ICU DELIRIUM T homas Tobinson , MD Associate Professor, Surgery August 5th, 2009
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Transcript of ICU DELIRIUM T homas Tobinson , MD Associate Professor, Surgery August 5th, 2009
ICU DELIRIUM
Thomas Tobinson, MDAssociate Professor, Surgery
August 5th, 2009AGS
WHO CARES ABOUT THE BRAIN?
Slide 2
WHY IS DELIRIUM IMPORTANT?
DELIRIUM
Most common postoperative complication in the elderly
Closely related to adverse outcomes
Potentially preventable, and there is room to improve treatment
Slide 3
WHAT IS DELIRIUM?
Curr Opin Crit Care (2005) 11:360.
Delirium is an acute, fluctuating change in mental status, with inattention and altered levels of consciousness
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DIAGNOSTIC CRITERIA FOR DELIRIUM
• Coexisting physiologic disturbance
• Acute onset
• Disturbance of consciousness
• Change in cognition
Diagnostic and Statistical Manual of MentalDisorders DSM IV - Fourth Edition (1994). Slide 5
MULTIFACTORIAL MODEL OF DELIRIUM
JAMA (1996) 275:852.
Predisposing Factors/Vulnerability
Precipitating Factors/Insults
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MULTIFACTORIAL MODEL OF DELIRIUM
JAMA (1996) 275:852.
High Risk
Low Risk
DELIRIUM
Predisposing Factors/Vulnerability
Precipitating Factors/Insults
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MULTIFACTORIAL MODEL OF DELIRIUM
JAMA (1996) 275:852.
High Vulnerability
Low Vulnerability
Noxious Insult
Less Noxious Insult
High Risk
Low Risk
DELIRIUM
Predisposing Factors/Vulnerability
Precipitating Factors/Insults
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MULTIFACTORIAL MODEL OF DELIRIUM
JAMA (1996) 275:852.
High Vulnerability
Low Vulnerability
Noxious Insult
Less Noxious Insult
Predisposing Factors/Vulnerability
Precipitating Factors/Insults
High Risk
Low Risk
DELIRIUM
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Cataract surgery1 < 5%
Medical ward2 15%Vascular operation3 36%Hip fracture4 40%VA SICU5 44%Trauma ICU6 59%Medical ICU7 72%
INCIDENCE OF DELIRIUM
1. Int Psych (2002) 14:301.
2. NEJM (1999) 340:669.
3. Gen Hosp Psych (2002) 24:28.
4. JAGS (2002) 50:850.
5. Ann Surg (2009) 249:173.
6. Am J Surg (2008) 196:864.
7. JAGS (2006) 54:479.
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MULTIFACTORIAL MODEL OF DELIRIUM
JAMA (1996) 275:852.
High Vulnerability
Low Vulnerability
Noxious Insult
Less Noxious Insult
Predisposing Factors/Vulnerability
Precipitating Factors/Insults
High Risk
Low Risk
DELIRIUM
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RISK FACTORSFOR DELIRIUM AFTER TRAUMA
Pre-existing Patient Factors
Injury- specific Factors
Emergency Room
Findings
Operative Variables
ICU Variables
TRAUMA TIMELINE
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Am J Surg (2008) 196:864.
PREEXISTING RISK FACTORS
DELIRIUM
Present(n = 41)
Absent(n = 28)
Age, years 48 ± 22 38 ± 16 P < .03
AUDIT Score (alcohol abuse) 9 ± 9 10 ± 11 P < .71
Charlson Index (comorbidities) 0.7 ± 1.3 0.4 ± 1.3 P < .35
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↑Age
RISK FACTORSFOR DELIRIUM AFTER TRAUMA
Pre-existing Patient Factors
Injury- specific Factors
Emergency Room
Findings
Operative Variables
ICU Variables
TRAUMA TIMELINE
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Am J Surg (2008) 196:864.
INJURY-SPECIFIC RISK FACTORS
DELIRIUM
Present(n = 41)
Absent(n = 28)
Injury Severity Score 26 ± 12 20 ± 9 P < .02
Head AIS 2.3 ± 2.0 1.7 ± 1.7 P < .20
Abdomen AIS 0.7 ± 1.4 0.9 ± 1.5 P < .48
Extremity AIS 1.5 ± 1.7 1.0 ± 1.6 P < .28
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↑Age ↑ISS
RISK FACTORSFOR DELIRIUM AFTER TRAUMA
Pre-existing Patient Factors
Injury- specific Factors
Emergency Room
Findings
Operative Variables
ICU Variables
TRAUMA TIMELINE
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Am J Surg (2008) 196:864.
EMERGENCY ROOM RISK FACTORS
DELIRIUMPresent(n = 41)
Absent(n = 28)
Systolic blood pressure (arrival) 129 ± 35 132 ± 22 p = .60
Heart rate (arrival) 98 ± 20 90 ± 21 p = .10
Glascow Coma Score (arrival) 12 ± 4 15 ± 1 p < .01
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↑Age ↑ISS ↓GCS
RISK FACTORSFOR DELIRIUM AFTER TRAUMA
Pre-existing Patient Factors
Injury- specific Factors
Emergency Room
Findings
Operative Variables
ICU Variables
TRAUMA TIMELINE
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Am J Surg (2008) 196:864.
OPERATIVE RISK FACTORS
DELIRIUMPresent(n = 41)
Absent(n = 28)
Number of operations 1.3 ± 1.3 0.4 ± 0.6 P < .01
Anesthesia time, minutes 267 ± 289 99 ± 178 P < .01
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↑Age ↑ISS ↓GCS ↑Operations↑Anesthesia
RISK FACTORS FOR DELIRIUM AFTER TRAUMA
Pre-existing Patient Factors
Injury- specific Factors
Emergency Room
Findings
Operative Variables
ICU Variables
TRAUMA TIMELINE
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Am J Surg (2008) 196:864.
ICU RISK FACTORS
DELIRIUMPresent(n = 41)
Absent(n = 28)
Max. base excess (1st 24 hours) 7.7 ± 4.7 4.8 ± 3.2 P = .11
Lowest hematocrit, % 31 ± 9 36 ± 8 P = .01
Blood transfusion total, units 2.8 ± 4.4 0.5 ± 1.5 P < .01
Multiple Organ Failure Score 1.2 ± 1.4 0.04 ± 0.2 P < .01
Required mechanical ventilation 92% 41% P < .01
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↑Age ↑ISS ↓GCS ↑Operations↑Anesthesia
↓Hct↑Transfusion↑ MOF ScoreNeeded Vent
RISK FACTORSFOR DELIRIUM AFTER TRAUMA
Pre-existing Patient Factors
Injury- specific Factors
Emergency Room
Findings
Operative Variables
ICU Variables
TRAUMA TIMELINE
MULTIFACTORIAL MODEL OF DELIRIUM
JAMA (1996) 275:852.
High Vulnerability
Low Vulnerability
Noxious Insult
Less Noxious Insult
Predisposing Factors/Vulnerability
Precipitating Factors/Insults
High Risk
Low Risk
DELIRIUM
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AGE AND POSTOPERATIVE DELIRIUM
0
20
40
60
80
100
5059 6069 7079 8089
Age, years
Incidence of
Delirium,%
Ann Surg (2009) 249:173.Slide 24
PREOPERATIVE RISK FACTORS
DELIRIUM
Present(n = 64)
Absent(n = 80)
Age, years 69 ± 9 61 ± 6 P < .001
Albumin, g/dL 3.3 ± 0.8 3.9 ± 0.4 P < .001
Hematocrit, % 38 ± 7 44 ± 4 P < .001
Functional status 91 ± 11 99 ± 3 P < .001
Cognitive dysfunction 2.8 ± 1.6 4.6 ± 0.7 P < .001
Comorbidities 4.6 ± 2.4 1.8 ± 1.4 P < .001
Ann Surg (2009) 249:173.Slide 25
INTRAOPERATIVE RISK FACTORS
DELIRIUM
Present (n = 64)
Absent (n = 80)
Blood loss, mL 752 ± 1033 655 ± 1515 P = .73
OR time, minutes 298 ± 137 282 ± 105 P = .44
Intraop hypotension (SBP < 90) 88% 27% P < .001
Ann Surg (2009) 249:173.Slide 26
MULTIFACTORIAL MODEL OF DELIRIUM
JAMA (1996) 275:852.
High Vulnerability
Low Vulnerability
Noxious Insult
Less Noxious Insult
Predisposing Factors/Vulnerability
Precipitating Factors/Insults
High Risk
Low Risk
DELIRIUM
Slide 27
WHY IS DELIRIUM IMPORTANT?
DELIRIUM
Most common postoperative complication in the elderly
Closely related to adverse outcomes
Potentially preventable, and there is room to improve treatment
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DELIRIUM AND POOR OUTCOMES
• Increased length of hospital stay
• Increased hospital cost
• Increased need for institutionalization
• Increased mortality
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OUTCOMES AND DELIRIUM: TRAUMA ICU
DELIRIUM
Present(n = 41)
Absent(n = 28)
ICU stay, days 8 ± 1 2 ± 1 P < .01
Hospital stay, days 15 ± 2 6 ± 1 P < .01
Discharge institutionalization 85% 44% P < .01
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OUTCOMES AND DELIRIUM: VA
DELIRIUM
Present(n = 64)
Absent(n = 80)
ICU stay, days 9.7 ± 8.0 4.6 ± 2.1 P < .001
Hospital stay, days 16.3 ± 10.9 7.9 ± 3.9 P < .001
Hospital cost, $1,000s 50.1 ± 33.6 31.6 ± 14.1 P < .001
Institutionalization 33% 1% P < .001
Ann Surg (2009) 249:173.Slide 31
MORTALITY AND DELIRIUM
DELIRIUM
Present(n = 64)
Absent(n = 80)
In-hospital mortality 5% 0% P = .086
30-day mortality 9% 1% P = .045
6-month mortality 20% 3%a P = .001
a n=78 (2 patients lost to 6-month follow-up)
Ann Surg (2009) 249:173.Slide 32
MOTOR SUBTYPES OF DELIRIUM
• A spectrum of psychomotor behavior is found in delirium
• Delirium motor subtypes: Hypoactive Hyperactive Mixed type
J Neuropsychiatry Clin Neurosci (2000) 12:51. Slide 33
RICHMOND AGITATION-SEDATION SCORE+4 Combative+3 Very agitated+2 Agitated+1 Restless 0 Alert/calm-1 Drowsy-2 Light sedation-3 Moderate sedation-4 Deep sedation-5 Unarousable
JAMA (2003) 289:2983. Am J Resp Crit Car Med (2002) 166:1228. Slide 34
MOTOR SUBTYPES OF DELIRIUM
+4 Combative+3 +2 +1 Restless 0 Alert/calm-1 Drowsy-2 -3 -4 -5 Unarousable
JAMA (2003) 289:2983. Am J Resp Crit Car Med (2002) 166:1228.
HYPERACTIVE
HYPOACTIVE
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MOTOR SUBTYPES OF DELIRIUM
+4 Combative+3 +2 +1 Restless 0 Alert / Calm-1 Drowsy-2 -3 -4 -5 Unarousable
JAMA (2003) 289:2983. Am J Resp Crit Car Med (2002) 166:1228.
MIXED
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MOTOR SUBTYPES OF DELIRIUM: INCIDENCE
Post-Op SICU Medical ICU Trauma ICUHypoactive 66% 44% 46%
Hyperactive 1% 2% 15%
Mixed type 33% 55% 39%
JAGS (2006) 54:479.Ann Surg (2009) 249:173.Am J Surg (2008) 196:864. Slide 37
MOTOR SUBTYPES OF DELIRIUM: OUTCOMES
DVAMC
MOTOR SUBTYPE
No deliriumn = 98
Mixedn = 23
Hypoactiven = 50
Age, years 60 ± 6 65 ± 9 71 ± 9 P = .001
6-month mortality 3% 9% 32% P = .041
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MOTOR SUBTYPES OF DELIRIUM:ADVERSE EVENTS
DVAMC
MOTOR SUBTYPE
Hypoactive(n = 8)
Mixed(n = 11)
Pulled line/tube 25% 82% P = .024
Sacral decubitus ulcer 75% 0 P = .001
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WHY IS DELIRIUM IMPORTANT?
DELIRIUM
Most common postoperative complication in the elderly
Closely related to adverse outcomes
Potentially preventable, and there is room to improve treatment
Slide 40
PREVENTING DELIRIUM IN THE HOSPITALIZED ELDERLY
• Hypothesis: Reducing the number of risk factors for delirium will prevent delirium in hospitalized elderly patients
• Methods• 852 hospitalized medical patients• Older than 70 years• Compare effectiveness of reducing the risk
factors for delirium to standard of care
NEJM (1999) 340:669. Slide 41
NEJM (1999) 340:669.
MULTICOMPONENT INTERVENTIONSTO PREVENT DELIRIUM
Risk factors Intervention
• Cognitive impairment
• Orientation protocol
• Sleep deprivation • Sleep enhancement
• Immobility • Early mobilization
• Visual impairment • Early vision correction
• Hearing impairment • Hearing protocol
• Dehydration • Change BUN/Cr ratio
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PREVENTING DELIRIUM IN THE HOSPITALIZED ELDERLY
NEJM (1999) 340:669.
STUDY GROUP
Intervention Usual care
Incidence of delirium 9.9% 15.0% P = .02
Total days of delirium 105 161 P = .02
Episodes of delirium 62 90 P = .03
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PREVENTING DELIRIUM IN THE HOSPITALIZED ELDERLY
NEJM (1999) 340:669.
Conclusion
Implementing supportive protocols to patients at high risk of developing delirium can prevent the occurrences and reduce the duration of delirium
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IDENTIFIABLE CAUSES OF DELIRIUM
DELIRIUMS (mnemonic) DEL I R I U MSS
rugs (anticholinergics, polypharmacy)motional (depression)ow PO2 states (MI, PE, anemia, CVA) nfection (sepsis)etention of urine or stoolctal states (seizure, post-ictal)ndernutrition/underhydration etabolic (electrolytes, glucose)ubdural (acute CNS processes) ensory (impaired vision or hearing)
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MEDICAL EVALUATION OF DELIRIUM
H&P evaluation• Mental status• Neuro exam• History of substance
abuse• Vital signs• Review of medications
Laboratory tests• CBC• Glucose• Electrolytes• BUN/Cr• UA• O2 Saturation
Clin Med (2006) 6:303.Slide 46
IDENTIFIABLE CAUSES OF DELIRIUM
0
20
40
60
80
100
No identifiablecause
Identifiablecause
Delirium,%
Ann Surg (2009) 249:173.Slide 47
THE BIPHASIC DISTRIBUTION OF POSTOPERATIVE DELIRIUM
0
5
10
15
20
25
30
1 3 5 7 9 112 4 6 8 10 12
Postoperative day
No identifiable cause of delirium
Delirium due to an identifiable causeNumber of subjects
Ann Surg (2009) 249:173.Slide 48
Haloperidol 2 mg q20 min (while agitation persists)
OR
Degree of agitation Initial dose of haloperidolPO, IM or IV
Mild 0.252 mg
Moderate 24 mg
Severe 48 mg
PHARMACOLOGIC TREATMENT: ICU
Crit Care Med (2002) 30:119. Slide 49
PHARMACOLOGIC TREATMENT: ICU
• Maintenance dose 50% of total loading dose is the maintenance
dose, divided every 68 hours daily Continue maintenance dose for 2448 hours
before tapering
• Taper maintenance dose by 20%30% daily until off
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PHARMACOLOGIC TREATMENT: ICU
Haloperidol AdministrationControl Moderate agitation
2:00 AM – 2 mg IV2:30 AM – 2 mg IV3:00 AM – 2 mg IV3:30 AM – Agitation controlled
Maintain 1 mg TID IV or PO 24 hoursKeep daily dose for 24–48 hours
Taper 0.5 mg PO BID for 24 hr, then DC
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• General recommendation Haloperidol 12 mg q24 hr PRN May be administered PO, IM, or IV
• For elderly patients Haloperidol 0.250.5 mg q4 hr PRN
PHARMACOLOGIC TREATMENT: WARD
American Psychiatric Association. Practice Guideline for Treatment of Patients with Delirium (1999). Slide 52
WHY IS DELIRIUM IMPORTANT?
DELIRIUM
Most common postoperative complication in the elderly
Closely related to adverse outcomes
Potentially preventable, and there is room to improve treatment
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