Transcript Crit Care Med - community360.net

A New Frontier in Critical Care:
Saving the Injured Brain
E. Wesley Ely, MD, MPH
Professor of Medicine and Critical Care
Vanderbilt University, Nashville, TN
VA TN Valley Health Care System GRECC
Disclosures: ICU Physician Vanderbilt
- Abbott, Hospira, Orion
- NIH and VA U.S. Federal Funding
- Author of PAD Guidelines of SCCM 2013
Delirium
SAG Guidelines for sustained use of sedatives
and analgesics in the critically ill adult
Jacobi, CCM 2002
Quote of the Day #1
Dr. Swenson explained, "I'll tell you the truth. What I
have discovered…is not what I expected. It is
something greater, much more ambitious than anything
we had hoped for…in science: Never be so focused on
what you are looking for that you overlook the thing
you actually find."
Ann Patchett - 2011, State of Wonder
Delirium
Barr J, et al. PAD Guidelines. Crit Care Med. 2013;41:263-306
Barr J et al, CCM 2013;41:263-306
Airplane Draft
ICU Liberation - 3 Columns
50-70%
© rustyrhodes via Flickr
Cognitively
Impaired
Wolters Intensive Care Med 2013; 39: 376
Jackson AJRCCM 2010; 182: 183
Girard Crit Care Med 2010; 38: 1513
60-80%
Marcel Oosterwijk via Flickr
Functionally
Impaired
Latronico Lancet Neurol 2011; 10: 931
ICU Survivorship
Family
Hobbies
Work
Iwashyna Annals of Int Med 2010; 153:204-5
“
After 5 months I felt better and returned to
work but was fired 10 weeks later... it didn't
surprise me because I was struggling
terribly. I couldn't organize my work;
committed many errors in documentation;
frequently lost things; forgot meetings, and
did not manage my time well
http://www.icudelirium.org/testimonials.html
“
When I returned to work, the work I did before seemed
foreign and unfamiliar. I became isolated and excluded
from everyone. No one wanted to be around me. My
wife of more than 36 years told me that I was just
“feeling sorry” for myself, and I just needed to get on
with my life. I nearly ended my life a few times. Then
after five years of this hell, Oct 2 2013 CBS News ran
a report about people just like me. From that report I
found your website. I cried for long time; it has
changed my wife’s opinion about me. For the first time
in the past five years, I think believe I have a future.
http://www.icudelirium.org/testimonials.html
Cognitive Impairment: Sepsis
25
Before Sepsis
After Sepsis
p<0.001
20
Mild Cognitive Impairment
15
Moderate/Severe Cog
Impairment
% survivors
cognitively
impaired 10
5
0
-3 years
-1 year
+1 year
+ 3 years
Iwashyna T, JAMA 2010;304:1787-1794
Ely EW, JAMA 2004;291:1753-62
Delirium Duration & Mortality
Relative Hazard of
Death
4
0 vs 1
3
HR 1.7
1.27-2.29
<0.001
0 vs 2
HR 2.69
p<.001
1.58-4.57
<0.001
0 vs 3
HR 3.73
1.92-7.23
<0.001
2
1
0
0
1
2
3
4
Days of Delirium
Shehabi Y, et al. CCM 2010; 38:2311–2318
5
6
NEJM 2013;369:1306-16
Editorial by M. Herridge
Delirium and Brain Atrophy
(A) 46 year old, no delirium
(B) 42 year old, 12 days of delirium
Gunther M et al. CCM 2012;40:2022-32
The Picture of Dementia Following ICU Care
Global Cognitive Scores by Age
Global Cognitive Scores by Age and Comorbidity
Delirium and Executive Function
Confirmed: Delirium Risk Factor for LongTerm Cognitive Problems after ICU Stay
• 1,101 survivors of critical illness, 37% with delirium
• Studied only survivors and used self report
• Multivariable analysis with adjustment for gender,
admission dx, severity of illness (both APACHE IV and
cumulative SOFA)
• Delirium independent predictor of mild (O.R. 2.41,
C.I. 1.57-3.69) and severe (3.1, 1.1-8.74) LTCI 1 year
Wolters AE, Crit Care 2014 June epub
If delirium is not screened for using a validated
delirium screening tool it is missed ~75% of time.
Inouye SK Arch Intern Med. 2001;161:2467-2473.
Devlin JW Crit Care Med. 2007;35:2721-2724.
Spronk PE Intensive Care Med. 2009;35:1276-1280.
van Eijk MM Crit Care Med. 2009;37:1881-1885.
Take Home Message
Delirium = Dangerous
Patient = Vulnerable
Andros Island by N Rakov, NEJM 2011;365:457
2013 PAD Guidelines:
“We recommend routine monitoring
for delirium in adult ICU patients”
Grade 1B Recommendation
Crit Care Med. 2013;41:263-308
Don’t forget about Dr. DRE
Diseases
Sepsis, COPD, CHF
Drug Removal
SATs and stopping benzodiazepines/
narcotics
Environment
Immobilization, sleep and day/night,
hearing aids, glasses, noise
Medical Intensive Care Unit
So let’s focus on potentially
modifiable aspects of care such as
potent medications, delirium, and
improving care and clinical
outcomes…
ABCDEs:
Building blocks of managing
Pain, Agitation & Delirium
A B
E
C
“Faced with the choice between
changing one's mind and proving that
there is no need to do so, almost
everyone gets busy on the proof.”
--John Kenneth Galbraith
A
B C
Awake and Breathing Coordination
 Duration of mechanical ventilation
 Duration of coma
 Mortality
Choose light sedation & avoid benzos
C
 Duration of mechanical ventilation
 Mortality
 Delirium
Delirium monitoring & management
 Delirium detection
E
Early Mobility & Environment




Duration of delirium
Disability
ICU Length of Stay
Rehospitalization/Mortality
Morandi et al Curr Opin Crit Care 2011;17:43-9
Vasilevskis et al Crit Care Med 2010;38:S683-91
Vasilevskis et al Chest 2010;138:1224-1233
Zaal et al, ICM 2013;39:481-88
Colombo et al, Minerva Anest 1012;78:1026-33
New Order Set: Benzodiazepine Use
Median dose - Lorazepam equivalents (mg)
Adjusted Ratio of Medians: 0.71 (95% CI: -1.31, -0.10)
Dale CR & Treggiari M, Ann ATS 2014 epub
Treggiari M et al. Crit Care Med 2009;37:2527-34
Probability of Delirium over Time
Adjusted OR of delirium: 0.67 (95% CI: 0.49, 0.91)
Dale CR & Treggiari M, Ann ATS 2014 epub
Treggiari M et al. Crit Care Med 2009;37:2527-34
1.5 year prospective QI (before/after) study of 296 ICU patients.
Balas M, CCM 2014 epub
Days
VENTILATOR FREE DAY RESULTS
Balas M CCM 2014
DELIRIUM RESULTS
70
Pre ABCDE Bundle
Post ABCDE Bundle
60
50
p=0.02
p=0.003
40
30
20
10
0
Percent Delirious
Percent ICU Days
Delirious
Days Delirious
Balas M CCM 2014
p=0.07
%
Balas M CCM 2014
28 DAY MORTALITY RESULTS
20
Pre ABCDE Bundle
18
Post ABCDE Bundle
16
14
p=0.07
p=0.04
12
10
8
6
4
2
0
ICU
Total Hospital
Balas M CCM 2014
ADJUSTED ANALYSIS
•
•
•
Controlling for age, sex, mechanical ventilation,
APACH II score, Charlson Comorbidity Index
Delirium anytime - OR 0.55 (0.33-0.93); p=0.03
OOB anytime in ICU - OR 2.11 (1.30-3.45)
p=0.003
Balas M CCM 2014
Hopkins QI Project = Reduced Delirium
via less benzodiazepines and more mobility
Pre-QI
(n=27)
Outcome
Post-QI
(n=30)
p
Days with any benzodiazepine use**
150 (50%) 118 (26%)
.002
Days alert (RASS -1 to +1)
88 (30%)
311 (67%)
<.001
PT/OT in MICU
19 (70%)
28 (93%)
.040
1 (0-3)
7 (3-15)
<.001
Days without delirium
61 (21%)
243 (53%)
.003
Days of delirium in ICU
107 (36%) 125 (28%)
Days of Coma
129 (43%)
Number of PT/OT treatments in ICU
86 (19%)
** Benzodiazepine dose (median midazolam eq) from 47mg down to 15 mg/day
Needham DM Arch Phys Med Rehabil 2010; 91:536-542
“I had never before understood how much good nursing care
contributes to patients’ safety and comfort, especially when
they are very sick or disabled. This is a lesson all physicians and
hospital administrators should learn. When nursing is not
optimal, patient care is never good.” Dr. Bud Relman
Remember: Monitoring of delirium in critical
illness, while not a feat resting solely in the
hands of nurses, will succeed only under
the guidance of nursing leadership and via
the day-to-day actions of nurses
intersecting with the other critical INTERdisciplinary members of our ICU teams at
every bed in ICUs across the land.
Pain, Agitation, and Delirium
Are Interrelated
Delirium
Barr J, et al. Crit Care Med. 2013;41:263-306.
2013 PAD Guidelines:
“Pain should be routinely monitored
in all adult ICU patients”
Grade 1B Recommendation
Crit Care Med. 2013;41:263-308
Pain, Agitation, and Delirium
Are Interrelated
Delirium
Barr J, et al. Crit Care Med. 2013;41:263-306.
Targeted Level of Consciousness
Choose Target RASS
Assess Actual RASS
Modify treatment so
Actual = Target
2013 PAD Guidelines:
“We recommend either daily sedation
interruption or a light level* of target
sedation be routinely used…”
Grade 1B Recommendation
*Light sedation = RASS 0 to -2
Crit Care Med. 2013;41:263-308
A
B C
Awake and Breathing Coordination
 Duration of mechanical ventilation
 Duration of coma
 Mortality
Choose light sedation & avoid benzos
 Duration of mechanical ventilation
 Mortality
 Delirium
Delirium monitoring & management
 Delirium detection
Early Mobility & Environment




Duration of delirium
Disability
ICU Length of Stay
Rehospitalization/Mortality
Morandi et al Curr Opin Crit Care 2011;17:43-9
Vasilevskis et al Crit Care Med 2010;38:S683-91
Vasilevskis et al Chest 2010;138:1224-1233
Zaal et al, ICM 2013;39:481-88
Colombo et al, Minerva Anest 1012;78:1026-33
Patients on Ventilator (%)
Liberating from Ventilator
SBT reduced weaning time by =
10
0
2 days
80
p<.001
60
40
Control (n =151)
20
Protocol (n =149)
0
0
5
10
15
20
25
30
Time (Days)
Ely EW, et al. N Engl J Med 1996;335:1864-9
Patients on Ventilator (%)
Liberating from Sedation
SAT reduced ventilator time by =
10
0
2 days
80
60
40
Control (n=60)
Adjusted
p<.001
20
Protocol (n=68)
0
0
5
10
15
20
Time (Days)
25
30
Kress JP, et al. N Engl J Med 2000;342:1471-7
Quote of the Day #2
“I came awake on the fifth day. My first memory is that
of floating up from the ocean bottom, my eyes still
waterlogged and with what felt like scuba gear stuffed
in my mouth and throat. I couldn’t speak. As I broke
to the surface, I understood that I was still in the ICU at
Our Lady, but I heard nothing of what anybody said.
Abraham Verghese - 2009, Cutting for Stone
SAT + SBT = 4
day shorter ICU/hosp LOS
ABC Trial: One-Year Survival
100
NNT=7
Patients Alive (%)
80
ABC approach (n=167)
60
40
Control (n=168)
20
p=.01
0
0
60
120
180
240
300
360
Days
Girard TD, et al. Lancet 2008;371:126-34
Sedation Interruption in SLEAP
Mehta S, JAMA 2012;308:1985-92
Benzodiazepine Use in Trials *
Study
Kress NEJM 2000
Control
90 mg/day
Treatment
53 mg/day
Girard ABC Lancet 2007
84 mg/day
54 mg/day
Mehta SLEAP JAMA 2012
82 mg/day
102 mg/day
OSCILLATE NEJM 2013
141 mg/day
199 mg/day
*
All values converted and expressed as mean midazolam dose per patient,
median for ABC study were 8 mg and 5 mg, respectively
From Canadian Authors of SLEAP…
n=712 and 3,620 patient-days
“We found that nearly all patients were managed with
continuous-infusion opioids and sedatives. We also
found that actual practice was different from what we
expected because the available clinical tools – such as
protocols and assessment scales – were not necessarily
applied at the bedside.”
Burry LD, Can J Anesth May 2014 epub
Data collected 2008-2009
SPICE Study – first 48 hours
mean 50 mg/d benzos
Shehabi AJRCCM 2012;186:724-31
Awake and Breathing Coordination
 Duration of mechanical ventilation
 Duration of coma
 Mortality
Choose light sedation & avoid benzos
C
 Duration of mechanical ventilation
 Mortality
 Delirium
Delirium monitoring & management
 Delirium detection
Early Mobility & Environment




Duration of delirium
Disability
ICU Length of Stay
Rehospitalization/Mortality
Morandi et al Curr Opin Crit Care 2011;17:43-9
Vasilevskis et al Crit Care Med 2010;38:S683-91
Vasilevskis et al Chest 2010;138:1224-1233
Zaal et al, ICM 2013;39:481-88
Colombo et al, Minerva Anest 1012;78:1026-33
No Sedation: ICU Length of Stay
Patients Remaining in ICU (%)
100
80
Control (n=58)
60
40
Intervention (n=55)
20
ICU stay reduced by
9.7 days
0
0
7
14
Days
21
28
Strom T, et al. Lancet 2010;375:475-80
2013 PAD Guidelines:
“We suggest that sedation strategies using
non-benzodiazepines (propofol or
dexmedetomidine) may be preferred over
sedation with benzodiazepines (midazolam
or lorazepam)”
Grade 2B Recommendation
Crit Care Med. 2013;41:263-308
Buffalos to Beer to Brain Cells
Cliff the mailman and philosopher
Cliff: “Well you see, Norm, it's like this . . A herd of
buffalo can only move as fast as the slowest
buffalo. And when the herd is hunted, it is the
slowest and weakest ones at the back that are
killed first. This natural selection is good for the
herd as a whole, because the general speed and
health of the whole group keeps improving by the
regular killing of the weakest members.”
sitcom CHEERS
Buffalos to Beer to Brain Cells
“In much the same way, Norm, the human brain
can only operate as fast as the slowest brain cells.
Now, as we know, excessive intake of alcohol kills
brain cells. But naturally, it attacks the slowest and
weakest brain cells first. In this way, regular
consumption of beer eliminates the weaker cells,
making the brain a faster and more efficient
machine. And that, Norm, is why you always feel
smarter after a few beers.”
sitcom CHEERS
Daily Risk of Delirium in MENDS
p=0.02
Pandharipande PP, et al. Crit Care 2010;14:R38
Daily Risk of Delirium in SEDCOM
p<0.001
Riker, et al. JAMA 2009;301:489-499
Pain, Agitation, and Delirium
Are Interrelated
Delirium
Barr J, et al. Crit Care Med. 2013;41:263-306.
Awake and Breathing Coordination
 Duration of mechanical ventilation
 Duration of coma
 Mortality
Choose light sedation & avoid benzos
 Duration of mechanical ventilation
 Mortality
 Delirium
Delirium monitoring & management
 Delirium detection
Early Mobility & Environment




Duration of delirium
Disability
ICU Length of Stay
Rehospitalization/Mortality
Morandi et al Curr Opin Crit Care 2011;17:43-9
Vasilevskis et al Crit Care Med 2010;38:S683-91
Vasilevskis et al Chest 2010;138:1224-1233
Zaal et al, ICM 2013;39:481-88
Colombo et al, Minerva Anest 1012;78:1026-33
Cardinal Symptoms of Delirium and Coma
Morandi A, et al. Intensive Care Med. 2008;34:1907-1915.
Ely EW, JAMA 2001;286:2703-10
Ely EW, JAMA 2003;289:2983-91
CAM-ICU Sensitivity and Specificity
• Over a dozen studies have now compared the
30 second CAM-ICU evaluation to Geriatric
psychiatrists’ 30 to 45 minute evaluations:
– Sensitivity 80% to 95%
– Specificity 90% to 97%
– Inter-rater reliability, kappa = 0.96 (0.92-0.99)
– Delirium prevalence rates in mechanically
ventilated ICU patients consistently 60% to 80%
Ely EW, JAMA 2001;286:2703-10
Gusmao-Flores Crit Care 2012;16:R115
Don’t forget about Dr. DRE
Diseases
Sepsis, COPD, CHF
Drug Removal
SATs and stopping benzodiazepines/
narcotics
Environment
Immobilization, sleep and day/night,
hearing aids, glasses, noise
Medical Intensive Care Unit
SLEEP
Consider reading these citations:
Patel J et al, Anesthesia 2014;69:540-549
Watson P et al, CCM 2013;41:1958-67
Weinhouse G, CO-Anesthesiology 2014;27:epub
Kamdar B et al, Anesthesia 2014;69:527-31
Kamdar B et al, CCM 2013;41:800-09
Hopkins Sleep Protocol Associated with
Reductions in Delirium
Environmental
Non-Pharmacologic
Pharmacologic
No overhead pages
No TV
Dim hall lights
Grouping Care Activities
Ear plugs
Eye masks
Soothing Music
Avoiding Benzos, Opiates
& trazodone as sleep aides
Zolpidem if CAM –
Haloperidol if CAM +
Mobilization
Lights on, blinds open
Decrease naps
No caffeine after 3pm
Following QI intervention, fewer patients developed delirium
(Adjusted OR 0.46, 95% CI 0.23-0.89, p=0.02)
Intervention patients had more days of ‘normal’ brain function
(Adjusted OR 1.64, 95% CI 1.04-2.58, p=0.03)
Kamdar B CCM 2013;41:800-09
Average ICU has background noise of
crowded restaurant, louder next to patient’s head
Noise spikes of >85dBA at least every 8 minutes
Darbyshire JL CCM 2013;17:R187
Sleep Promotion In ICU Reduces
Delirium Prevalence
SLEEP Program
%
Weeks
Rummelhard D, Schelle-Chaple H (UCSF) CCM 2012
MIND-USA
Modifying the Impact of ICU-Associated
Neurological Dysfunction
Brain Road Map
(A framework for bedside rounds)
1. Where is the patient going?
Target RASS
2. Where is the patient now?
Current RASS
Current CAM-ICU
© Brian Sloan via Flickr
3. How did they get there?
Drugs
Awake and Breathing Coordination
 Duration of mechanical ventilation
 Duration of coma
 Mortality
Choose light sedation & avoid benzos
 Duration of mechanical ventilation
 Mortality
 Delirium
Delirium monitoring & management
 Delirium detection
E
Early Mobility & Environment




Duration of delirium
Disability
ICU Length of Stay
Rehospitalization/Mortality
Morandi et al Curr Opin Crit Care 2011;17:43-9
Vasilevskis et al Crit Care Med 2010;38:S683-91
Vasilevskis et al Chest 2010;138:1224-1233
Zaal et al, ICM 2013;39:481-88
Colombo et al, Minerva Anest 1012;78:1026-33
The Iconic Picture of Early Mobility
• Point prevalence study in Germany showed <10% walking
• “Yes ‘n How many deaths will it take, Till he knows
that too many people have died?” Dylan, Times They Are A-Changin’
Needham DM, JAMA 2008;300:1685-90
Nydahl P et al, CCM 2014;42:1178-1186
Clemmer T, CCM 2014;42:1308-09
Mobilization = Less Delirium
Variable
Intervention
(n=49)
2 days
Control
(n=55)
4 days
P-value
Time in ICU
with Delirium
33%
57%
0.02
Time in Hosp.
with Delirium
28%
41%
0.01
ICU/Hosp
Delirium Days
0.03
Schweickert et al, Lancet 2009;373:1874-82
Minimum Criteria for Consulting PT/OT
and Initiating Early Exercise
M – Myocardial Stability
• No evidence of active myocardial ischemia
• Stable heart rate and cardiac rhythm
O – Oxygenation adequate on
• FIO2<0.6
• PEEP<10 cm H2O.
V – Vasopressor(s) Minimal
• No increase dose of any vasopressor infusion for at least 2 hours*
E – Engages to Voice
• Patient response to verbal stimulation (RASS > -3)
Mobilizing the Brain with Sudoku & Scrabble
RETURN to
Land of the Living
Returning to Everyday Tasks
Utilizing Rehabilitation Networks
RETURN – Cognitive Rehabilitation
Intervention
Control
18
14
Executive 10
Function
6
2
Enrollment
3 Month Follow-Up
Jackson et al, Critical Care Med. 2012
ABCDEs:
Building blocks of managing
Pain, Agitation & Delirium
A B
E
C
Airplane Draft
ICU Liberation - 3 Columns
abcdef…
•
•
•
•
•
F = FAMILY
Family rounding
Family visitation
Family importance to reducing delirium
Good EOL planning
Good transitions of care, IMPACT project
Excellence
Aristotle: “We are what we repeatedly do.
Excellence is not an act, but a habit”
Jiro Dreams of Sushi - Tokyo
““
I survived and that is the main thing.
And I am so grateful to God that I
survived and am now off all oxygen
and consider myself all well except
that I can’t remember to take my
medications...
-SB
The ICU Delirium and Cognitive Impairment Study
Group at the Loveless Café, Nashville TN
ICU Delirium and Cognitive Impairment Study Group: selected local
members
Pratik Pandharipande
Jim Jackson
Jin Han
Ed Vasilevskis
Chris Hughes
Alessandro Morandi
Paula Watson
Lorraine Ware
Gordon Bernard
Bob Dittus
Ted Speroff
Wes Ely
Leanne Boehm
Joyce Okahashi
Cayce Strength
Brenda Pun
Lauren Hardy
Amy Lipsey
Ryan Black
Jessica McCurley
Michael Santoro
Carrie Jones
Morgan Crawford
Mayur Patel
Tim Girard
John Gore
Baxter Rogers
Stephan Heckers
Cathy Fuchs
Heidi Smith
Ty Berutti
Brad Strohler
Elizabeth Card
Jennifer Thompson
Ayumi Shintani
Stephanie Hamilton