Confused in the ICU

1. Jud Mehl, CA-2 Tulane Dept. of Anesthesiology Confused in the ICU

2. Called to the PACU • 73 yo female • s/p right THA, extubated • PMHX: HTN, DM, RA • PSHX: TKA, ex-lap with LOA, appy • Allx: PCN, Sulfa • Meds: Pravachol, Lisinopril, Coreg, Morphine, Zofran, Benedryl;

3. Uneventful intraop course • HR 104 • RR 24 • BP 163/104 • Gas: 7.32 / 41 / 87 on room air

4. And she is angry • Confused, cursing • Punched one of the nurses • “Will 'come to' for a minute, but then starts talking nonsense” • She was just a nice, old, church-going lady several hours ago

5. So now what? • Differential diagnosis? • Tests?

6. Well, its all negative • So, what do we have? • A screaming old lady • A nurse with a black eye • Another nurse who doesn't understand why you cant just give her some ativan. Didn't they teach you anything in med school? You are not advocating for your patient, doctor !!

7. Delirium is NOT Agitation • Agitation • Excess motor activity. Nonspecific and may be caused by a myriad of problems post-op. • May result from pain or anxiety, both of which are easy to treat. Agitated patients do not necessarily have cognitive impairment

8. Prodromal phase Lucid intervals Psychomotor abnormalities Impaired memory Disturbed sleep/wake Dysorientation Dysgraphia Disorganized thinking/speech Delirium: acute brain failure • Acute cognitive dysfunction • Hyperactive or hypoactive • Fluctuates over the course of the day • Not better accounted for by dementia

9. Rule out organic causes • Drug / Alcohol intoxication or withdrawl • HTN encephalopathy • Hypoglycemia • Hypoperfusion (shock) • Hypoxemia • Intracranial bleed • Meningitis or encephalitis

10. A quick shout-out to the Noss • Post-op delirium develops between POD 2-7 • Correlates with the progression of the post op systemic inflammatory response • Hypothesized delirium is an increase in inflammatory cytokines acting as neurotoxin

11. Who is at risk ? • Age > 70 • EtOH abuse history • Abnormal sodium, potassium or glucose levels • Hypoalbuminemia • Hip fracture surgery • Non-cardiac thoracic surgery • Aortic aneurysm surgery • Vascular surgery patients have twice the incidence of other elective surgery pts

12. What percentage of non-ventilated ICU patients develop ICU delirium? A: 10 % B: 25% C: 35% D: 50%

13. What percentage of ventilated ICU patients develop delirium? A: 25% B: 50% C: 75% D: 80%

14. How prevalent is ICU delirium? • 50 % of non-ventilated ICU patients • Thomason JWW, Shintani A, Paterson JF, et al. Intensive care unit delirium is an independent predictor of longer hospital stay: a prospective analysis of 260 nonventilated patients. Crit Care 2005; 375-381 • 80% in intubated patients • Ely EW, Shintani A, Truman B, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 2004; 291:1753-1762 • And yet, only 25-50% of intensivists routinely screen for delirium.

15. OK, so how do we screen for it? • Multiple assessment models • Ramsay scale • Richmond Agitation Scale • ICU Delirium Screening checklist • Cognitive Test for Delirium • Neelon and Champagne Confusion Scale • CAM-ICU

16. CAM-ICU

17. How much do we really know? • Can we prevent it? • Evidence is lacking and conflicting • 'Common sense measures' vs. dogma • Treatment of infections • Sleep wake cycles • Early ambulation • Frequent orientation • Avoid restraints

18. Here is what the literature shows: • 1. ETT, drains, catheters and pain all appear to be triggers • 2. Delirium in the PACU is highly correlated with continued postop delirium. • 3. GABA is probably not good • 4. Neuraxial offers no significant benefit over opiates

19. A few interesting studies • Morrison RS, Magaziner J, Gilbert M, et al. Relationship between pain and opioid analgesics on the development of delirium following hip fracture. J Gerontol A Biol Sci Med Sci 2003; 58:76-81 Results. Eighty-seven of 541 patients (16%) became delirious. Among all subjects, risk factors for delirium were cognitive impairment (relative risk, or RR, 3.6; 95% confidence interval, or CI, 1.8–7.2), abnormal blood pressure (RR 2.3, 95% CI 1.2–4.7), and heart failure (RR 2.9, 95% CI 1.6–5.3). Patients who received less than 10 mg of parenteral morphine sulfate equivalents per day were more likely to develop delirium than patients who received more analgesia (RR 5.4, 95% CI 2.4–12.3). Patients who received meperidine were at increased risk of developing delirium as compared with patients who received other opioid analgesics (RR 2.4, 95% CI 1.3–4.5). In cognitively intact patients, severe pain significantly increased the risk of delirium (RR 9.0, 95% CI 1.8–45.2). Conclusions. Using admission data, clinicians can identify patients at high risk for delirium following hip fracture. Avoiding opioids or using very low doses of opioids increased the risk of delirium. Cognitively intact patients with undertreated pain were nine times more likely to develop delirium than patients whose pain was adequately treated. Undertreated pain and inadequate analgesia appear to be risk factors for delirium in frail older adults

20. A few interesting studies • Sieber FE, Zakriya KJ, Gottschalk A, et al. Sedation depth during spinal anesthesia and the development of postoperative delirium in the elderly patient undergoing hip fracture repair. Mayo Clinic Proc; 85 18-26 • RESULTS: From April 2, 2005, through October 30, 2008, a total of 114 patients were randomized. The prevalence of postoperative delirium was significantly lower in the light sedation group (11/57 [19%] vs 23/57 [40%] in the deep sedation group; P=.02), indicating that 1 incident of delirium will be prevented for every 4.7 patients treated with light sedation. The mean ± SD number of days of delirium during hospitalization was lower in the light sedation group than in the deep sedation group (0.5±1.5 days vs 1.4±4.0 days; P=.01). • CONCLUSION: The use of light propofol sedation decreased the prevalence of postoperative delirium by 50% compared with deep sedation. Limiting depth of sedation during spinal anesthesia is a simple, safe, and cost-effective intervention for preventing postoperative delirium in elderly patients that could be widely and readily adopted.

22. A few interesting studies • Hudetz JA, Patterson KM, Iqbal Z, et al. Ketamine attenuates delirium after cardiac surgery with cardiopulmonary bypass. J Cardiothoracic Vasc Anesthesia 2009 • Delirium was assessed by using the Intensive Care Delirium Screening Checklist before and after surgery. Serum C-reactive protein concentrations were determined before and 1 day after surgery. The incidence of postoperative delirium was lower (p = 0.01, Fisher exact test) in patients receiving ketamine (3%) compared with placebo (31%). Postoperative C-reactive protein concentration was also lower (p < 0.05) in the ketamine-treated patients compared with the placebo-treated patients. The odds of developing postoperative delirium were greater for patients receiving placebo compared with ketamine treatment (odds ratio = 12.6; 95% confidence interval, 1.5-107.5; logistic regression). • Conclusions • After cardiac surgery using cardiopulmonary bypass, ketamine attenuates postoperative delirium concomitant with an anti-inflammatory effect.

23. Pharmacologic options • Benzos? • Haldol • - Butyrophenone D2 agonist • - “Go-to” drug, though not well studied in delirium • - associated with neuroleptic malignant syndrome • - may redose every 20 min

24. Max dose of Haldol? • A: 5 mg • B: 10 mg • C: 0.3 mg/kg • D: 1 mg/kg

25. Other drugs Zyprexa (olanzapine) prophylaxis reduced incidence, but not severity or duration of delirium Cholinesterase inhibitors studied, but increase mortality for delirium patients Several studies of Precedex show some positive effects in the setting of ICU/PACU delirium

26. True or false? Once delirium is present, treatment will likely improve the patient’s outcome. A: True B:False

27. FALSE • Witlox J, Eurelings LS, de Jonghe JF, et al: Delerium in elderly patients and the risk of postdischarge mortality, institutionalization and dementia. JAMA 2010; 304:443-451 • Meta Analysis including 42 previous studies. • COMMENT • The results of this meta-analysis provide evidence that delirium in elderly patients is associated with an increased risk of death, institutionalization, and dementia, independent of age, sex, comorbid illness or illness severity, and presence of dementia at baseline. Moreover, our stratified models confirm that this association persists when excluding studies that included in-hospital deaths and patients residing in an institution at baseline. • The results of this meta-analysis can be instrumental in patient care. The low rate of survival and the high rates of institutionalization and dementia indicate that older people who experience delirium should be considered an especially vulnerable population (see Figure 3 and Table 2). The results of this meta-analysis gain special clinical relevance considering that delirium in some cases can be prevented.8​ However, once delirium is present, management of delirium has not been found to improve long-term mortality or need for institutional care.67 Thus, identifying patients at high risk for delirium and implementing strategies aimed at preventing delirium may help to avert some of the delirium–associated poor outcomes these patients experience.

28. The big picture Outcomes for elderly patients who experience ICU delirium: • Prolonged ICU/hospital length of stay • Greater use of sedatives • Greater use of physical restraints • Increased hospital costs • Higher mortality rates More likely to be discharged to a place other than home

29. Lastly . . . It is noteworthy that a single occurrence of post-op delirium is not an independent predictor of mortality . . . However Current literature is showing that persistence of delirium is, in fact, a predictor of increased 1-month mortality. One quarter of delirious elderly patients die within 6 months