventilator- free time
  39. 39. 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
  40. 40. 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
  41. 41. DELIRIUM MONITORING SCALES AND SEDATION SCALES .
  42. 42. 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
  43. 43. . .
  44. 44. . .
  45. 45. 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
  46. 46. Monitoring depth of sedation 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
  47. 47. . .
  48. 48. Monitoring depth of sedation 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)
  49. 49. TREATMENT .
  50. 50. 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
  51. 51. PSYCHIATRIC MANAGEMENT .
  52. 52. ENVIRONMENTAL AND SUPPORTIVE INTERVENTIONS understimulation is also dangerous; gprovide a regular amount of modest stimulation (vocal, visual,
  53. 53. 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
  54. 54. 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
  55. 55. PHARMACOLO GY .
  56. 56. 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
  57. 57. 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
  58. 58. 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 :
  59. 59. 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
  60. 60. 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
  61. 61. Dosing pattern combination 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
  62. 62. 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
  63. 63. Other drugs Consider giving short-term (usually for 1 week or less) haloperidol or olanzapine [NICE –guidelines 2010] Phenothiazines : prototype- Chlorpromazine
  64. 64. Side effects in general extrapyramidal 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
  65. 65. 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]
  66. 66. QuesT The 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
  67. 67. Milk My name is Propofol and I love GABAA, glycine, nicotinic, and M1 muscarinic receptors 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
  68. 68. 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)]
  69. 69. Such an agent will be a very valuable addition... Sedation Analgesia Reduce delirium incidence Easy awakening for assessment Minimal respiratory depression
  70. 70. Dexmedetomidine ⍺2 Agonist-- sedative, analgesic/opioid sparing [reduce opioid requirements in critically ill patients], and sympatholytic properties Patients are more easily arousable and interactive The onset of sedation occurs within 15 mins and peak sedation occurs within 1 hr of starting an IV infusion of dexmedetomidine 1 mcg/kg loading dose, administered over 10
  71. 71. 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)
  72. 72. 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.
  73. 73. 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
  74. 74. 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”
  75. 75. 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]
  76. 76. 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
  77. 77. 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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  81. 81. 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
  82. 82. Special situations Use antipsychotic drugs with caution or not at all for people with conditions such as Parkinson's disease
  83. 83. FINAL STATEMENTS a
  84. 84. ICU CARE BUNDLE-PAD a
  85. 85. ICU CARE BUNDLE-PAD a
  86. 86.  .
  87. 87. 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
  88. 88. Visit me @

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