Transcript Confused in the ICU

Confused in the ICU
Jud Mehl, CA-2
Tulane Dept. of Anesthesiology
Called to the PACU

73 yo female

s/p right THA, extubated

PMHX: HTN, DM, RA

PSHX: TKA, ex-lap with LOA, appy

Allx: PCN, Sulfa

Meds: Pravachol, Lisinopril, Coreg, Morphine,
Zofran, Benedryl;

Uneventful intraop course

HR 104

RR 24

BP 163/104

Gas: 7.32 / 41 / 87 on room air
And she is angry




Confused, cursing
Punched one of the
nurses
“Will 'come to' for a
minute, but then starts
talking nonsense”
She was just a nice,
old, church-going lady
several hours ago
So now what?

Differential diagnosis?

Tests?
Well, its all negative

So, what do we have?

A screaming old lady

A nurse with a black eye

Another nurse who doesn't understand
why you cant just give her some ativan.
Didn't they teach you anything in med
school? You are not advocating for your
patient, doctor !!
Delirium is NOT Agitation

Agitation

Excess motor activity. Nonspecific and may
be caused by a myriad of problems post-op.

May result from pain or anxiety, both of
which are easy to treat.
Agitated patients do not necessarily have
cognitive impairment
Delirium: acute brain failure




Acute cognitive
dysfunction
Prodromal phase
Hyperactive or
hypoactive
Psychomotor abnormalities
Fluctuates over the
course of the day
Disturbed sleep/wake
Not better accounted
for by dementia
Lucid intervals
Impaired memory
Dysorientation
Dysgraphia
Disorganized
thinking/speech
Rule out organic causes
•
Drug / Alcohol intoxication or withdrawl
•
HTN encephalopathy
•
Hypoglycemia
•
Hypoperfusion (shock)
•
Hypoxemia
•
Intracranial bleed
•
Meningitis or encephalitis
A quick shout-out to the Noss
•
•
•
Post-op delirium develops between POD 2-7
Correlates with the progression of the post op
systemic inflammatory response
Hypothesized delirium is an increase in inflammatory cytokines acting as
neurotoxin
Who is at risk ?
•
Age > 70
•
EtOH abuse history
•
Abnormal sodium, potassium or glucose levels
•
Hypoalbuminemia
•
Hip fracture surgery
•
Non-cardiac thoracic surgery
•
Aortic aneurysm surgery
–
Vascular surgery patients have twice the incidence of other elective surgery pts
What percentage of non-ventilated ICU patients develop ICU delirium?
A: 10 %
B: 25%
C: 35%
D: 50%
What percentage of ventilated ICU patients develop delirium?
A: 25%
B: 50%
C: 75%
D: 80%
How prevalent is ICU delirium?
•
50 % of non-ventilated ICU patients
–
•
Thomason JWW, Shintani A, Paterson JF, et al. Intensive care unit delirium is an independent
predictor of longer hospital stay: a prospective analysis of 260 nonventilated patients. Crit Care
2005; 375-381
80% in intubated patients
–
–
Ely EW, Shintani A, Truman B, et al. Delirium as a predictor of mortality in mechanically ventilated
patients in the intensive care unit. JAMA 2004; 291:1753-1762
And yet, only 25-50% of intensivists routinely screen for delirium.
OK, so how do we screen for it?
•
Multiple assessment models
–
Ramsay scale
–
Richmond Agitation Scale
–
ICU Delirium Screening checklist
–
Cognitive Test for Delirium
–
Neelon and Champagne Confusion Scale
–
CAM-ICU
CAM-ICU
How much do we really know?

Can we prevent it?

Evidence is lacking and conflicting

'Common sense measures' vs. dogma





Treatment of infections
Sleep wake cycles
Early ambulation
Frequent orientation
Avoid restraints
Here is what the literature shows:


1. ETT, drains, catheters and pain all appear to be
triggers
2. Delirium in the PACU is highly correlated with
continued postop delirium.

3. GABA is probably not good

4. Neuraxial offers no significant benefit over opiates
A few interesting studies

Morrison RS, Magaziner J, Gilbert M, et al. Relationship between
pain and opioid analgesics on the development of delirium
following hip fracture. J Gerontol A Biol Sci Med Sci 2003; 58:7681
Results. Eighty-seven of 541 patients (16%) became delirious. Among all subjects, risk
factors for delirium were cognitive impairment (relative risk, or RR, 3.6; 95% confidence
interval, or CI, 1.8–7.2), abnormal blood pressure (RR 2.3, 95% CI 1.2–4.7), and heart
failure (RR 2.9, 95% CI 1.6–5.3). Patients who received less than 10 mg of parenteral
morphine sulfate equivalents per day were more likely to develop delirium than patients who
received more analgesia (RR 5.4, 95% CI 2.4–12.3). Patients who received meperidine were
at increased risk of developing delirium as compared with patients who received other opioid
analgesics (RR 2.4, 95% CI 1.3–4.5). In cognitively intact patients, severe pain significantly
increased the risk of delirium (RR 9.0, 95% CI 1.8–45.2).
Conclusions. Using admission data, clinicians can identify patients at high risk for delirium
following hip fracture. Avoiding opioids or using very low doses of opioids increased the risk
of delirium. Cognitively intact patients with undertreated pain were nine times more likely to
develop delirium than patients whose pain was adequately treated. Undertreated pain and
inadequate analgesia appear to be risk factors for delirium in frail older adults
A few interesting studies



Sieber FE, Zakriya KJ, Gottschalk A, et al. Sedation depth during
spinal anesthesia and the development of postoperative delirium
in the elderly patient undergoing hip fracture repair. Mayo Clinic
Proc; 85 18-26
RESULTS: From April 2, 2005, through October 30, 2008, a total of 114 patients were
randomized. The prevalence of postoperative delirium was significantly lower in the light sedation
group (11/57 [19%] vs 23/57 [40%] in the deep sedation group; P=.02), indicating that 1 incident
of delirium will be prevented for every 4.7 patients treated with light sedation. The mean ± SD
number of days of delirium during hospitalization was lower in the light sedation group than in the
deep sedation group (0.5±1.5 days vs 1.4±4.0 days; P=.01).
CONCLUSION: The use of light propofol sedation decreased the prevalence of postoperative
delirium by 50% compared with deep sedation. Limiting depth of sedation during spinal
anesthesia is a simple, safe, and cost-effective intervention for preventing postoperative delirium
in elderly patients that could be widely and readily adopted.
A few interesting studies


Hudetz JA, Patterson KM, Iqbal Z, et al. Ketamine attenuates
delirium after cardiac surgery with cardiopulmonary bypass. J
Cardiothoracic Vasc Anesthesia 2009
Delirium was assessed by using the Intensive Care Delirium Screening Checklist before and after
surgery. Serum C-reactive protein concentrations were determined before and 1 day after
surgery. The incidence of postoperative delirium was lower (p = 0.01, Fisher exact test) in
patients receiving ketamine (3%) compared with placebo (31%). Postoperative C-reactive protein
concentration was also lower (p < 0.05) in the ketamine-treated patients compared with the
placebo-treated patients. The odds of developing postoperative delirium were greater for patients
receiving placebo compared with ketamine treatment (odds ratio = 12.6; 95% confidence interval,
1.5-107.5; logistic regression).

Conclusions

After cardiac surgery using cardiopulmonary bypass, ketamine attenuates postoperative delirium
concomitant with an anti-inflammatory effect.
Pharmacologic options
Benzos?
Haldol
- Butyrophenone D2 agonist
- “Go-to” drug, though not well studied in delirium
- associated with neuroleptic malignant syndrome
- may redose every 20 min
Max dose of Haldol?
A: 5 mg
B: 10 mg
C: 0.3 mg/kg
D: 1 mg/kg
Other drugs
Zyprexa (olanzapine) prophylaxis reduced incidence, but not
severity or duration of delirium
Cholinesterase inhibitors studied, but increase mortality for
delirium patients
Several studies of Precedex show some positive effects in the
setting of ICU/PACU delirium
True or false?
Once delirium is present, treatment will likely
improve the patient’s outcome.
A: True
B:False
FALSE
Witlox J, Eurelings LS, de Jonghe JF, et al: Delerium in elderly patients and the risk of
postdischarge mortality, institutionalization and dementia. JAMA 2010; 304:443451
Meta Analysis including 42 previous studies.
COMMENT
The results of this meta-analysis provide evidence that delirium in elderly patients is associated with an increased risk of death,
institutionalization, and dementia, independent of age, sex, comorbid illness or illness severity, and presence of dementia at
baseline. Moreover, our stratified models confirm that this association persists when excluding studies that included inhospital deaths and patients residing in an institution at baseline.
The results of this meta-analysis can be instrumental in patient care. The low rate of survival and the high rates of
institutionalization and dementia indicate that older people who experience delirium should be considered an especially
vulnerable population (see Figure 3 and Table 2). The results of this meta-analysis gain special clinical
relevance considering that delirium in some cases can be prevented.8 However, once delirium is
present, management of delirium has not been found to improve long-term mortality or need for
institutional care.67 Thus, identifying patients at high risk for delirium and implementing strategies aimed at preventing
delirium may help to avert some of the delirium–associated poor outcomes these patients experience.
The big picture
Outcomes for elderly patients who experience ICU delirium:
1. Prolonged ICU/hospital length of stay
2. Greater use of sedatives
3. Greater use of physical restraints
4. Increased hospital costs
5. Higher mortality rates
More likely to be discharged to a place other than home
Lastly . . .
It is noteworthy that a single occurrence of post-op delirium is
not an independent predictor of mortality . . . However
Current literature is showing that persistence of delirium is, in
fact, a predictor of increased 1-month mortality.
One quarter of delirious elderly patients die within 6 months