Transcript Bad, Mad, or Delirious?

Bad, Mad, or Delirious?
•Dealing with confusion
in Intensive Care
David Quayle PgC, RGN, FETC
Charge Nurse, CTCC, JRH
Acknowledgments
• Vanderbilt University, USA
• Pharmacy Department,
John Radcliffe Hospital
Delirium? – What is it!
• “A disturbance of
consciousness with
inattention accompanied
by a change in cognition
or perceptual disturbance
that develops over a short
period of time (hours to
days) and fluctuates over
time” (The Diagnostic and Statistical Manual of Mental
Disorders )
Subtypes
• Hyperactive
– ICU Psychosis
• Hypoactive
– acute encephalopathy
• Mixed
At Risk?
• On average ICU
patients have
greater than 10
risk factors for
delirium which
places them at a
very high risk for
this complication.
• One of the most frequent
forms of organ dysfunction
experienced by critically ill
patients
• Despite this prevalence,
delirium (usually in the
hypoactive state) remains
unrecognized in 66% to
84% of patients whether
they be in the ICU, hospital
ward, or A&E
• In a recent study Jason et
al (2005) demonstrated
that 48% of a cohort in ICU
experienced at least 1
episode of delirium
• http://ccforum.com/conte
nt/9/4/R375
Delirium – The Cost?
• Ely et al (2001) identified delirium as
the strongest independent
determinant of length of stay in the
hospital
• Ely et al (2004) identified delirium as a
cause of higher mortality
• Milbrant et al (2004) calculated that
delirium was associated with an
increase in the cost of care by 39% in
ICU and 31% across the whole hospital
stay
• Delirium may also predispose ICU
survivors to prolonged
neuropsychological deficits
Our Perspective
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Self Harm
Harm to other patients
Harm to staff
Concerns about the Use of
Restraint (physical or chemical)
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Staff Discomfort
Not Trained
Using correct drugs?
Using correct doses
Over sedation?
• The need to
protect patients
from self harm, to
protect staff from
incidents of
aggressive
behaviour from
patients and the
need to avoid
increases in the
levels of post
operative
morbidity and
mortality, make a
coordinated
approach to the
care of delirium a
very high priority.
How Do We Identify It?
•Richmond Aggitation & Sedation
Scale
– RASS
•ICU - Confusion Assessment
Method
– ICU-CAM
Score
Term
Description
Stimulation
+4
Combative
Overtly combative, violent, immediate danger to staff
+3
Very Aggitated
Pulls or removes tubes; aggressive
+2
Agitated
Frequent non purposeful movements. Fights ventilator
+1
Restless
Anxious, but movements not aggressive
0
Alert & Calm
-1
Drowsy
Not fully alert, but has sustained wakening (eye
opening/ eye contact) to voice >/= 10s
-2
Light Sedation
Briefly awakens with eye contact to voice <10s
Verbal
-3
Moderate Sedation
Movement or eye opening to voice (but no eye
contact)
Verbal
-4
Deep Sedation
No response to voice, but movement or eye opening to
physical stimulation
Physical
-5
Unrousable
No response to voice or physical stimulation
Physical
If RASS is -4 or -5 then Stop & Reassess patient at a later time
If RASS is above -4 (-3 to +4) then proceed to step two
Ref: Sessler et al, Am J Respir Crit Care Med 2002 and Ely et al JAMA 2003
1. Acute onset of mental status changes or a
fluctuating course
And
2. Inattention
And / Or
3. Disorganised
Thinking
4. Altered Level of
Consciousness
= DELIRIUM
WHAT NOW?
• Is it Delirium? – Assessment
• Hyper/ Hypo/ Mixed?
• Treatment Plan
• Restraint?
BACCN Position Statement
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The purpose of restraint is to facilitate optimal care of the
patient
Use of restraint must not be an alternative to inadequate
human or environmental resources
Restraint should only be used when alternative therapeutic
measures have proved to be ineffective to obtain the
desired outcome.
Decisions regarding the use or non-use of restraint must be
made following a detailed patient assessment by the
interdisciplinary team.
Critical care areas must develop and implement protocol/
guidelines in order to assist nurses and others in this process.
Whatever form of restraint is used there must be appropriate,
continual assessment tools used and the findings acted upon
Clear concise documentation of decisions, plans and
treatment must be held within the patient’s record.
The patient and their family should be engaged within the
discussions to inform them of the reason for choice of the
restraint method.
Education for all staff regarding chemical, physical and
psychological restraint must encompass training and
competency programmes in critical care units
Ethical Planning
• Nursing Care
– Environment
– Noise Levels
– Orientation
• Assessment
– Are they Delirious?
• Treatment
– Right drug, right time,
right diagnosis
Nursing care
• minimise risk factors
• repeated reorientation of patients
• provisions of stimulating activities for
the patients throughout the day
• avoidance of night sedation
• early mobilization
• the earliest possible removal of
invasive lines/ catheters etc
• use of spectacles and hearing aids to
facilitate effective communication
• early correction of dehydration
• effective pain control
• minimization of unnecessary
noise/stimuli.
Standard For The Night Environment on CTCC
(based on staff identified issues)
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Blinds to outside windows will be drawn by 22.00
Main lights (not including night lights) will be switched off by 22.00
Pre-prescribed night sedation will be given by 22.00
Radios will be switched off by 22.00
Printing will not be done between 22.00 & 07.00
All phone ringers will be set to low
Patients will not be woken for a non essential wash
Alarm limits will be checked at the beginning of the night shift & adjusted to individually
required parameters
Alarms will be cancelled & attended to within 20 seconds of onset
Alarm parameters will be adjusted when an alarm reoccurs for a known condition
which is being attended to
Alarms will be cancelled prior to undertaking a planned procedure (e.g. . removal of
an arterial line, taking an ABG, etc)
Routine medical examinations will take place before 22.00 & after 07.00
All main corridor light switches will be labelled to identify which switch controls which
light
Registrars ward round will be completed by 23.00
Restocking will take place before 22.00 & after 07.00
Patient care activities will be grouped into the fewest possible interventions based
upon individual assessment
Staff noise to be kept to a minimal level between 22.00 & 07.00
Treatment?
• Use an antipsychotic to treat the delirium
PLUS a benzodiazepine for rapid control of
agitation
• Neuroleptics are superior to
benzodiazepines in treating delirium that
has been caused by factors other than
alcohol withdrawal or sedative hypnotics.
• Haloperidol is the preferred antipsychotic
because it has fewer active metabolites,
limited anticholinergic effects, less
sedative and hypotensive effects and can
be administered by different routes.
• Lorazepam is the benzodiazepine of
choice due to its sedative properties,
rapid onset and short duration of action; it
also has a low risk of accumulation.
Treating Hyper Active Delirium
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ADMINISTRATION OF IV LORAZEPAM/ MIDAZOLAM:
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Midazolam intravenously 0.5-2mg stat
This can be repeated as often as required to attain
appropriate sedation
Give one dose and wait for the haloperidol to take
effect if possible
If available use Lorazepam intravenously 1-2mg stat
This can be repeated up to a max of 2mg every 4
hours
Flumazenil should be available to rapidly reverse side
effects if they occur
Start Haloperidol intravenously at 0.5-5mg stat
Observe the patient for 20-30mins
If the patient remains unmanageable but has not had
any adverse effects (e.g. hypotension, neuroleptic
effects) DOUBLE the dose and continue monitoring
Repeat the cycle until an acceptable response or
unacceptable side effects occur
Upper limits on doses have not been clearly
established
Haloperidol IV up to 100mg in 24 hours
Haloperidol IV in conjunction with benzodiazepines up
to 60mg in 24 hours.
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Treating Hypo Active Delirium
• Haloperidol IV/PO 0.5-5mg
2-3 times a day
• Regular treatment for a
few days may be required
to treat delirium.
• Reduce the dose gradually
over the following few
days.
Alcohol Withdrawal?
• Benzodiazepines are the
first line treatment
• Antipsychotics are not
effective in treating
delirium associated with
alcohol withdrawal
• Take note of your patients
history
Any Other Factors?
• Drug therapy can
contribute to the
development of delirium
• Prompt cessation of
medication that is no
longer required can help
to minimise the risk
• Drugs that exhibit
antimuscarinic activity are
particularly associated with
the development of
delirium
• Establishing a day / night
cycle is widely held to be
important and many drugs
are known to affect sleep
pattern.
 Analgesics
-Codeine
-Fentanyl
-Morphine
-Pethidine
 Antidepressants
-Amitriptyline
-Paroxetine
 Anticonvulsants
-Phenytoin
-Phenobarbitone
 Antihistamines
-Chlorphenamine
-Promethazine
 Antiemetics
-Prochlorperazine
 Antipsychotics
-Chlorpromazine
 Antimuscarinics
-Atropine
-Hyoscine
 Cardiovascular
agents
-Atenolol
-Digoxin
-Dopamine
-Lignocaine
 Corticosteroids
-Dexamethasone
-Hydrocortisone
-Prednisolone
 Hypnotic agents
-Chlordiazepoxide
-Chloral Hydrate
-Diazepam
-Thiopentone
 Miscellaneous
agents
-Frusemide
-Ranitidine
-Suxamethonium
Drug or Drug Class
Sleep Disorder
Benzodiazepines
 REM,  SWS
Opioids
 REM,  SWS
Clonidine
 REM
Non steroidal anti-inflammatory drugs
 TST,  SE
Norepinephrine/ Epinephrine
Insomnia,  REM,  SWS
Dopamine
Insomnia,  REM,  SWS
-Blockers
Insomnia,  REM, Nightmares
Amiodarone
Nightmares
Corticosteroids
Insomnia,  REM,  SWS
Aminophylline
Insomnia, REM,  SWS,  TST,  SE
Quinolones
Insomnia
Tricyclic antidepressants
 REM
Selective Serotonin Reuptake Inhibitors
 REM,  TST,  SE
Phenytoin
 Sleep Disturbances
Phenobarbital
 REM
Carbamazepine
 REM
In Conclusion
• Ethics – Are we contributing?
– Environment
– Drugs
• Assessment
– 2 Step Approach
– RASS & ICU-CAM
• Treatment Plan
– HyperActive Delirium
– HypoActive Delirium
References
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BNF No 49 March 2005
Bray et al. British Association of Critical Care Nurses position statement on the use of
restraint in adult critical care units, BACCN, Nursing in Critical Care, 2004, Vol 9, No 5.
Bourne RS and Mills GH. Sleep disruption in critically ill patients - pharmacological
considerations. Anaesthesia 2004; 59: 374-84.
Ely E.W. and Vanderbilt University. http://www.icudelirium.org/delirium/trainingpages/trainingman.pdf. 2002
Ely EW, Gautam S, Margolin R, Francis J, May L, Speroff T et al. The impact of delirium
in the intensive care unit on hospital length of stay. Intensive Care Med 2001; 27:18921900.
Ely, E.W., Shintani, A., Truman, B., Speroff, T., Gordon, S.M., Harrell, F.E., Inouye, S.K.,
Bernard, G.R., Dittus, R.S. Delirium as a predictor of mortality in mechanically
ventilated patients in the intensive care unit. JAMA. 291(14): 1753-1762, 2004.
Han L et al. Use of medications with anticholinergic effect predicts clinical severity of
delirium symptoms in older medical inpatients. Arch Intern Med 2001; 161: 1099-1105.
Jacobi J et al. Clinical practice guidelines for the sustained use of sedatives and
analgesics in the critically ill adult. Crit Care Med 2002; 30: 119-41.
Jason WW Thomason, Ayumi Shintani, Josh F Peterson, Brenda T Pun, James C
Jackson and E Wesley Ely. 2005. Intensive care unit delirium is an independent
predictor of longer hospital stay: a prospective analysis of 261 non-ventilated
patients. http://ccforum.com/content/9/4/R375
Mayo-Smith, M et al. 2004 Management of alcohol withdrawal delirium. Arch Intern
Med (164) 1405-1412
Meagher D. ‘Delirium: Optimising Mangement’, BMJ 2001; 322: 144-9
Milbrandt, E.B., Deppen, S., Harrison, P.L., Shintani, A.K., Speroff, T., Stiles, R.A., Truman,
B., Bernard, G.R., Dittus, R.S., Ely, E.W. Costs Associated with Delirium in Mechanically
Ventilated Patients. Crit. Care Med. 32 (4):955-962,2004.
NICE Guidance. 2005. Violence – The short-term management of disturbed/violent
behaviour in psychiatric in-patient settings and emergency departments
Sessler et al, Am J Respir Crit Care Med 2002 and Ely et al JAMA 2003
Skrobik Y, Bergeron N, Dumont M, Gottfried S (2004) “Olanzapine vs Haloperidol:
treating delirium in a critical care setting” Intensive Care Med 30:444-449
Truman B, Ely EW. Monitoring delirium in critically ill patients. Crit Care Nurse
2003; 23:25-36.
Any Questions
• Please feel
free to wake
up and ask
any questions
that you may
have!