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DELIRIUM

DELIRIUM. Lindsay Trantum ACNP-BC VUMC Neuroscience ICU. Objectives. By the end of the presentation…… Identify the key features of delirium Identify risk factors for delirium Demonstrate understanding of the treatment plan for delirium. Delirium = Brain Dysfunction.

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DELIRIUM

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  1. DELIRIUM Lindsay Trantum ACNP-BC VUMC Neuroscience ICU

  2. Objectives • By the end of the presentation…… • Identify the key features of delirium • Identify risk factors for delirium • Demonstrate understanding of the treatment plan for delirium

  3. Delirium = Brain Dysfunction • Definition: DSM IV officially defines delirium as a disturbance of consciousness with inattention accompanied by a change in cognition or perceptual disturbance that develops over a short period of time (hours to days) and fluctuates over time • “The 6th vital sign”

  4. Subtypes • Hyperactive • characterized by agitation, restlessness, and emotional lability • Hypoactive • decreased responsiveness, withdrawal, and apathy • Mixed • Periods of hyperactivity and lethargy

  5. Incidence • 60%-80% of mechanically ventilated patients • 50%-70% of non-ventilated patients • Hypoactive delirium = 43.5% • Hyperactive delirium = 1.6% • Mixed delirium = 54.1% (Girard, 2008)

  6. Outcomes • 3 fold increase in 6 month mortality • 1 in 3 delirium survivors develop permanent cognitive impairment • Associated with….. • New nursing home placement • Increased length of stay > 8.0 days • Increased mortality • Increased number of days on the ventilator

  7. Outcomes Continued…. • Associated with……. • Depression/PTSD • Increased risk of aspiration • Increased need for re-intubation • Increased hospital cost: national burden $38 billion/year (Ely, 2004); (Inouye, 1998)

  8. Risk Factors • I WATCH DEATH (many acronyms) • Infection • Withdrawl (Etoh, Sedatives) • Acute Metabolic (renal/liver failure, electrolytes, etc) • Trauma • CNS Pathology • Hypoxia • Deficiencies (B12, thiamine, folate, niacin) • Endocrine (hyper/hypo) • Acute vascular • Toxins • Heavy metals

  9. Pathophysiology • Multi-factorial and poorly understood • Neurotransmitter imbalance • Dopamine (excess) & acetlycholine (depleation) • Results in neuroexcitability and unpredictable synapses • GABA, serotonin, endorphins and glutamate

  10. Pathophysiology • Inflammation • Inflammatory mediators cross blood-brain barrier and increase vascular permeability • Result = decrease cerebral blood flow (CBF) • Platelets, fibrin, neutrophils obstruct CBF (Gunther, 2008)

  11. Monitoring • Step 1: RASS= Richmond Agitation Sedation Scale • RASS goal • Actual RASS • Minimize Sedation • Step 2: CAM-ICU = Confusion Assessment Method • Takes approximately 1 minute • Sensitivity/Specificity 95%

  12. Targets 4 Key Features Feature 1: Acute onset of mental status changes, or Fluctuating course. AND Feature 2: Inattention AND Feature 4: Altered level of consciousness Feature 3: Disorganised thinking OR

  13. CAM-ICU Worksheet

  14. CAM-ICU Video • http://www.youtube.com/watch?v=1hSDNOVHMVs

  15. Management of Delirium • Environmental • Early mobility • Maintaining a day/night cycle • Minimize light/noise • Promoting sleep at night • Assessing for extubation • Daily sedation interruption • Correct hearing/visual deficits • Hearing aids • Glasses/magnifying glasses

  16. Management of Delirium • Pharmacologic Options (intubated) • Sedation choices • Pain relief? • Morphine, fentanyl, dilaudid • Sedation? • Dexamedatomidine • Not for patients that need RASS -2 or greater • Propofol • Avoid benzodiazepines except in ETOH withdrawal

  17. Management of Delirium • Pharmacologic Options (non-intubated) • Antipsychotics • Haldol 2.5-10mg q2h prn • Monitor daily EKG • Add Seroquel 25mg BID and titrate by 25mg q12h • Zyprexa • Dex • Benzodiazepines • Don’t use unless managing ETOH withdrawal

  18. Delirium Timeline • Usually seen within the first 24 to 48 hrs • Can last as long as 2 weeks or longer • Be patient

  19. Questions????

  20. Resources Icudelirium.org Surgicalcriticalcare.net

  21. Delirium Review Article

  22. References • Girard, Timothy; Pandharipande, Pratik; Ely, Wesley; (2008). Delirium in the Intensive Care Unit.; Critical Care. 12 (Suppl 3); S3 • Gunther, Max, L.; Morandi, Alessandro; Ely, Wesley; (2008) Pathophysiology of Delirium in the ICU. Critical Care Clinics. 24: 45-6 • Inouye, S. et al. (1998). Does delirium contribute to poor hospital outcomes? A three-site epidemiological study. Journal of General Internal Medicine. 13(4): 234-42. • Ely, EW et al. (2004). Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA. 14; 291 (14): 1753-62. • Barr, J. et al. (2013). Clinical Practice Guidelines for the Management of Pain, Agitation and Delirium in Adult Patients in the Intensive Care Unit. Critical Care Medicine. Jan 41(1): 263-306. • Cheatham, M.D. (Jan 4, 2011); Delirium Management Guidelines. Retrieved from http://www.surgicalcriticalcare.net/Guidelines/delirium_2011.pdf

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