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CAM-ICU Basics
ICU Delirium and Cognitive Impairment Study Group
www.ICUdelirium.org
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What is Delirium?
Delirium is a common clinical syndrome characterized b
Inattention
Acute cognitive
dysfunction
Pathophysiology: Disruption of neurotransmission (drug action,
inflammation, acute stress response)
Delirium: Think rapid onset, inattention, clouding of consciousne(bewildered), fluctuation
Dementia: Think gradual onset, intellectual impairment, memorydisturbance, personality/mood change, no conscious clouding
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HyperactivePatient may be combative with agitation that may
require sedation (is diagnosed more frequently).
Subtypes of Delirium
HypoactivePatient may be quiet and even peaceful, despite
cognitive impairment. More difficult to assess.
Mixed
Combination of both types
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Why monitor for Delirium?
50-80% of ventilated patients develop delirium 20-50% of lower severity ICU patients develop
delirium
Over 40,000 ventilated patients are deliriousevery day
Delirium leads to increased mortality, longerhospital stay, poorer recovery, higher costs ofhealthcare, long-term neurocognitive problems.
Ely EW JAMA 2001;286,2703-2710
Ely EW CCM 2001;29,1370-79
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ICU Delirium:
The Canary in the Coal Mine
Under recognized form of organ
dysfunction
3-fold increase in mortality at 6
months
Each DAY a patients is delirious =
10% INCREASE in risk of death
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Delirium in the ICUClinical Value of RASS/CAM-ICU Measurement
Stimulates thinking of Rx:
Delirium recognition is a Burglar Alarm for us
(early sign of danger)
Forces us to consider treatable causes earlier
Utilize nonpharmacologic interventions
Do NOT automatically link delirium monitoring with
a specific drug treatment
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www.ICUdelirium.org
Educational Delirium Website
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A Two Step Approach to Assessing
Consciousness
Step 1
Level of Consciousness (arousal): RASS
Step 2Content of Consciousness (delirium): CAM-ICU
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Step 1: LOC Assessment
Assess for arousal
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Step 1: Arousal Assessment (RASS
+3
+2
+1
0
- 1
- 2
- 3
- 4
- 5
Richmond
Agitation-Sedation
Scale (RASS)
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Step 2: Content Assessment
Assess for Delirium
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Confusion Assessment Method
for the ICU (CAM-ICU)
Feature 1: Acute change orfluctuating course of mental
status
And
Feature 2: Inattention
And
Feature 3: Altered level ofconsciousness
Feature 4: DisorganizedThinking
Or
Inouye, et. al. Ann Intern Med 1990; 113:941-948.1
Ely, et. al. CCM 2001; 29:1370-1379.4
Ely, et. al. JAMA 2001; 286:2703-2710.5
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Feature 1: Alteration/Fluctuation
in Mental Status
Is the pt different than his/herbaseline mentalstatus?
OR
Has the patient had any fluctuation in mental
status in the past 24 hours (eg fluctuating
RASS, GCS, previous delirium assessments,
etc)
Present: If either question is YES.
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Feature 1: Alteration/Fluctuation in
Mental Status
Common Questions:
What if you do not know the patients baseline?
Assume normal unless you have red flags that make
you suspicious
Red Flag: patient came from institution
What about dementia?
Ask family What could she/he do prior to thisillness?
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Feature 2: Inattention
Screening for Attention two options
Letter A test
Letters: S A V E A H A A R T (or numbers)
Say 10 letters (or numbers) and instruct the patient tosqueeze on the letter A (or on a certain number)
Pictures
Similar test with pictures(instructions are in picture packets)
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Feature 2: Inattention
1. Attempt Letters first.
2. If pt is able to perform the Letter test you are sure ofthe results, you are done with Inattention test.
3. If pt is unable to perform the Letter test or you areunsure of the results, use the Pictures.
If you perform both tests, use the Pictures result todetermine if inattention is present.
Inattention Present :If >2 errors
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Feature 2: Inattention
What if the patient only squeezes once and thenfalls back to sleep? orWhat if the patient is too
hyperactive/combative to participate in
squeezing?
Remember what you are assessingAttention This patient is inattentive
If you have to explain the directions more than
twice, start to be suspicious for inattention
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If either Feature 1 or 2 are absent,
Stop
Overall CAM-ICU is Negative
If Features 1 and 2 are present,
Proceed
to Feature 3
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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!
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Feature 4: Disorganized Thinking
Present: If there is >1 error for the combinedquestions + command.
Notes:
If pt is unable to move both arms, for the secondpart 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 patientmisses more than 1 question.
Confusion Assessment Method
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Confusion Assessment Method
for the ICU (CAM-ICU)
Feature 1: Acute change orfluctuating course of mental
status
And
Feature 2: Inattention
And
Feature 3: Altered level ofconsciousness
Feature 4: DisorganizedThinking
Or
Inouye, et. al. Ann Intern Med 1990; 113:941-948.1
Ely, et. al. CCM 2001; 29:1370-1379.4
Ely, et. al. JAMA 2001; 286:2703-2710.5
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Case Studies
C #1 M I
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Case #1: Mr. Icy
45 y/o man, lawyer with no previous memory or attention
problemDx: DKA, Intubated
In the past 24hrs the RASS scores have been -3 to +1.
Step 1: Arousal AssessmentCurrently: Awake and moving around restless in bed, but
not aggressive.
RASS = +1
What do we do next?
C #1 M I
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Step 2: CAM-ICU
- Feature 1:
Is he at his MS baseline?
Fluctuation?
- Feature 2:
Letters = 4 errors
- Feature 3:
RASS = +1- Feature 4
Pos Neg
Feature
1
Feature2
Feature
3
Feature4
Case #1: Mr. Icy
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C #1 M I
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Step 2: CAM-ICU
- Feature 1:
Is he at his MS baseline?
Fluctuation?
Other RASS Scores: -3 +1
- Feature 2:
Letters = 4 errors
- Feature 3:
RASS = +1- Feature 4
Pos Neg
Feature
1
X
Feature2 X
Feature
3
X
Feature4
Case #1: Mr. Icy
Case #2 Mrs Dapple
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Case #2 Mrs. Dapple
75 y/o female
Dx: Severe pneumonia requiring prolonged mechanicalventilation and difficulty weaning
In past 24 hours: RASS scores -3 to -1
Step 1: Arousal Assessment
Eyes closed, but awakens to voice; maintains eye contact fo>10 seconds
RASS = -1
What do we do next?
C #2 M D l
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Step 2: CAM-ICU
- Feature 1:
Is she at her MS baseline?
Fluctuation?
- Feature 2:Letters = 1 error
- Feature 3
- Feature 4
Pos Neg
Feature
1
Feature2
Feature
3
Feature4
Case #2 Mrs. Dapple
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Case #2 Mrs Dapple
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Step 2: CAM-ICU
- Feature 1:
Is he at his MS baseline?
Fluctuation?
RASS Variance: 2- Feature 2:
Letters = 1 error
- Feature 3
- Feature 4
Pos Neg
Feature
1
X
Feature2 X
Feature
3
Feature4
Case #2 Mrs. Dapple
Case # 3 Miss Universe
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Case # 3 Miss Universe
Miss Universe was successfully extubated from the
Vent at 0800. All sedation and analgesia had beenstopped earlier in the AM. Yesterday evening andlast night she had periods of agitation with adocumented RASS range of -1 to +3.
Step 1: Arousal Assessment
Pt alert and calm.
RASS = 0
What do we do next?
Case #3: Miss Universe
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Step 2: CAM-ICU
- Feature 1:
Is she at her MS baseline?
Fluctuation?
- Feature 2:
Letters = 3 errors, but you arent
sure
Pictures = 4 errors
- Feature 3:
RASS = 0
- Feature 4
Pos Neg
Feature
1
Feature
2
Feature
3
Feature
4
Case #3: Miss Universe
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Case #3: Miss Universe
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Step 2: CAM-ICU
- Feature 1:
Is she at her MS baseline?
Fluctuation?
RASS Variance = 4
- Feature 2:Letters = 3 errors, but youarent sure.
Pictures = 4 errors
- Feature 3:
RASS = 0
- Feature 4
Pos Neg
Feature
1
X
Feature
2
X
Feature
3
X
Feature
4
Case #3: Miss Universe
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Case #3: Miss Universe
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Step 2: CAM-ICU
- Feature 1:Is she at her MS baseline?
Fluctuation?
- Feature 2:
Letters = 3 errors, but you arent
sure.Pictures = 4 errors
- Feature 3:
RASS = 0
- Feature 4:
Answered half the questions wrongUnable to perform 2-step command
3 errors
Pos Neg
Feature
1
X
Feature
2
X
Feature
3
X
Feature
4
X
Case #3: Miss Universe
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What if Miss Universe had
gotten all 4 of her
questions right?
Case #3: Miss Universe
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Step 2: CAM-ICU
- Feature 1:
Is she at her MS baseline?
Fluctuation?
- Feature 2:
Letters = 3 errors, but you arent
sure.
Pictures = 4 errors
- Feature 3:
RASS = 0
- Feature 4:
Answered all 4 questions correct
Unable to perform 2-step command
1 error
Pos Neg
Feature
1
X
Feature
2
X
Feature
3
X
Feature
4
X
Case #3: Miss Universe
Case # 4 Mr. Bubble
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Case # 4 Mr. Bubble
Mr. Bubble works as a traveling salesman, and has been full
independent until admission. He is admitted with acutepancreatitis. His sedatives were turned off 30 minutes agofor a Spontaneous Awakening Trial (SAT).
Step 1: Arousal Assessment
Eyes closed, moves head to verbal stimulation, no eyecontact
RASS = -3
What do we do next?
Case #4: Mr. Bubble
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Step 2: CAM-ICU
- Feature 1:
Is he at his MS baseline?
Fluctuation?
- Feature 2:
Letters= no squeeze for any letters
- Feature 3:
RASS = -3
- Feature 4:
Pos Neg
Feature
1
Feature
2Feature
3
Feature
4
Case #4: Mr. Bubble
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Case #4: Mr. Bubble
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Step 2: CAM-ICU
- Feature 1:
Is he at his MS baseline?
Fluctuation?
- Feature 2:
Letters= no squeeze for any letters
- Feature 3:
RASS = -3
- Feature 4:
Pos Neg
Feature
1
X
Feature
2
X
Feature
3
X
Feature
4
Case # ubb e
Confusion Assessment Method
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for the ICU (CAM-ICU)
Feature 1: Acute change orfluctuating course of mental
status
And
Feature 2: Inattention
And
Feature 3: Altered level of
consciousness
Feature 4: Disorganized
ThinkingOr
Inouye, et. al. Ann Intern Med 1990; 113:941-948.1
Ely, et. al. CCM 2001; 29:1370-1379.4
Ely, et. al. JAMA 2001; 286:2703-2710.5
Stop and THINK
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p
Do any meds need to be stopped
or lowered?
Especially considersedatives
Is patient on minimal amountnecessary?
Daily sedation cessation
Targeted sedation plan
Assess target daily
Do sedatives need to be changed?
Remember to assess for pain!
Toxic Situations CHF, shock, dehydration New organ failure (liver/kidney)
Hypoxemia
Infection/sepsis (nosocomial),Immobilization
Nonpharmacologic interventions Hearing aids, glasses, reorient,
sleep protocols, music, noise control,
ambulation
K+ or electrolyte problems
Consider antipsychotics after evaluating etiology & risk factors
N h l i I t ti
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Nonpharmacologic Interventions
Environmental changes (e.g. noise
reduction)
Sensory aids (e.g. hearing aids, glasses)
Reorientation and stimulation
Sleep preservation & enhancement
Exercise and mobility
RASS
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RASS
(N/D & reason if not done)
CAM-ICU Feature 1
(MS change or fluctuation)
Absent
Present
CAM-ICU Feature 2
(Inattention)
Absent
Present
CAM-ICU Feature 3
(Altered LOC)
Absent
Present
CAM-ICU Feature 4
(Disorganized thinking)
Absent
Present
Overall CAM-ICU1 + 2 + [3 or 4] = CAM-ICU+
Negative
PositiveUTA (RASS -4/-5 only)
Not done:________
Brain Road Map for Rounds
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Brain Road Map for Rounds(Script for Interdisciplinary Communication)
Skipping any of these steps could leave the clini cal team wanting more inf ormatio
Investigate (Ask these questions) Report (only takes 10 seconds)
Where is the patient going? Target sedation score (RASS, SAS, etc)
Where is the patient now?Actual sedation score (RASS, SAS, etc)
Delirium assessment (CAM-ICU, ICDSC, etc
How did they get there? Drug exposures
Case Study - Day 1
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Female, age 61
Hx: hypertension
CC: altered mental status, pneumonia
Dx: Septic shock, ARDS, acute renal failure
Vent settings: A/C rate 16, TV 400, PEEP 14, FiO2 70%
Infusions: Levophed 8 mcg/min, vasopressin 0.4 units/min, insulin gtt, IVF
Assessment: Target RASS -3, actual RASS +1 to +2, displaying vent
asynchrony, CAM-ICU positive, bilateral rhonchi, pulses present
Drugs: Receiving intermittent boluses of fentanyl and midazolam
What next?
Review your Road Map
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Review your Road Map
Report:
Action:
What do you do now?
Where is the patient going? Target sedation score: RASS -3
Where is the patient now?Actual sedation score: RASS +1 to +2
Delirium: CAM-ICU positive
How did they get there? Drug exposures: Intermittent fentanyl & midazolam
Case Study Day 3
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y y
Vent settings: AC rate 16, TV 400, PEEP 6, FiO2 40%
Infusions: propofol 40 mcg/kg/hr, Levophed 4 mcg/min,
vasopressin 0.4 units/min, insulin gtt, IVF
Drugs: Intermittent fentanyl for analgesia
Assessment: Target RASS -1, actual RASS -3, CAM-ICU
positive, not breathing over vent set rate, bilateral rhonchi,
pulses present, moving extremities spontaneously
What next?
Review your Road Map
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Review your Road Map
Report:
Action:
What do you do now?
Where is the patient going? Target sedation score: RASS -1
Where is the patient now?Actual sedation score: RASS -3
Delirium: CAM-ICU positive
How did they get there?Drug exposures: Propofol infusion 40 mcg/kg/min &
intermittent fentanyl for pain
Case Study Day 5
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y y
Vent settings: Pressure support 5, PEEP 5, 40% and tolerating
spontaneous breathing trial
Infusions: Levophed/vasopressin off, insulin gtt, IVF, propofol
off
Septic shock resolved, passed SAT/SBT
Assessment: Target RASS 0, actual RASS 0, CAM-ICU positiv
lungs clear, moves all extremities
What next?
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Questions?
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www.ICUdelirium.org
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