Confused in the ICU

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Confused in the ICU

• Jud Mehl, CA-2
• Tulane Dept. of Anesthesiology

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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

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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

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So now what?

• Differential diagnosis?
• Tests?

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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 !!

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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

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Delirium acute brain failure

• Acute cognitive dysfunction
• Hyperactive or hypoactive
• Fluctuates over the course of the day
• Not better accounted for by dementia

• Prodromal phase
• Lucid intervals
• Psychomotor abnormalities
• Impaired memory
• Disturbed sleep/wake
• Dysorientation
• Dysgraphia
• Disorganized thinking/speech

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Rule out organic causes

• Drug / Alcohol intoxication or withdrawl
• HTN encephalopathy
• Hypoglycemia
• Hypoperfusion (shock)
• Hypoxemia
• Intracranial bleed
• Meningitis or encephalitis

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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

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Who is at risk ?

• Age gt 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

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What percentage of non-ventilated ICU patients
develop ICU delirium?

• A 10
• B 25
• C 35
• D 50

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What percentage of ventilated ICU patients
develop delirium?

• A 25
• B 50
• C 75
• D 80

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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 2911753-1762
• And yet, only 25-50 of intensivists routinely
  screen for delirium.

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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
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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

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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

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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
  5876-81

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, 1.87.2), abnormal blood
pressure (RR 2.3, 95 CI 1.24.7), and heart
failure (RR 2.9, 95 CI 1.65.3). 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 2.412.3). 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
1.34.5). In cognitively intact patients, severe
pain significantly increased the risk of delirium
(RR 9.0, 95 CI 1.845.2). 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
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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 (0.51.5 days vs 1.44.0
  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.

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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 lt 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.

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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

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Max dose of Haldol?

• A 5 mg
• B 10 mg
• C 0.3 mg/kg
• D 1 mg/kg

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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

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True or false?

• Once delirium is present, treatment will likely
  improve the patients outcome.
• A True
• BFalse

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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 304443-451
• 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 institutionalizatio
  n 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
  deliriumassociated poor outcomes these patients
  experience.

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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

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• 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