What is delirium Answer 2 How do I diagnose delirium Case 1 Attention Screening Examination How do I diagnose delirium Case 1 revisited Managing ICU Delirium Modify Risk Factors

What is delirium Answer 2 How do I diagnose delirium Case 1 Attention Screening Examination How do I diagnose delirium Case 1 revisited Managing ICU Delirium Modify Risk Factors www.phwiki.com

What is delirium Answer 2 How do I diagnose delirium Case 1 Attention Screening Examination How do I diagnose delirium Case 1 revisited Managing ICU Delirium Modify Risk Factors

King, Glen, News Director has reference to this Academic Journal, PHwiki organized this Journal Diagnosis in addition to Management of ICU Delirium June 24, 2010 – July 1, 2010 Dave Miller, MD in addition to Becky Logiudice, MS, RN Talk Outline Why is this important What is delirium Using CAM-ICU to diagnose ICU delirium How do I treat delirium Goal-oriented sedation Why is this important Perspective from SB About my delirium memories from the ICU, I have had few. The time I spent seems 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. Every once in a while I would get to an edge of something horrible in addition to once I remember I thought, “if I just let go, then this horror will be over ” When I try to write about that time ( in addition to I have tried over in addition to over), words just won’t come in addition to in my line of writing, personal essays, if it doesn’t just come gushing out, I have to stop. And that’s where I am now http://www.icudelirium.org/outcomes.html reports

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Why is this important Pun B T , Ely E W Chest 2007;132:624-636 183 ÷ (183+41) = 0.82 Why is this important Common Increased mortality Increased LOS Increased complications Increased costs May be associated with increased dementia in addition to long-term cognitive impairment Girard DT et al. Crit Care Med 2010;38(7):epub ahead of print

Pun BT in addition to Ely EW. Chest 2007;132:624-636 What is Delirium Answer 1 You’ll Know it when you see it What is delirium Pun B T , Ely E W Chest 2007;132:624-636

What is delirium Answer 2 Disturbance of consciousness Inattention Change in cognition or perceptual disturbance Develops over hours to days Fluctuates over time How do I diagnose delirium Case 1 Mr. D, a 70-year old with severe COPD, is in the MICU on a ventilator as long as respiratory failure. Initially he needed high levels of sedation, but now Propofol has been decreased in addition to Mr. D is awake but agitated, grimacing, thrashing in addition to trying to sit up in bed. He makes eye contact, but won’t follow comm in addition to s Is Mr. D delirious How do you know Assessment of ICU patients

Assessment tool: CAM-ICU Assessment tool: CAM-ICU RASS

Assessment tool: CAM-ICU Attention Screening Examination Auditory Squeeze my h in addition to each time I say the letter “A” SAVEAHAART More than 2 wrong responses = POSTIVE Visual (cannot hear or squeeze h in addition to s) Show 5 pictures, then show 5 repeat in addition to 5 new in r in addition to om order More than 2 wrong responses = POSITIVE Assessment tool: CAM-ICU

How do I diagnose delirium Case 1 revisited Mr. D, a 70-year old with severe COPD, is in the MICU on a ventilator as long as respiratory failure. Initially he needed high levels of sedation, but now Propofol has been decreased in addition to Mr. D is awake but agitated, grimacing, thrashing in addition to trying to sit up in bed. He makes eye contact, but won’t follow comm in addition to s Is Mr. D delirious How do you know Case 1 revisited STEP 1: Mr. D is assessed to be a RASS +2, which is an acute change from his baseline STEP 2: He squeezes h in addition to s on “A” once out of 5 times (4 errors) so is inattentive STEP 4: Because his level of consciousness is altered (RASS +2), STEP 3 does not need to be assessed. Mr. D is delirious! Case 2 The next day, Mr. D is awake in addition to calm (RASS 0). He was given several doses of lorazepam overnight as long as “agitation.” He remains intubated, but is following comm in addition to s appropriately. Is Mr. D delirious now

STEP 1: He is awake in addition to calm (RASS 0) now, but fluctuated within the last 24 hours STEP 2: He scores 6/10 on the Attention Screening Examination (POSITIVE) STEP 3: Because his level of consciousness is not currently altered, he is tested as long as disorganized thinking. He scores 3 out of 5 because when asked “Are there elephants in the sea” in addition to “Can you use a hammer to cut wood” he answers “YES!” (POSITIVE) How should we manage Mr. D Managing ICU Delirium Look as long as it Communication between nursing in addition to MDs Identify in addition to treat correctable risk factors Optimize non-pharmacologic interventions Goal-oriented sedation with daily wake-ups Pharmacologic intervention Managing ICU Delirium Modify Risk Factors

King, Glen WJUS-AM News Director www.phwiki.com

Severity of illness in addition to age are independent risk factors as long as delirium P in addition to harip in addition to e et al. Anesthesiology 2006;104:21-26 Lorazepam dose is an independent risk factor as long as delirium Also: Other Benzos Opiates Propofol Anticholinergics H2 blockers Steroids Some antibiotics Psych meds P in addition to harip in addition to e et al. Anesthesiology 2006;104:21-26 Non-Pharmacologic Management Orientation Visual in addition to hearing aids Communicate in addition to re-orient frequently Familiar objects in addition to people Consistent nursing staff TV, news, music during the day Environment Sleep hygiene: Lights off at night, on during day. Sleep aids Control excess noise at night Ambulate or mobilize early in addition to often Pun B T , Ely E W Chest 2007;132:624-636

Pharmacologic Management Antipsychotics Little controlled data, but anecdotal in addition to case-series evidence One small recent RCT comparing Haldol vs placebo found no difference in mortality, LOS, side effects Haldol IV recommended by SCCM Long half-life (18-54 hours) Risk of: QT prolongation, NMS, akathisia Monitor QTc BID, follow K, Mg, Ca. Beware other drugs that prolong QT (MANY including anti-arrhythmics, quinolones, erythromycin, methadone) Jacobi et al. Crit Care Med 2002;30:119-141 Girard et al. Crit Care Med 2010; 38: 428-37 Pharmacologic Management Haloperidol (Haldol) Action: CNS depressant in addition to dopamine receptor antagonist Side Effects: Prolonged QT interval, Extrapyramidal symptoms, tardive dyskinesia (long term use) IV Dosing: Starting dose: Mild agitation 2mg IV, Moderate to severe agitation 5mg IV After 20 min. of 1st dose, if still agitated increase the previous doses by 5mg every 20min until calm. Max dose 30 mg in 24 hours Once pt is calm, 25% of loading dose should be given Q 6 hours scheduled Once pt is delirium free as long as 24 hours taper off haldol Atypical Antipsychotics Recent double-blind RCT of quetiapine (Seroquil) 50mg BID vs placebo Haldol PRN – study drug increased if any PRN in 24 hours 36 ICU patients with delirium Shorter time to resolution of delirium (1 vs 4.5 days) Reduced duration of delirium (36 vs 120 hours) More somnolence with quetiapine, other SEs similar Devlin JW et al. Crit Care Med 2010; 38: 419-426

Summary Delirium is common in addition to has serious negative consequences May be missed without assessment Management is multidisciplinary Risk factor modification Non-pharmacologic intervention Pharmacologic intervention Optimize goal-directed sedation in addition to analgesia WWW.ICUDELIRIUM.ORG

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