Delirium in ICU -By Dr.Tinku Joseph

PowerPoint presentation on Delirium in ICU.

1. Delirium in ICU
Dr.Tinku Joseph
DM Resident
Department of Pulmonary Medicine
AIMS, Kochi.
Email: [email protected]

2. Overview
What is delerium ?
How is it categorised?
Why does it matter?
Why does it happen?
How do we diagnose/monitor it?
How do we prevent and treat it?

3. What is Delirium?
An acute confusional state
with:
Fluctuating mental status
Disordered attention
Disorganised thinking or altered
consciousness

4. DSM –IV definition:
“A disturbance of consciousness with
inattention accompanied by a change in
cognition or perceptual disturbance that
develops over a short period (hours to
days) and fluctuates with time”
What is Delirium?
Synonyms:
ICU psychosis, septic encephalopathy, ICU
syndrome, acute brain failure, acute confusional
state

5. Delirium develops over a short period of time (usually hours to
days) and tends to fluctuate during the course of the day.
Delirium is typically caused by a:
 Medical condition
 Substance intoxication
 Medication side effect.
What is Delirium?

6. How is Delirium Categorized?DM ResidntR
HyperactiveDM psidntR
HypoactiveanrRm
MixedM
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1.6% of cases, “ICU psychosis”,
agitation, restlessness, pulling lines and
tubes emotional lability M
ycMDReResiedntpt
54.1% % of cases M
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43.5% of cases, “encephalopathy”,
often unrecognized, withdrawal,
apathy, lethargy, decreased
responsiveness, may be misdiagnosed
as depression.
Far more common, likely due to
sedating medications

7. Why does delirium matter?
Increased reintubation risk (OR=3)
Increased ICU & hospital stay* (up to 10 days extra)
Each day in delirium increases risk of longer stay by 20%
Increased mortality in ICU & out to 6 months** (OR=3)
Each day spent in delirium increases risk of death by 10%
Increased ICU & hospital costs***
10-24% risk of long-term cognitive impairment
Increased dementia risk
Reduced functional status at 3 & 6 months
* Ely et al, Intensive Care Med 2001; 27: 1892-1900** Ely et al, JAMA 2004; 291: 1753-62*** Milbrandt et al, CCM 2004; 32: 955-62

9. Why does delirium happen?
Higher cortical dysfunction (on functional neuroimaging)
Pre-frontal cortex, non-dominant posterior parietal regions,
anterior thalamus, basal ganglia, temporal-occipital cortex
Neurotransmitter dysfunction
Reduced acetylcholine levels – blockade or deficiency
Endogenous anticholinergic substances
Opiates/hypoxia/inflammation
Serotonin fluctuation
Dopamine excess
Glutamate excess (2
o
to IFN-g, LPS, hypoxia, hypoglycaemia)
Predisposition (baseline vulnerability)
Precipitants (clinical, iatrogenic, organisational risk factors)

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11. Predisposing factors (host factors)
Present before ICU admission
1.Age
2.Alcoholism
3.Smoking
4.Hypertension
5.Apolipoprotein 4 polymorphism
6.Cognitive impairment
7.Hearing/visual impairment
8.Depression
Risk factors

12. Precipitating factors.
Occur during course of critical illness
May involve factors of acute illness or
be iatrogenic;

13. Factors of critical illness
1.Acidosis
2.Anemia
3.Infection/sepsis
4.Hypotension
5.Metabolic disturbances
6.Respiratory disease
7.High severity of illness
Iatrogenic factors
1.Immobilization
2.Medication (opoids,
BDZ)
3.Sleep disturbances

14. Modifiable Risk factors

15. Pun AgelnynfRoc
SeverityAnISM,a
Benzo’s
Pun & Ely, Chest 2007; 132: 624–636
Pandharipande et al, Anesthesiology 2006; 104: 21-26

16. DELIRIUM(S) - causes
DDDrugs, dementia
EEyes & ears (poor vision and hearing)
LLow O
2
states (CHF, COPD, ARDS, MI, PE)
IInfection
RRetention (urine and stool)
IIctal states
UUnderhydration/undernutrition
MMetabolic upset
(S)Subdural, sleep deprivation

17. I WATCH DEATH
IInfection
WWithdrawal (alcohol, sedatives, barbiturates etc.)
AAcute metabolic (acidosis, alkalosis, electrolytes)
TTrauma (closed head injury, haematoma etc.)
CCNS pathology (seizures, stroke, encephalitis)
HHypoxia
DDeficiencies (thiamine, niacin, B12, folate)
EEndocrinopathies (thyroid, glucose, adrenal)
AAcute vascular (hypertensive crisis, arrhythmia)
TToxins/drugs
HHeavy metals

20. Diagnosis & monitoring
Intensive Care Delirium Screening Checklist (ICDSC)
and the Confusion Assessment Method for the ICU
(CAM-ICU)
Using ICDSC, each patient is assigned a score from 0 to
8; a cut-off score of 4 has sensitivity 99% and
specificity 64% for identifying delirium

22. CAM-ICU has a more modest
sensitivity ranging from 64% to
81%, high specificity from 88%
to 98%.
Diagnosis & monitoring

27. S100B protein indicator of glial activation and/or
death. Shown to be elevated in patients with delirium.
Higher baseline levels of procalcitonin or C-reactive
protein were associated with more days with delirium.
Other biomarkers elevated-brain-derived
neurotrophic factor, neuron-specific enolase,
interleukins, cortisol.
Biomarkers

28. What should we do to prevent/treat What should we do to prevent/treat
delerium in ICU patientsdelerium in ICU patients

29. Treating/Preventing delirium
Monitoring
Non-pharmacological
interventions
Reduction in deliriogenic
medications
Pharmacological interventions

30. Environmental factors
Extremes in sensory impairment Extremes in sensory impairment
eg: hypothermia.eg: hypothermia.
Deficits in vision or hearingDeficits in vision or hearing
Immobility or decreased activityImmobility or decreased activity
Social isolationSocial isolation
Novel environmentNovel environment
stressstress

31. A bundle for delirium prevention ??
Family support (all levels, kids, children)
Allow family at bed side when ever possible

32. Orientation improvements:
Day lights, wall clocks,
exterior view from ICU.
Privacy for patients.
Hearing aid
Glasses
Television/ Music therapy
Proper sleep
A bundle for delirium prevention ??

35. Role of doctor & Nursing staff
Introduce yourself, smile and be
friendly with patients.
A bundle for delirium prevention ??

36. Treating/Preventing delirium
Non-pharmacological (Summary)
Up to 40% risk reduction achieved
Repeated reorientation of patients
Early mobilization
Visual and hearing aids (and wax removal!)
Early catheter, line etc. removal
Minimize restraints and sedatives
Sedation Interval
Sleep protocol
Delirium bundle

37. First address complication of critical illness that may
lead to delirium (hypoxia, hypercapnia, hypoglycemia,
shock, electrolyte imbalances)
Any drug intended to improve cognition may have
adverse psychoactive effects thus paradoxically
exacerbating delirium.
Pharmacological treatment

38. Haloperidol recommended as drug of choice for treatment
of ICU delirium by SCCM
Blocks D2 dopamine receptors, resulting in amelioration
of hallucinations, delusions, unstructured thought patterns
SCCM guidelines-hyperactive delirium to be treated with
2 mg intravenously, followed by repeated doses (doubling
previous dose) every 15 to 20 minutes while agitation
persists
Haloperidol

39. Once agitation subsides scheduled doses (every 4 to 6
hours) may be continued for few days, followed by
tapered doses for several days.
Common doses for ICU patients range from 4 to 20
mg/day
Adverse effects Adverse effects – extrapyramidal, prolonged QTc, – extrapyramidal, prolonged QTc,
torsades (3.8%), neuroleptic malignant syndrometorsades (3.8%), neuroleptic malignant syndrome
Haloperidol

40. Treating delirium – atypical antipsychotics
Olanzepine, quetiapine, risperidone
Alter multiple neurotransmitters
including DA, NA, serotonin, ACh,
histamine
Suggestion of decreased
extrapyramidal side-effects compared
to haloperidol
As effective as haloperidol

44. Dexmedetomidine, novel α2- receptor agonist that does
not act on GABA receptors, may to be alternative
sedative agent less likely to cause delirium.
Pandharipande P. et al (2007) showed ICU patients
sedated with dexmedetomidine spent fewer days in
coma and more days neurologically normal than
lorazepam.
Benzodiazepines are not recommended for management
of delirium
Dexmedetomidine

49. Conclusion
Delirium is a frequent disease in the
ICU and associated with poor
outcomes.
Delirium is often under recognized, can
be monitored and rapidly identified.
New approaches to manage and prevent
delirium are emerging everyday.
Dexmedetomidine has a place in this
new strategies.