Faculty Disclosures I have nothing to disclose Kathleen Puntillo - PDF document

5/31/2014 Delirium Screening and Prevention Faculty Disclosures I have nothing to disclose Kathleen Puntillo RN, PhD, FAAN, FCCM Professor Emeritus School of Nursing, UCSF Objectives Case Study • Discuss prevalence, risk factors and outcomes • Mr. McLaughlin • 80 years old, 100 pk yr related to delirium smoker • Present 2 delirium screening tools • Surgery: nephrectomy recommended by recent SCCM guidelines • P .O. day 1: • Propose interventions to prevent delirium – Restless, agitated – Bugs on wall, cigarette in bed development or decrease duration in ICU – Afraid when watching TV patients – Watched Kentucky Derby but • Discuss a delirium prevention initiative at didn’t remember – Restrained when no family UCSF Medical Center ICU present 1

5/31/2014 Cardinal Symptoms of Delirium & Coma Case Study (cont’d) • Daughters present almost 24 hrs/day x 2 days • Evening of P.O. day 2: – Haloperidol – Dilaudid – Midazolam • Slept all night, with RN daughter at bedside • Awoke cognitively clear Morandi A, et al. Intensive Care Med . 2008;34:1907-1915. Basic Pathoetiological Model of Delirium Maldonado, 2008 Types of Delirium 9% 35% Hyperactive Hypoactive Mixed 56% 2

5/31/2014 Delirium in the Critically Ill Delirium in the Critically Ill • Associated with: Mechanisms numerous and not clearly understood – Increased mortality – Prolonged hospitalization – Prolonged duration of mechanical ventilation Disturbance(s) in brain chemistry – Increased cost – Worse consequences than in non-ICU patients Maldonado JR. Crit Care Clin. 2008;24(4):789-856. Pandharipande PP. ICM, 2009; Adams-Wilson JR, et al. Crit Care Med. 2012; Dubois, MJ et al., ICM, 2007; Maldonado JR. Crit Care Clin. 2008;24(4):789-856. Pandharipande PP. ICM, 2009; Ouimet S et al., ICM, 2007 Adams-Wilson JR, et al. Crit Care Med. 2012; Dubois, MJ et al., ICM, 2007; Ouimet S et al., ICM, 2007 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit What is the state-of-the-science on delirium in the ICU? Authors : Juliana Barr, MD, FCCM; Gilles L. Fraser, PharmD, FCCM; Kathleen Puntillo, RN, PhD, FAAN, FCCM; E. Wesley Ely, MD, MPH, FACP, FCCM; Céline Gélinas, RN, PhD; Joseph F. Dasta, MSc; Judy E. Davidson, DNP, RN; John W. Screening and Prevention Devlin, PharmD, FCCM; John P. Kress, MD; Aaron M. Joffe, DO; Douglas B. Coursin, MD; Daniel L. Herr, MD, MS, FCCM; Avery Tung, MD; Bryce RH Robinson, MD, FACS; Dorrie K. Fontaine, PhD, RN, FAAN; Michael A. Ramsay, MD; Richard R. Riker, MD, FCCM; Curtis N. Sessler, MD, FCCP, FCCM; Brenda Pun, RN, MSN, ACNP; Yoanna Skrobik, MD, FRCP; Roman Jaeschke, MD, MSc Barr J, Fraser GL, Puntillo K, et al., CC 2013 3

5/31/2014 Outcomes Associated with Delirium Interpreting the PAD Guidelines in ICU Patients Statements and Recommendations GRADE* Methodology: (www.gradeworkinggroup.org) i. Delirium is associated with increased mortality in * Grading of Recommendations Assessment, Development and Evaluation adult ICU patients (A). Quality of evidence : statements and recommendations ii. Delirium is associated with prolonged ICU and • High (A) hospital lengths of stay in adult ICU patients (A). • Moderate (B) • Low/Very Low (C) iii. Delirium is associated with the development of post- Strength of recommendations: recommendations only ICU cognitive impairment in adult ICU patients (B). • Either strong (1) , weak (2), or none (0) • Either in favor of an intervention (+) or against an Barr J, Fraser GL, Puntillo K, et al., CC 2013 intervention (-) Worse Long-term Delirium Risk Factors in ICU Patients Cognitive Performance i. Four baseline risk factors positively and significantly • ½ of all ICU survivors experience cognitive associated with the development of delirium (B): impairment . dementia • Duration of delirium (“the delirium dose”) is an . hypertension independent predictor of cognitive impairment . alcoholism • An increase from 1 day of delirium to 5 days associated with nearly a 5-point decline in cognitive battery scores • “Delirium dose” independent predictor of disability: . high severity of illness – of ADLs (bathing, dressing, incontinence) i. Coma is an independent risk factor. Definitive – Motor-sensory function (eyesight, movement, hearing) relationship between various subtypes of coma and delirium in ICU patients requires further study (B). Girard TD, et al. Crit Care Med. 2010;38:1513-1520. Misak CJ . Am J Respir Crit Care Med . 2004;170(4):357-359. Barr J, Fraser GL, Puntillo K, et al., CC 2013 Brummel NE et al. Crit Care Med.2014;42:369-377) 4

5/31/2014 Delirium Med Risk Factors in ICU Delirium Med Risk Factors in ICU Patients Patients (cont.) iii. Conflicting data surround the relationship between opioid use and development of delirium (B). vi. In MV patients at risk for delirium, IV dexmedetomidine for sedation may be associated with a lower prevalence iv. Benzodiazepines may be a risk factor (B). of delirium compared to IV benzodiazepines (B). v. Insufficient data on relationship between propofol use and delirium (C). Barr J, Fraser GL, Puntillo K, et al., CC 2013 Barr J, Fraser GL, Puntillo K, et al., CC 2013 Delirium Screening CAUTION!! If you don’t know where you’re going… Any road will take you there! 5

5/31/2014 Delirium Scales Delirium Monitoring in ICU Patients i. Recommend routine monitoring for delirium (+1B). ii. Routine monitoring of delirium is feasible in clinical practice (B). iii. The Confusion Assessment Method for the ICU (CAM- ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) are the most valid and reliable (A). ICDSC CAM-ICU (Intensive Care Delirium Screening Checklist) Barr J, Fraser GL, Puntillo K, et al., CC 2013 (Confusion Assessment Method-ICU) Patient scored 0 to 8 points; ≥4/8=delirium Binary scale Delirium Assessment ICU Delirium Screening Checklist CAM-ICU 8 items based on DSM criteria • Altered LOC 1 • Inattention 1 • Disorientation 11 • Hallucination, delusion, psychosis 0 • Agitation or psychomotor retardation 1 • Inappropriate speech or mood 0 • Sleep/Wake cycle disturbance 1 • Symptom fluctuation 1 • Total score (0 – 8) 6/8 Score 0 = No Delirium, 1-3 = Subsyndromal, ≥ 4 = Delirium Bergeron N, et al. Intensive Care Med . 2001;27:859-864. ICUdelirium.org 6

5/31/2014 Sub-syndromal Delirium Delirium Prevention in ICU Patients (per ICDSC) i. Recommend early mobilization whenever feasible to • Frequency: reduce the incidence and duration of delirium (+1B). – 604 consecutively admitted patients “Early mobilization – No delirium 31.5% might be only beneficial strategy in preventing – Sub-syndromal delirium 33.3% delirium” Devlin 2013 – Clinical delirium 35.2% Ouimet S et al., 2007. Inten Care Med. Subsyndromal delirium in the ICU: Evidence for a disease spectrum. • But: – LOC/sedation could be a critical confounder (Devlin et al, ICM, 2013) Photo with permission from: Needham, D. M. JAMA 2008;300:1685-1690 . Barr J, Fraser GL, Puntillo K, et al., CC 2013 Percent of patients in each category of Sleep Promotion cognitive status as measured by NEECHAM scale . ii. Recommend promoting sleep by optimizing patients' environments: control light and noise, cluster patient care activities, decreasing stimuli (+1C). Patients sleeping (from 2200 to 0600) with earplugs reported significantly better sleep after 1 st night, but effect didn’t last Van Rompaey et al., Criti Care, 2012 Barr J, Fraser GL, Puntillo K, et al., CC 2013 7

5/31/2014 Delirium Prevention in ICU Patients (cont.) Delirium Prevention in ICU Patients (cont.) iv. No recommendation for pharmacological delirium prevention protocol, no compelling data on reduction vi. Do not suggest that either haloperidol or atypical of incidence or duration (0,C). antipsychotics prevent delirium (-2C). iv. No recommendation for combined non- vii.No recommendation for dexmedetomidine to prevent pharmacological and pharmacological delirium delirium (0,C). prevention protocol (0,C). Barr J, Fraser GL, Puntillo K, et al., CC 2013 Barr J, Fraser GL, Puntillo K, et al., CC 2013 Haloperidol prophylaxis in critically ill An ICU Delirium Initiative at patients with a high risk for delirium UCSF Medical Center • Mixed medical-surgical-trauma-neuro patient ICU – Intervention (n=177) vs. historical control (n=299) • High delirium risk; dementia; alcohol abuse • Intervention: haloperidol 1 mg/8hr (or lower) within 24 hours after ICU admission • Significant Intervention Control differences Delirium incidence 65% 76% Delirium-free days median 20 [IQR8,27]) median 13 [IQR 3,27] (p < 0.05): ICU re-admissions 11% 18% Unplanned tube/line 12% 19% removals 28-day mortality 7.3% 12% Van den Boogaard et al., Critical Care, 2013 8