the delirious icu patient
TRANSCRIPT
The Delirious ICU Patient
Timothy D. Girard, MD, MSCITimothy D. Girard, MD, MSCIICU Delirium and Cognitive Impairment Study Group
Division of Allergy, Pulmonary, & Critical Care Medicine
Center for Health Services Research
Vanderbilt University School of Medicine
VA Tennessee Valley GRECC
Nashville, Tennessee
Disclosure
• Hospira, Inc.
• Pfizer, Inc.
What’s
1. What is delirium?
2. How can I diagnose it?What’s
ahead
2. How can I diagnose it?
3. Why does it matter?
4. How should I treat it?
What is delirium?
Consciousness CognitionConsciousness Cognition
“a disturbance of consciousness that is
accompanied by a change in cognition that
di-'lir-E-&m
accompanied by a change in cognition that
cannot be better accounted for by a preexisting
or evolving dementia”
– American Psychiatric Association
Estimated delirium rates
Mechanically ventilated ICU patients
26%-50%
Non-ventilated ICU patients
10%-25%
Patel R, et al. Crit Care Med 2009;37:825-32
Ely, ‘01
McNicoll, ‘03
Ely, ‘04
McNicoll, ‘05
Micek, ‘05
Thomason, ‘05 Medical
ICUs
(40%-80%)
Pisani, ‘07
Riker, ‘09
Girard, ‘08
0 20 40 60 80 100
Bergeron, ‘01
Skrobik, ‘04
Ouimet, ‘07
Pandharipande, ‘07
Actual Prevalence of Delirium
Mixed
ICUs
(10%-40%)
Plaschke, ‘07
Lat, ‘09
Guenther, ‘09
60
80
100
%
Delirium Subtypes in the ICU
0
20
40
Hypoactive Mixed Hyperactive
%
Peterson JF, et al. J Am Geriatr Soc 2006;54:479-84
11. Definition
2. Prevalence1Summary
2. Prevalence
3. Subtypes
How can I diagnose ICU delirium?
1 2
Which diagnostic method?
41% - none
37% - clinical assessment
14% - Confusion Assessment Method-ICU14% - Confusion Assessment Method-ICU14% - Confusion Assessment Method-ICU
2% - Delirium Rating Scale
2% - Mini Mental State Examination
1% - Delirium Screening Checklist
14% - Confusion Assessment Method-ICU
01% - Delirium Screening Checklist
Patel R, et al. Crit Care Med 2009;37:825-32
Feature 1
Feature 2
and
Confusion Assessment Method-ICU
Acute onset of changes or
fluctuations in the course
of mental status
Feature 3
Feature 2
Feature 4
and either
or
Ely EW, et al. JAMA 2001; 286:2703-10
Inattention
Altered level of
consciousnessDisorganized thinking
Intensive Care
Delirium Screening Checklist (ICDSC)
� Altered level of consciousness
� Inattentiveness
� Disorientation
� Hallucination-delusion-psychosis
≥4 = delirium
Bergeron N, et al. Intensive Care Med 2001; 27:1297-1304
� Hallucination-delusion-psychosis
� Psychomotor agitation or retardation
� Inappropriate speech or mood
� Sleep/wake cycle disturbance
� Symptom fluctuation
60
80
100
%
Validity of ICU Delirium Assessment Tools
Sensitivity Specificity
0
20
40
CAM-ICU
%
Luetz A, et al. Crit Care Med 2010;38: [ePub ahead of print]
Nu-DESC DDS ICDSC*
*Van Eijk MM, et al. Crit Care Med 2009;37:1881-5
21. Challenges
2. Diagnostic instruments2Summary
2. Diagnostic instruments
Why is ICU delirium important?
5X self-extubation
Dubois MJ, et al. Intensive Care Med 2001;27:1297-1304
$21,289
$48,666
$34,007$34,976
$30,000
$40,000
$50,000
$60,000
Me
dia
n C
ost
per patient = $9,000ICU Cost
$21,289 $19,702
$11,870
$10,000
$20,000
$30,000
Mild Moderate Severe
Delirium Severity Index
Me
dia
n C
ost
Milbrandt EB, et al. Crit Care Med 2005;32:955-62
Surv
iva
l (%
)
60
80
100
Never Delirious (n=41)
Ever Delirious (n=183)
3X
Delirium and Mortality
0 1 2 3 4 5 6
Months
Surv
iva
l (%
)
0
20
40
Persistently Comatose (n=51)
HR, 3.2; 95% CI, 1.4-7.7; p=0.008
Ely EW, et al. JAMA 2004;291:1753-62
3X death
49-yr-old women with sepsis/ARDS
>3 years later
30
40
50
60
Co
gn
itiv
e P
erf
orm
an
ce
(Pre
dic
ted
Me
an
T-S
co
re)
Delirium and Post-ICU Cognition
0 5 10 15 20
10
20
30
0
Co
gn
itiv
e P
erf
orm
an
ce
(Pre
dic
ted
Me
an
T
Days of Delirium among ICU Survivors
*Adjusted β -5.2, 95% CI -9.8 to -0.7
p=.02
Girard TD, et al. Unpublished data from the ABC Trial
3
1. 5X self-extubation
2. 2X hospital stays
3. $9000 ICU costs3Summary
3. $9000 ICU costs
4. 3X 6-month mortality
5. More cognitive impairment
How should I treat ICU delirium?
Treat pain with opioids
Morrison RS, et al. J Geront A Biol Sci Med 2003;58:76-81
Is intervention needed?
yes – 92%yes
no
– 92%
– 1%
Patel R, et al. Crit Care Med 2009;37:825-32
70
80
90
100
Pre
vale
nce
of
De
liri
um
(%
)Lorazepam and Delirium
50
60
70
No Drug
Lorazepam Dose (mg)
Log scale
Original scale
0-1 1-2 2-3 3-4 4+
0-2.7 2.7-7.4 7.4-20 20-55 55+
Pre
vale
nce
of
De
liri
um
(%
)
Pandharipande PP, et al. Anesthesiology 2006;104:21-6
of
Be
nzo
dia
zep
ine
s
40
50
60
70
ABC Trial - Benzodiazepines
Control
Protocol
Study Day
Da
ily
Do
se o
f B
en
zod
iaze
pin
es
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
01
02
03
0
Effect of Wake Up and Breathe on
Brain Function
10
12
14
16p=.002
p=.50
Control Protocol
Coma
0
2
4
6
8
10
Control Protocol
Delirium
Days
Girard TD, et al. Lancet 2008;371:126-34
50
60
70
80
90
100
Co
ma
tose
Pa
tie
nts
(n
) Protocol
Control
Effect of Wake Up and Breathe
on Coma
0
10
20
30
40
50
1 2 3 4 5 6 7 8 9 10111213141516171819202122232425262728
Co
ma
tose
Pa
tie
nts
(n
)
Study Day
Girard TD, et al. Unpublished data from the ABC
Trial.
30
40
50
60
Pa
tie
nts
(n
) Protocol
Control
Effect of Wake Up and Breathe
on Delirium
0
10
20
30
1 2 3 4 5 6 7 8 9 10111213141516171819202122232425262728
De
liri
ou
s P
ati
en
ts (
Study Day
Girard TD, et al. Unpublished data from the ABC
Trial.
Which drug for delirium?
86% - haloperidol
37% - atypical antipsychotics
35% - benzodiazepines35% - benzodiazepines
13% - propofol
8% - opiates
5% - dexmedetomidine
Patel R, et al. Crit Care Med 2009;37:825-32
HaloperidolInitial: 2 mg iv
Double the dose q15-20 min until calm
Then: Continue q4-6 hrs for 2-3 days
Taper for 2-3 days
Jacobi J, et al. Crit Care Med 2002;30:119-41
WarningsQT prolongation
EPS/NMS
Esophageal dysmotility
Trial of Antipsychotics for ICU Delirium
6
7
8
De
liriu
m I
nd
ex
Sco
re
Haloperidol
Olanzapine
3
4
5
1 2 3 4 5
Days
De
liriu
m I
nd
ex
Sco
re
Skrobik YK, et al. Intensive Care Med 2004;30:444-9
Antipsychotics – Delirium and ComaP
ati
en
ts w
ith
ou
t D
elir
ium
or
Co
ma
(%
)
60
80
100
p=0.66
1 5 10 15 20
Day
Pa
tie
nts
wit
ho
ut
De
liriu
m o
r C
om
a (
0
20
40
Girard TD, et al. Crit Care Med 2010;38:428-37
Haloperidol (n=35)
Ziprasidone (n=32)
Placebo (n=36)
Quetiapine – Resolution of DeliriumP
ati
en
ts w
ith
De
liriu
m (
%)
60
80
100
Quetiapine (n=18)
Placebo (n=18)
p=0.001
0 2 4 6 10Day
Pa
tie
nts
wit
h D
elir
ium
(
0
20
40
Devlin JW, et al. Crit Care Med 2009 Nov 18. [Epub ahead of print]
8
Which drug for delirium?
86% - haloperidol
37% - atypical antipsychotics
35% - benzodiazepines35% - benzodiazepines
13% - propofol
8% - opiates
5% - dexmedetomidine
Patel R, et al. Crit Care Med 2009;37:825-32
68
10
12
p=0.01 p=0.09 p<0.001
Dexmedetomidine vs. Lorazepam
Delirium/Coma-Free Days
02
46
Delirium-Free Days Coma-Free Days
Dexmedetomidine
Lorazepam
Pandharipande PP, et al. JAMA 2007;298:2644-53
50
60
70
80
90
Pa
tie
nts
(%
)
Dexmedetomidine Lorazepam
Daily Risk of Delirium in MENDS
p=0.02
0
10
20
30
40
50
1 2 3 4 5 6
De
liri
ou
s P
ati
en
ts
Study Day
Pandharipande PP, et al. Unpublished data from MENDS
40
50
60
70
80
Pa
tie
nts
(%
)
Dexmedetomidine Midazolam
Daily Risk of Delirium in SEDCOM
p<0.001
0
10
20
30
40
Baseline 1 2 3 4 5 6
De
liri
ou
s P
ati
en
ts
Study Day
Riker RR, et al. JAMA 2009;301:489-499
Dexmedetomidine – Extubation
p=.01
60
80
100
Pa
tie
nts
Me
cha
nic
all
y V
en
tila
ted
(%
)
Midazolam
Riker RR, et al. JAMA 2009;301:489-499
0
20
40
Pa
tie
nts
Me
cha
nic
all
y V
en
tila
ted
(%
)
Days0 2 4 6 8
Dexmedetomidine
Reduce immobility
Promote consciousness
Photo by Chris Hartlove for The New York Times
Outcome* Early PT/OT Control p
Independent functional status
at discharge, % 59% 35% 0.02
Barthel Index score at discharge 75 [7.5-95] 55 [0-85] 0.05
ICU-acquired paresis at discharge 31% 49% 0.09
Ventilator-free days 23.5 [7.4-25.6] 21.1 [0-23.8] 0.05
Effect of Early Mobility on Outcomes
ICU delirium, days 2.0 [0-6.0] 4.0 [2.0-7.0] 0.03
ICU length of stay, days 5.9 [4.5-13.2] 7.9 [6.1-12.9] 0.08
Hospital length of stay, days 13.5 [8.0-23.1] 12.9 [8.9-19.8] 0.93
In-hospital mortality 18% 25% 0.53
*Median [IQR] or %
Schweickert WD, et al. Lancet 2009;373:1874-82
4
1. Prevention
2. Diagnose etiology
3. Treat pain
4. Avoid benzodiazepines4Summary
4. Avoid benzodiazepines
5. Antipsychotics
6. Dexmedetomidine
7. Early mobility
Looking
1. What is delirium?
2. How can I diagnose it?Looking
back
2. How can I diagnose it?
3. Why does it matter?
4. How should I treat it?