Icu Psychosis

Presentation by Dr Hanan Zaghla, Critical Care Department, Cairo University

1. A protochol for
assessment and
managment of
PATIENTWITH
INTE
NSIVE CARE UNIT
PSYCHOSIS
1
ICU PSYCHOSIS

2. A protocol for assessment and
managment of patients with
ICUpsychosis
Hanan Zaghla
Critical care department
Cairo University

3. Outline
DEFINITION
INCIDENCE
CAUSES
PATHOGENESIS
WHYDOWENEEDGUIDLINESFOR
ICUPSYCHOSIS?
MANAGMENT STRATEGY
RECOGNITION
PREVNENTION
MANAGMENT
TAKEHOMEMESSAGE

4. ICU Psychosis
Or
ICU Delirium ?
Is it

5. Psychosis or Delirium ?
Manydifferenttermshavebeenusedtodescribethe
spectrumofcognitiveimpairmentintheICU,
includingICUpsychosis,ICUsyndrome,acute
confusionalstate,septicencephalopathy,andacute
brainfailure.
Recently,themedicalliteraturesindicatethatthesigns
andsymptomsof
ICU psychosis are consistent with delirium
Boltey EM, . J Crit Care. 2019 Mar 01;51:192-197.

6. Deliriumisdefinedasarapidchangein
consciousness(hourstodays)characterizedby
reducedenvironmentalawareness,decreased
attentionandalteredcognition.
Theseclinicalfeaturescanmanifestthemselvesas
memorydeficits,disorientation,hallucinations,
fluctuatinglevelsofalertness,andmotor
abnormalities.
. Washington, DC: American Psychiatric Association; 2013
Definition

7. Incidence of delirium
Deliriumisoneofthemostcommonofmedical
emergenciesaffectingupto80%ofpatientsintheintensive
careunit[ICU]),
Annoying fact.......Annoying disease
Marcantonio ER. N Engl J Med 2017;377(15):1456-66.
Mostcommonpsychiatricsyndromefoundinthegeneral
hospitalsetting.
Upto25%ofhospitalizedcancerpatients
Upto51%ofpostoperativepatients
Patients,whodevelopdeliriumintheintensivecareuntil
(ICU),haveatwotofourfold-increasedriskofdeath
outofthehospital.

8. Why Should We Use Delirium Guidelines
?

9. Risk
factors
`
Environmental
causes
Medical
causes
Causesofdelirium
Delirium is the Brain’s way of demonstrating
“acute organ dysfunction ”

10. DDrugs
EEyes, ears, and other sensory deficits
L Low O2 states
IInfection
RRetention (of urine or stool)
IIctal state
UUnderhydraton/undernutrition
MMetabolic causes (DM, Post-operative state,
electrolytes abnormalities)
Illness and Treatment-Related Causes of Delirium
Brummel N, Girard T. . Crit Care Clin 2013; 29(1): 51–65

11. Drug-induced delirium is not uncommon
and the diagnosis is easily missed !!
AnalgesicsAspirin,indometacinandopioidanalgesicscancause
paranoidpsychosisanddelirium.
Naproxenandibuprofencauseimpairmentofmemory
Antidepressants
Anticonvulsants
Antisecretorydrugsandmucosalprotectants.
CardiacdrugsDigoxin
Class1Aantiarrhythmics
Calciumantagonists,
Angiotensin-convertingenzyme(ACE)inhibitors
Amiodarone
Antibioticse.g.quinolones.

12. Neuroinflammation.:(IL-1B, TNF-a, ILGF-1) and
metalloproteinases,reactiveoxygenspeciessecretionandincrementof
thenitrousoxidesynthase.→neuronalloss
CholinergicDeficiency:acetylcholineactsasamodulatorin
sensoryandcognitiveinput
NeurotransmitterImbalance:↑dopamine
↓acetylcholine
ChronicStress;↑sympatheticnervoussystemand↑hypothalamic-
hypophyseal-adrenalaxis,↑cytokineslevelsandresultsin
chronichypercortisolism→alterationinthehippocampusfunction.
Pathophysiology of Delirium
The Lancet Volume 383, Issue 9920, 8–14March 2014, Pages 911-922

13. RECOGNITIONOFDELIRIUM
1-EARLY PREDICTION
ThePredictionofDeliriuminICUPatients(PRE-
DELIRIC)modeluses10predictors:
AGE
APACHE II
Admission group,
Urgent admission,
Urea level,
Morphine use,
Metabolic acidosis
Sepsis
Sedation,
Coma,
Wassenaar A, et al. Intensive Care Med 2015;41:1048–56.[Article] [PubMed] [PMC]

14. 2.CLINICAL FEATURES
Itmaybehyperactive,hypoactiveor
mixeddelirium
↓awareness of the environment .
↓ability to focus, sustain, or shift attention.
A change in cognition
Emotional disturbances
https://www.mayoclinic.org › delirium › symptoms-causes › syc-20371386
Jun 27, 2018
RECOGNITIONOFDELIRIUM
Previous studies 32%-66% of cases are
unrecognized by Medical Staff

15. Intensive Care Delirium
Screening Checklist
(ICDSC)
The Confusion Assessment
Method forICU
(CAM-ICU)
RECOGNITIONOFDELIRIUM
Babar A. Khan et al ,Crit Care Med. 2017 May; 45(5): 851–857.
Novel ICU delirium detection
strategies -Critical Care Canada ...
.
(Published online 2019 Apr 24. )
3.ASSESSMENT OF DELIRIUM

16. Intensive Care Delirium Screening Checklist
(ICDSC)
1.Altered level of consciousness 1
2.Inattention 1
3.Disorientation 1
4.Hallucinations
5.Psychomotor agitation or retardation 1
6.Inappropriate speech 1
7.Sleep/wake cycle disturbances 1
8.Symptom fluctuation 1
Total score (0‐8)
ICDSC is an 8-item checklist performed by the bedside nurses
giving 1 for each item and if the score is more than 4 ,the attending
physician should be informed for posibility of delirium
TF Kallenbach & LA Amado (2017) ,Southern African Journal of
Anaesthesia and Analgesia,

17. CMAJ Open. 2019 Apr-Jun; 7(2): E294–E299.Published online 2019 Apr 24
CAM –Confusion Assessment Method
Sensitivity (94 to 100%), specificity (90 to 95%)
Requirement for delirium = 1, 2 ANDeither 3 OR 4
1.Abrupt change?
2.Inattention, can’t focus?
3.Disorganized thinking? Incoherent, illogical?
4. Altered level of consciousness? (Hyper-alert to stupor?)
Decision Tree

18. Once we identify delirium, Now What?
Identify the acute medical problems that could be either
triggering the delirium, or prolonging it!
Clarify pre-morbid functional status, sequence of events
and previous admission cognitive baseline.
Identify allpredisposing and precipitating factors
consider the differential diagnosis:
Dementia
Psychiatric Disorders
(ex. schizophrenia)
Depression
Traumatic Head Injury

19. Norecommendationforusingapharmacologicdelirium
preventionprotocol[administeringprophylactic
antipsychoticstothegeneralICUpopulation]inadult
ICUpatients
Earlyandaggressivemobilizationmayreducethe
incidenceanddurationofdelirium,shortenICUand
hospitalLOS,andlowerhospitalcosts.
There is evidence based delirium prevention strategy .
[“ESCAPE” bundle]
What About Prevention?
Arch Intern Med. 2003;163(8):958-964. doi:10.1001/archinte.163.8.958
Try to Make ICU Less Traumatic for Patients, Families-Medscape-Jul 16 2019.

20. E S C A P E
Early
mobility
Calm
Choise of
sedation
Sleep
managment
Assess
pain and
analgesia
Psychosis
evaluation
Emotional
communicat
ion
ESCAPE bundle
Chin Med J(Engl).2017 Oct 20; 130(20): 2498–2502..

21. PHARMACOLOGIC MANAGMENT
It is important to remember that:
DrugsarebestgivenPRNwhenagitation
becomesaconcernorbecomesasafetyissue
Medicationsmustbediscontinuedoncethe
agitationfromthedeliriumisresolved

22. 1.Benzodiazepines:
Anxiolytic,amnestic,sedating,hypnotic,and
anticonvulsanteffects,butnoanalgesicactivity
Theiramnesticeffectsextendbeyondtheirsedativeeffects
Raisetheseizurethreshold
Contraindicatedinhepaticencephalopathy
Couldbecombinedwithantipsychoticmedicationto
lowerthedosesofantipsychoticorforthosewithsevere
agitation.
K Schomer, J Duby, R Firestone, E Nagle…-Critical Care …, 2019 -

23. Ahigh-potencydopamine-blockingagentismostfrequently
usedbecauseofitsshorthalf-life,fewornoanticholinergic
sideeffects,noactivemetabolites,andlowersedation.
Oralorparenteral.
Safe inhepatic insufficiency
2.Butyrophenones
Comparisonsofhaloperidolandotherantipsychoticsdidnotfind
anyantipsychotictobemoreeffectivethananother.(e.g
quetapineorrespirdone)
World Health Organization (WHO). [cited 29 Nov 2018].
Available from url: https://www.who.int/classifications/icd/en/GRNBOOK.pdf

24. 3.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.
T Saito, H Toda, GN Duncan, SS Jellison, T Yu… -bioRxiv, 2019 -biorxiv.org

25. Side effects
Extrapyramidalsideeffects,dyskinesia,andneuroleptic
malignantsyndrome.
LengthentheQTinterval.
loweringoftheseizurethreshold,elevationsinliverenzymes
Phenothiazinescanbeassociatedwithsedation,anticholinergic
effects,andα-adrenergicblockingeffectsthatcancause
hypotension
KL Houseknecht et al -The FASEB …, 2019 -fasebj.org

26. 4 .Propofol:
Such an agentwill be a very valuable addition..
Sedation
Analgesia
Reduce deliriumincidence
Easy awakening forassessment
Minimal respiratorydepression
amnestic effect is less than
benzodiazipines
Propofol Side Effects Drugs.cohttps://www.drugs.com
. Anesthesia › Propofol › Nov 6, 2017

27. Dose-dependent respiratory depressionand 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 (> 70μg/kg/min)]
Side effects :
Kam, PC; .(July 2007). "Propofol infusion syndrome". Anaesthesia. 62
(7): 690–701.last edited on 29January 2019

28. ⍺
2Agonist--sedative,analgesic/opioidsparing,with
sympatholyticproperties.
Patientsaremoreeasilyarousableandinteractive
Theonsetofsedationoccurswithin15minsandpeak
sedation
occurswithin1hrofstartinganIVinfusion.
DexmedetomidineistheonlysedativeapprovedintheUnited
StatesforadministrationinIntubatedICUpatients
Sideeffects:Hypotension
5.Dexmedetomidine
Jun 4, 2018 -The North American guidelines proposed strategies to prevent
delirium

29. 2013 guidelines by the Society of Critical
CareMedicine
Continuous IV infusions of dexmedetomidine is preferred
than benzodiazepine infusions for sedation in in ICU
patients with delirium unrelated to alcohol or
benzodiazepine withdrawal.
Althoughdexmedetomidinehasonlybeenapprovedinthe
UnitedStatesforshort-termsedationofICUpatients(<24hrs),
severalstudiesdemonstratethesafetyandefficacyof
dexmedetomidineinfusionsadministeredforgreaterthan24hrs
(upto28days).
Barr J, , et al;guidelines for the management of pain, agitation, and delirium
in adult patients in the intensive care unit. Crit Care Med 2013; 41:263–306

30. Which agent touse ?!
The (PADIS) guidelines 2018;
Sedationstrategiesusingnonbenzodiazepinesedativesmaybe
preferredoversedationwithbenzodiazepinestoimprove
clinicaloutcomesinmechanicallyventilatedadultICU
patientswhereagitationisprecludingweaning/extubation.
Suggestedusinghaloperidoloranatypicalantipsychoticto
treatdeliriumincriticallyilladults.
Clinical Practice Guidelines for the Prevention and Management of Pain,
Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the
ICU.Crit Care Med 2018; 46:e825–e873

31. Follow-up care
Inpatient (out of icu ) Care:
Carefully assess patients to determine their level of care needs.
Assessment should include
behavior(for24h).
dailymentalstatus.
potentialforinjury.
underlyingmedicalandmetabolicstatus.
https://emedicine.medscape.com/article/288890-followup

32. Outpatient(outofhospital)Care
Followingrecovery,patient'smemoriesarevariable.
Besuretoeducatethepatient,family,andprimary
caregiversaboutfutureriskfactors.
Elderlypatientsmayrequire6-8weeksorlongerforfull
recovery.
Follow-up care
https://emedicine.medscape.com/article/288890-followup

33. patientsshouldbefollowedupforpsychological
sequelaeincludingcognitiveimpairmentwith
Screeningfor:
a.Dementia
b.Functionalpsychiatricdisorders–post-
traumaticstressdisorder
c.Depression
Salluh JIF et al. Outcome of delirium in critically ill patients:systematic review
and meta-analysis. BMJ 2015;350:h2538.
Long-Term Outcomes of ICU delirium

34. Take home message
Deliriumisacommonmedicalemergencyaffectingthe
criticallyillpatientoutcome.
Avoidanceofriskfactorsdecreasestheincidence.
Nonpharmacologicalpreventionisessential.
Earlydetectionofthedeliriumimprovestheoutcome.
Pharmacologicaltreatmentbynonbenzodiaipines
(propfolordexmedotemedine)orantipsychoticis
preferredratherthanbenzodiazepines.
Thepatientshouldbefollowedupafterdischargeto
monitorandmanagelongtermcomplications.

35. REFFERENCES
1.BolteyEM,IwashynaTJ,HyzyRC,WatsonSR,RossC,CostaDK.JCritCare.
2019Mar01;51:192-197.
2.MarcantonioER..NEnglJMed2017;377(15):1456-66.
3.PersicoI,CesariM,MorandiA,HaasJ,MazzolaP,ZambonA,etal.JAmGeriatr
Soc2018;66(10):2022-30https://www.mayoclinic.org-20371386Jun27,2018MAJ
Open.2019Apr-Jun;7(2):E294–E299.
4.BabarA.Khanetal,CritCareMed.2017May;45(5):851–857.
5.DevlinJW,SkrobikY,GelinasC,etal.CritCareMed2018;46:e825–e873
Medscape-Jul162019.
6.WhitlockEL.etal.KSchomer,JDuby,RFirestone,ENagle…-CriticalCare…,
2019-Anesthesia&Analgesia2014;118(4):809-17.WorldHealthOrganization
(WHO)..[cited29Nov2018].
7.NHaque,RMNaqvi,MDasgupta-CanadianGeriatricsJournal, 2019-
gjonline.ca
8.TSaito,HToda,GNDuncan,SSJellison,TYu…-bioRxiv,2019-biorxiv.org
9.KLHouseknecht,MMay,MBeauchemin,DBarlow…-TheFASEB…,2019
10.Kam,PC;CardoneD.(July2007).Anaesthesia.62(7):690–701.lasteditedon29
January2019
11.LouisC,GodetT,ChanquesG,BourguignonN,MorandD,PereiraB,.2018
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CareMed2013;41:263–306
13.DevlinJW,SkrobikY,GelinasC,etal:CritCareMed2018;46:e825–e87
14.SalluhJIF,WangH,SchneiderEB,NagarajaN,YenokyanG,DamlujiA,etalBMJ
2015;350:h2538.

36. A huge thanks to all my inspiring
professors that have gone above and
beyond to open my mind and my heart