I.C.U. and Other Things Too

Pamela DuVall, MS, CCC-SLPSpeech PathologistVanderbilt University Medical Center

• The background of the current ICU Liberation Initiative

• The importance of early intervention with our critically-ill patients

• Introduce the ABCDEF bundle in ICU care and our role

• Discuss Post-Intensive Care Syndrome (PICS) and the needs of the patient after discharge

What we will cover today

Where we are and how we got here

The Backdrop to ICU Liberation

How did we get here?

• Sicker and sicker patients

• Above all else do no harm

• Sedation drugs

Above all else do not harm!• The physician’s oath contributed to the belief that the humane thing to do in the ICU is help people not remember this horrible time in their lives and what better way to do that than to heavily sedate and make little to no effort to engage them.

• “take over the patient” – as patients presented to ICUs sicker and sicker it began to be presumed necessary to have docile passive patients. The end result has been a state of deep anesthesia and paralysis in the ICU setting, typical of that seen in an OR

Schweickert, W et al. Chest, 2011;140;6 1612-1616

Sedation drugs

• In the 1980s and 1990s, sedation practice and drug selection, for adult ICU patients, was largely an extension of the practice of general anesthesia. Generally, the goal was deep sedation, and neuromuscular blocker use was not uncommon

• “I am troubled when I make rounds in critical care units today. What I see these days are paralyzed, sedated patients lying without motion, appearing to be dead, except for the monitors that tell me otherwise.”

Chest 1998; 114;360-361

A Healing Paradox

• Is the hospital a healing or dangerous place?– At least 30% of patients older than 70 years and hospitalized for a

medical illness are discharged with an ADL disability they did not have before becoming acutely ill.

– Approximately 50% of disability among older adults occurs in the setting of medical hospitalization.

• What if that hospitalization wasn’t for something “minor” and/or required a stay in ICU?– 2.7 milllion patients in the United states each year are unable to

communicate for significant timeframes due to artificial airways– Inability to communicate is the most commonly reported distressing

symptom for ICU patients requiring mechanical ventilation– Only 10% of ICU patients in the USA walk

ICU Liberation

• The Society of Critical Care Medicine's ICU Liberation initiative aims to liberate patients from the harmful effects of pain, agitation, and delirium in the intensive care unit (ICU).

• The ICU Liberation guidelines and the “ABCDEF Bundle” are vital resources in assessing, treating and preventing pain, agitation, and delirium. The initiative also is focused on early intervention strategies that can help reduce the risk of short and long-term consequences from an ICU stay.

ABCDEF

Bundle

.

Vasilevskis EE, et al. Chest. 2010;138(5):1224-1233.

Davidson JE, et al. Am Nurse Today. 2013;8(5):32-38.

ABCDEF Bundle

A

D

E

C

F

B

Assess, Prevent and Manage Pain

Both SAT and SBT

Choice of Analgesia and Sedation

Delirium: Assess, Prevent and Manage

Early Mobility and Exercise

Family Engagement and Empowerment

Respiratory

ST/PT/OT

Physicians

Nursing

Pharmacists

Implementation of Bundle

Benefits of the ABCDEF Protocol

Assess, prevent, and management pain

Both SAT and

SBT

• Why is it important to know?

• Each medication class produces different effects

• Monitor patient response

• Modify therapy treatment

Pharmacology

Choice of sedation

• Blunting of pain or noxious stimuli• Opioids, NSAIDS, acetaminophen

• Common opioids:– Morphine– Fentanyl– Hydromorphone– Oxycodone

Analgesics

• Side effects:• Apnea• Hypoventilation• Confusion • Dizziness

• Propofol– Rapid onset, short duration

• Benzodiazepines***– Xanax

– Versed

– Valium

– Ativan

Sedatives

• Haldol

– Achieve rapid response in delirious patients

• Precedex

– Agitated delirium

– Decreased number of vent-free days

– Increased number of delirium-free days

Delirium Medications

Jacobi et al. Crit Care Med. 30(1), 119-141

Reade et al. JAMA. 315(14), 1460-1468.

• What is delirium?

• What are the risk factors for delirium?

• How do we assess for delirium?

• What are the functional implications of delirium?

Delirium

De-lir-i-um

• A common and serious problem among acutely unwell persons

• A disturbance of consciousness and awarenessaccompanied by a change in cognition

• Linked to higher rates of mortality, long term

disability and it remains underdiagnosed

- American Psychiatric Association, 2014

• “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,

Cutting for Stone

Morandi A et al. ICM 2009;34:1907-15

Meagher D, J Psychosom Res 2008;65:207-14 Girard & Ely. Handbook of Clin Neurol (ed:Young) 2008

Cardinal symptoms

* Dashed line encircles non-cardinal features, i.e., the others are more diagnostic;

Inattention is the most pivotal feature of delirium.

*

• Hypoactive delirium• Decreased physical and mental activity• Inattention is most prevalent

• Hyperactive delirium• Combative and agitated

• Mixed delirium• Features of both

• Subsyndromal• Intermediate stage between delirium and normal

cognition

Types of delirium

Delirium Risk Factors in the ICU

Ely EW, et al. Intensive Care Med 2001; 27:1892-900Prevalence of Risk Factors

Pain, Agitation, and Delirium (PAD) Guidelines

• Developers: American College of Critical Care Medicine

• 20 person, multidisciplinary task force

• Collaborated over 6 years

• Used a database of over 19,000 references

• Group consensus for all statements

Primary goal of 2013 PAD guidelines

“…provide a roadmap for developing integrated, evidence-based, and patient-centered protocols for preventing and treating Pain, Agitation, and

Delirium in critically ill patients.”

2013 PAD Statements & Recommendations

• Delirium assessment should be routinely performed on ALL ICU patients (Q shift & PRN)

• Use the lightest sedation possible level

• ICU Delirium assessment tools– ICDSC (0-8)

– CAM-ICU (positive or negative)

• Agitation and Sedation:

– Richmond Agitation and Sedation Scale (RASS)

– Riker Sedation-Agitation Scale (SAS)

• Delirium:

– Confusion Assessment Method for the ICU (CAM-ICU)

– Intensive Care Delirium Screening Checklist (ICDSC)

How do we assess delirium?

A Two Step Approach to Assessing Consciousness

Step 1

Level of Consciousness (arousal): RASS

Step 2

Content of Consciousness (delirium): CAM-ICU

Richmond Agitation Sedation Scale (RASS)

Scale Label Description

+ 4 Combative Combative, violent, immediate danger to staff

+ 3 Very agitated Pulls to remove catheters or tubes, aggressive

+ 2 Agitated Frequent non-purposeful movement, fights ventilator

+ 1 Restless Anxious, apprehensive, movements non-aggressive

0Alert and

calmSpontaneously pays attention to caregiver

-1 Drowsy eye contact > 10 sec

-2 Light sedation eye contact < 10 sec

-3 Moderate sedation no eye contact

-4 Deep sedation physical stimulation

-5 Unarousable no response even with physical

Verbal Stimulus

Physical Stimulus

Confusion Assessment Method for the ICU (CAM-ICU)

4. Disorganized Thinking

1. Acute onset of mental status changes or a fluctuating course

and

2. Inattention

and

or

= DeliriumEly et al, Crit Care Med 2001;29:1370-79 Ely, E.W., et al. JAMA2001; 286, 2703-2710

3. Altered level of consciousness

Feature 1: Alteration/Fluctuation in Mental Status

Is the patient different than his/her baselinemental status?

OR

Has the patient had any fluctuation in mental status in the past 24 hours (e.g., fluctuating RASS, GCS, previous delirium assessments, etc)

Present: If either question is YES.

Feature 2: Inattention

Screening for Attention– two options

• Letter “A” test

Letters: S-A-V-E-A-H-A-A-R-T

Say 10 letters and instruct the patient to squeeze

on the letter “A” , C A S A B L A N C A

• Pictures

Similar test with pictures

(instructions are in picture packets)

Inattention is present: If >2 errors

Pictures

Feature 2: Inattention

Common Questions: • What if the patient only squeezes once and then falls

back to “sleep”?

• What if the patient is too hyperactive or combative to participate in squeezing?

• Remember what you are assessing for…..Attention! This patient is inattentive.

• If you have to explain the directions more than twice, start to be suspicious for inattention.

Feature 3: Alt Level of Consciousness

Any LOC other than Alert.

Present: If the Actual RASS score is anything other than “0” (zero).

You have already done this assessment. It was the first thing you did when you walked

in the room!

“Her mind tottered and slithered again, broke from its foundation and spun like a cast wheel in a ditch. . . She sank easily through deeps and deeps of darkness until she lay like a stone at the farthest bottom of life. . .”

Katherine Anne Porter, Pale Horse, Pale Rider

Feature 4: Disorganized Thinking

Yes/No Questions (Use either Set A or Set B) :

Set A Set B

1. Will a stone float on water? 1. Will a leaf float on water?

2. Are there fish in the sea? 2. Are there elephants in the sea?

3. Does one pound weigh more than 3. Do two pounds weigh

two pounds? more than one pound?

4. Can you use a hammer to pound a nail? 4. Can you use a hammer to cut wood?

Note: Use whatever form of communication that works (nodding, hand squeezing, blinking, etc).

Feature 4: Disorganized Thinking

Command

Say to patient, “Hold up this many fingers”

(Examiner holds 2 fingers in front of patient)

“Now do the same thing with the other hand.”

(Not repeating the number of fingers)

• Patient gets credit only if able to successfully complete the entire command.

Feature 4: Disorganized ThinkingPresent: If there is >1 error for the

combined questions + command.

Notes:

– If pt is unable to move both arms, for the second part of the command ask patient “Add one more finger”.

– If patient is unable to move arms at all (quadriplegic), then Feature 4 is present if patient misses more than 1 question.

bCAM

Delirium Triage Screen and bCAM

Han JH, et al. row AB, Shuster J, Ely EW. Ann Emerg Med. 2013;62:457-465.

DTS

• Screening tool for Non-

ICU setting

• Spell LUNCH Backwards

Brief CAM (bCAM)

• Similar to CAM-ICU

• Say the months of the

year backwards

Characteristic Critical Illness Brain Injury

Traumatic Brain Injury Alzheimer’s Disease

Age All ages All ages Older ages a

Onset Abrupt Abrupt Insidious

Initial deficit(s) Numerous Numerous Memory b

Course Variable Variable Progressive

Psychiatric disorder(s) Depression, anxiety, PTSD

Depression, anxiety Depression

a Inherited forms of Alzheimer’s disease, which account for <1% of all cases, can present during middle age.b Though primarily a memory disorder early in its course, Alzheimer’s disease affects other cognitive

domains with disease progression

Girard TD, et al. Annu Rev. Med. 2016; 67:497-513

Compliance with “E”

• What is the definition of early intervention in terms of ICU rehab?

• What activities count as cognitive communication interventions in this populaton?– Communication board if intubated

– Smart phone/iPad with communication apps

– Restoration of verbal communication for trach/vent

– Daily orientation exercises

– All about me boards with pictures

– ICU Diary/Journal daily activities

– Consistency

ICU Communication Tool Kit

Restoring Verbal Communication for Tracheostomy/Vent Patients

• Leak speech

• In-line Speaking Valve

• BLUSA: Portex Blueline Ultra Suctionaide Trach

• Open visitation policy

• Communication boards in each room

• Family participation in daily rounds

• Family presence and involvement documented

• Education materials for family members to inform them on a stay in the ICU

• ICU diaries

Family Engagement

• Purpose– To help patient and loved one remember what

happened– Memories and periods of time “lost”– Understanding what happened aids in recovery

• What to record– Events– Procedures– Milestones– News about loved ones– Updates from family/friends

ICU Diaries

O-Log

Help Set Realistic Expectations

• Little appreciation for critical illness as a traumatic stressor (even sophisticated patients)

• Provide education to help adjust expectations

Brochures on what to expect after discharge

Websites with patient/family-centered info

Signs of depression, anxiety, and PTSD

• Consider creating educational materials for discharge packets

Society of Critical Care Medicine, Critical Care Statistics in the United States,

2012

Annually

a Critical Illness

People Survive

Post-Intensive Care Syndrome (PICS)

• The term PICS was agreed on as the recommended term at a 2010 SCCM Task Force Meeting.

• Describes new or worsening impairments in physical, cognitive, or mental health status arising after critical illness and persisting beyond acute care hospitalization.

Needham DM, et al. Crit Care Med. 2012;40:502–509.

• Long Tern Cognitive impairment• Abrupt onset• Diffuse effects• Critical Illness Brain Injury

• Physical disability

• Psychological outcomes

Functional implications of delirium

Long-term Cognitive ImpairmentLTCI

➢Duration of delirium = predictor of cognitive impairment.▪ An increase from 1 day of delirium to 5 days was associated

with nearly a 5-point decline in cognitive battery scores

➢>50% of ICU survivors leave the hospital with cognitive impairment▪ Of those, 1 in 3 have cognitive impairment akin to TBI or

Alzheimer's Disease

Delirium and Cognitive Impairment in the news

Girard TD, et al. Crit Care Med 2010; 38.

Pandharipande P et al. NEJM 2013; 369(14):1306-1316

Cognitive Impairment

• Extremely prevalent 1 year after hospital discharge

– 34% with scores similar to Traumatic Brain Injury

– 24% with scores similar to Alzheimer’s disease

• Delirium in the ICU was an independent risk factor for long-term cognitive impairment

• Affects all age ranges

Pandharipande PP, et al. N Engl J Med. 2013;369(14):1306-16.

Employment Status

12 month survivors, 47% employed at baseline:

Of these previously employed survivors:

48% not working at 12 months

77% of these attribute unemployment due to health-related reasons (cognitive and physical)

Needham et al., BMJ, 2013; 346; f1532

Cognitive Impairment

• 50%–70% of patients are cognitively impaired

• Deficits Attention

Memory

Executive Functions

Hopkins RO, et al. Chest. 2006;130(3):869–878.

Jackson JC, et al. Am J Respir Crit Care Med. 2010;

182(2):183-191.

Girard TD, et al. Crit Care Med. 2010;38(7):1513-1520.

Long-term cognitive impairmentGunther ML, et al. Crit Care Med. 2012; 24:1478-1484.

Girard TD, et al. Annu Rev Med. 2016; 67:497-513.

Likelihood of Post ICU PICS

Symptoms

+ Up to 40% of former ICU patients suffer from depression

+ Up to 60% of former ICU patients suffer from anxiety

+ Up to 40% of former ICU patients have cognitive

deficits (similar to a traumatic brain injury)

+ Up to 25% of former ICU patients have cognitive

deficits (similar to patients with mild dementia)

Needham DM, et al. Crit Care Med. 2012;40:502–509.

Davidson JE, et al. Am Nurse Today. 2013;8(5):32-38.

Needham DM, et al. Crit Care Med. 2012;40:502–509.

Davidson JE, et al. Am Nurse Today. 2013;8(5):32-38.

Needham DM, et al. Crit Care Med. 2012;40:502–509.

Davidson JE, et al. Am Nurse Today. 2013;8(5):32-38.

What can be done after the hospital?

Back End Strategies: After the ICU• Post-ICU care:

□ Need rehabilitation staff to coordinate the post-ICU care: Referral to Speech Pathology at next level of care.

□ Barriers to this may be:▪ Limited awareness of long-term consequences

▪ No rehabilitation pathway for post-ICU (eg, stroke and traumatic brain injury)

▪ Limited exposure to critical care issues

• What can we do?□ Increase awareness—spread the word!□ Educate professionals in our institutions□ Encourage rehab services to check out resources from SCCM

Needham DM, et al. Crit Care Med. 2012;40:502–509.

Questions?

www.ICUdelirium.org

delirium@vanderbilt.edu

References• Brummel NE, Jackson JE, Pandharipande PP, et al: Delirium in the ICU and

subsequent long-term disability among survivors of mechanical ventilation. Critical Care Medicine 2014; 42:369-377.

• Pandharipande PP, Girard TD, Jackson JC, et al: Long-term cognitive impairment after critical illness. N Engl J Med 2013; 369:1306-1316.

• Wilcox ME, Brummel NE, Archer K, et al: Cognitive dysfunction in ICU patients: risk factors, predictors, and rehabilitation interventions. Critical Care Medicine 2013; 41:S81-S98.

• Girard TD, Dittus RS, Ely EW: Critical illness brain injury. Annu. Rev. Med.2016; 67:497-513

• Frimpong K, Stollings JL, Carlo ME, Ely EW. (2016). ICU delirium viewed through the lens of the PAD guidelines and the ABCDEF implementation bundle. ICU Liberation: The Power of Pain Control, Minimal Sedation, Early Mobility (1-10).

• http://www.heart.org/HEARTORG/Conditions/More/MyHeartandStrokeN

ews/How-do-beta-blocker-drugs-affect-

exercise_UCM_450771_Article.jsp#.WXKhATM1Twc

References

• Frimpong K, Ely EW, Banerjee A, personal communication, January 27, 2016

• Whitney K. (2015). Undone in the ICU. Vanderbilt Medicine. https://www.mc.vanderbilt.edu/vanderbiltmedicine/undone-in-the-icu/

• Jutte JE, Erb CT, Jackson JC: Physical, cognitive, and psychological disability following critical illness: What is the risk? Semin Respir Crit Care Med 2015; 36:943-958.

• American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed, text revision. Washington, DC.: American Psychiatric Association; 2013.

• Schweickert, WD et al: Lancet 2009; 373:1874-1882.• Buntin, C et al: Crit Care Med 2005; 37:2499-2505.• Morris, PE et al: Crit Care Med 2008; 36: 2238-2243.

References• Expert consensus and recommendations on safety criteria for

active mobilization of mechanically ventilated critically ill adults Critical Care 2014, 18:658 doi:10.1186/s13054-014-0658-y

• Sricharoenchai, T et al: J of Crit Care 2014; 29: 395-400.

• Lord RK et al: Crit Care Med 2013; 41:717-724.

• Moss M et al: A Randomized Trial of an Intensive Physical Therapy Promgram for Acute Respiratory Failure Patients. Respir Crit Care Med; Dec 10, 2015.

• Fields, C., Trotsky, A., Fernandez, N., & Smith, B.A. (2015). Mobility and ambulation for patients with pulmonary artery catheters: a retrospective descriptive study. Journal of Acute Care Physical Therapy, 6(2), 64-70.

• Jacobi, J, et. al. (2002). Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med, 30(1), 119-141.

• Perme C, Nalty T, Winkelman C, Nawa RK, Masud F. (2013). Safety and efficacy of mobility intervention in patients with femoral catheters in the ICU: a prospective observational study. Cardiopulmonary Physical Therapy Journal, 24(2): 12-17

• Reade MC, Eastwood GM, et. al. (2016). Effects of Dexmedetomodine added to standard care on ventilator-free time in patients with agitated delirium. JAMA, 315(14), 1460-1468.

• Toonstra, A L, Zanni, J M, Sperati, C J, Nelliot, A, Mantheiy, E, et al. (2016). Annals of the American Thoracic Society, 13(5), 699-704.

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