Transcript Crit Care Med - community360.net

CUSP4MVP-VAP
SATs and SBTs: of Guidelines & Implementation
E. Wesley Ely, MD, MPH
Professor of Medicine
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
- Chair of SCCM Delirium section for PAD
- Co-Chair of SCCM ICU Liberation project to aid worldwide implementation
Delirium
Barr J, et al. Crit Care Med. 2013;41:263-306.
Barr J et al, CCM 2013;41:263-306
New guidelines emphasize individual
symptom management
OLD
(2002)
New
(2013)
Clinical Practice Guidelines for the sustained use of
sedatives and analgesics in the critically ill adult
Jacobi, CCM 2002
Clinical Practice Guidelines for the management of
Pain, Agitation, and Delirium in adult patients in the
Intensive Care Unit
Barr, CCM 2013
Take Home Message
Delirium = Dangerous
Patient = Vulnerable
Andros Island by N Rakov, NEJM 2011;365:457
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
“
...like it was in a huge, empty gray
space, sort of like a monstrous
underground parking garage with no
cars, only me, floating or seeming to
float, on something…
-SB
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
Primum non Nocere
- Hippocratic Oath
- First do no harm
“Nothing to Fear but Fear Itself”
- FDR inauguration, 1933
- Overcome Fear of ICU Culture Change
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
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
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
Crit Care Med. 2013;41:263-308
2013 PAD Guidelines:
“We recommend that sedative medications
be titrated to maintain a light* rather than
deep level of sedation”
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
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
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
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.
2013 PAD Guidelines:
“We recommend routine monitoring
for delirium in adult ICU patients”
Grade 1B Recommendation
Crit Care Med. 2013;41:263-308
Delirium and Executive Function
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.
Ely EW, JAMA 2001;286:2703-10
Ely EW, JAMA 2003;289:2983-91
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
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
Excellence
Aristotle: “We are what we repeatedly do.
Excellence is not an act, but a habit”
Jiro Dreams of Sushi - Tokyo
ABCDEs:
Building blocks of managing
Pain, Agitation & Delirium
A B
E
C
““
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
Key Epidemiological Points:
1) Patients suffer from long-lasting and disabling aspects of critical
illness that demand our attention as a medical community
2) Acquired or accelerated cognitive impairment is a major public
health problem following ICU care for both the old and young
3) This cognitive impairment appears most pronounced in domains
of executive dysfunction and memory
4) Frontal lobe and hippocampal atrophy are being consistently
found in recent studies
5) This injury is likely distinct from or complementary to
Alzheimer’s pathology, though we are in our infancy in learning
about this entity (e.g., large pathology study under review)
6) Delirium and drug exposure appear to be the most modifiable
aspects of care, with need for more trials to delineate next steps
Key Management Points:
1) Establish an overarching protocolized approach to daily ICU
patient management using 2013 PAD Guidelines
2) Assess & treat pain first (may be sufficient)
3) If patient remains agitated after adequately treating pain, use
prn/bolus sedation initially, if frequent boluses (>3/hr) use
continuous sedation
4) Avoid benzodiazepines in most patients
5) Turn off sedation daily and restart only if needed at lowest dose
to maintain chosen target level of consciousness
6) Deep sedation (RASS -4/-5) appears harmful; target awake/alert
7) Screen for delirium (CAM-ICU or ICDSC); If delirious, first seek
reversible causes and attempt non-pharmacologic management
8) Use the ABCDEs to improve outcomes for your patients
CUSP4MVP-VAP project measures
• As part of this project, teams will collect and receive
reports for metrics to support your improvement
efforts.
• We held calls with your data facilitator. The data
collection tool, including instructions are available at:
https://armstrongresearch.hopkinsmedicine.org/cusp4m
vp/datatools.aspx
Medical Intensive Care Unit
CUSP4MVP Data Collection
Sedation and Delirium
1) Percentage of RASS/SAS actual being {-1, 0, 1}
or {4, 5}
2) Percentage of achieving RASS/SAS target
3) Distribution of RASS/SAS actual scores
4) Delirium assessment compliance rate
5) Percentage of incorrectly reporting CAM-ICU/
ASE UTA (higher is worse)
6) Percentage of CAM-ICU negative or ASE <=2
(no delirium)
Medical Intensive Care Unit
CUSP4MVP Data Collection
SAT/SBT (next call on March 18)
(1) SAT compliance rate
(2) SBT compliance rate
(3) SAT contraindication rate
(4) SBT contraindication rate
(5) Percentage of ventilated patient days without sedation
(6) SBT with Seds off compliance rate
(7) SAT contraindication distribution plot and table (counts
and percentages)
(8) SBT contraindication distribution plot and table (counts
and percentages)
Medical Intensive Care Unit
Your Next Steps:
• Share your protocols regarding sedation and
delirium management; will share with other
participating teams
• Email to [email protected]
• Review data collection requirements and
develop plan to collect and submit data.
Medical Intensive Care Unit
Reminder:
By Content Call, Module 5 (April 1, 2014):
1.
Watch the Science of Safety (SOS) Video
–
http://www.ahrq.gov/professionals/education/curriculumtools/cusptoolkit/videos/04a_scisafety/index.html
2.
Develop a method to deliver the SOS Video to your entire
unit’s staff
3.
Administer the SSA and submit aggregated results to CE
4.
Facilitate at least one team meeting
Next Call
March 18, 2014
SAT / SBT
Dr Mike Klompas