Delirium is an acute confusional state that commonly occurs in the ICU. It can be hyperactive, hypoactive, or mixed. Delirium increases mortality, length of stay, costs, and long-term cognitive impairment. It results from neurotransmitter imbalances and higher cortical dysfunction exacerbated by predisposing patient factors and precipitating insults like medications and critical illness. Screening tools like ICDSC and CAM-ICU can help diagnose delirium which non-pharmacological prevention bundles, reducing deliriogenic medications, and treatments like haloperidol or dexmedetomidine may help address.
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Delirium in ICU -By Dr.Tinku Joseph
1. Delirium in ICU
Dr.Tinku Joseph
DM Resident
Department of Pulmonary Medicine
AIMS, Kochi.
Email: tinkujoseph2010@gmail.com
2. Overview
What is delerium ?
How is it categorised?
Why does it matter?
Why does it happen?
How do we diagnose/monitor it?
How do we prevent and treat it?
3. What is Delirium?
An acute confusional state
with:
Fluctuating mental status
Disordered attention
Disorganised thinking or altered
consciousness
4. DSM –IV definition:
“A disturbance of consciousness with
inattention accompanied by a change in
cognition or perceptual disturbance that
develops over a short period (hours to
days) and fluctuates with time”
What is Delirium?
Synonyms:
ICU psychosis, septic encephalopathy, ICU
syndrome, acute brain failure, acute confusional
state
5. Delirium develops over a short period of time (usually hours to
days) and tends to fluctuate during the course of the day.
Delirium is typically caused by a:
Medical condition
Substance intoxication
Medication side effect.
What is Delirium?
6. How is Delirium Categorized?
HyperactiveHyperactive
HypoactiveHypoactive
MixedMixed
1.6% of cases, “ICU psychosis”,
agitation, restlessness, pulling lines and
tubes emotional lability
1.6% of cases, “ICU psychosis”,
agitation, restlessness, pulling lines and
tubes emotional lability
54.1% % of cases54.1% % of cases
43.5% of cases, “encephalopathy”,
often unrecognized, withdrawal,
apathy, lethargy, decreased
responsiveness, may be misdiagnosed
as depression.
Far more common, likely due to
sedating medications
43.5% of cases, “encephalopathy”,
often unrecognized, withdrawal,
apathy, lethargy, decreased
responsiveness, may be misdiagnosed
as depression.
Far more common, likely due to
sedating medications
7. Why does delirium matter?
Increased reintubation risk (OR=3)
Increased ICU & hospital stay* (up to 10 days extra)
Each day in delirium increases risk of longer stay by 20%
Increased mortality in ICU & out to 6 months** (OR=3)
Each day spent in delirium increases risk of death by 10%
Increased ICU & hospital costs***
10-24% risk of long-term cognitive impairment
Increased dementia risk
Reduced functional status at 3 & 6 months
* Ely et al, Intensive Care Med 2001; 27: 1892-1900 ** Ely et al, JAMA 2004; 291: 1753-62 *** Milbrandt et al, CCM 2004; 32: 955-62
16. DELIRIUM(S) - causes
DD Drugs, dementia
E Eyes & ears (poor vision and hearing)
L Low O2 states (CHF, COPD, ARDS, MI, PE)
I Infection
R Retention (urine and stool)
I Ictal states
U Underhydration/undernutrition
M Metabolic upset
(S) Subdural, sleep deprivation
17. I WATCH DEATH
I Infection
W Withdrawal (alcohol, sedatives, barbiturates etc.)
A Acute metabolic (acidosis, alkalosis, electrolytes)
T Trauma (closed head injury, haematoma etc.)
C CNS pathology (seizures, stroke, encephalitis)
H Hypoxia
D Deficiencies (thiamine, niacin, B12, folate)
E Endocrinopathies (thyroid, glucose, adrenal)
A Acute vascular (hypertensive crisis, arrhythmia)
T Toxins/drugs
H Heavy metals
18.
19.
20. Diagnosis & monitoring
Intensive Care Delirium Screening Checklist (ICDSC)
and the Confusion Assessment Method for the ICU
(CAM-ICU)
Using ICDSC, each patient is assigned a score from 0 to
8; a cut-off score of 4 has sensitivity 99% and
specificity 64% for identifying delirium
21.
22. CAM-ICU has a more modest
sensitivity ranging from 64% to
81%, high specificity from 88%
to 98%.
Diagnosis & monitoring
23.
24.
25.
26.
27. S100B protein indicator of glial activation and/or
death. Shown to be elevated in patients with delirium.
Higher baseline levels of procalcitonin or C-reactive
protein were associated with more days with delirium.
Other biomarkers elevated-brain-derived
neurotrophic factor, neuron-specific enolase,
interleukins, cortisol.
Biomarkers
28. What should we do to prevent/treatWhat should we do to prevent/treat
delerium in ICU patientsdelerium in ICU patients
30. Environmental factors
Extremes in sensory impairmentExtremes in sensory impairment
eg: hypothermia.eg: hypothermia.
Deficits in vision or hearingDeficits in vision or hearing
Immobility or decreased activityImmobility or decreased activity
Social isolationSocial isolation
Novel environmentNovel environment
stressstress
31. A bundle for delirium prevention ??
Family support (all levels, kids, children)
Allow family at bed side when ever possible
32. Orientation improvements:
Day lights, wall clocks,
exterior view from ICU.
Privacy for patients.
Hearing aid
Glasses
Television/ Music therapy
Proper sleep
A bundle for delirium prevention ??
33.
34.
35. Role of doctor & Nursing staff
Introduce yourself, smile and be
friendly with patients.
A bundle for delirium prevention ??
36. Treating/Preventing delirium
Non-pharmacological (Summary)
Up to 40% risk reduction achieved
Repeated reorientation of patients
Early mobilization
Visual and hearing aids (and wax removal!)
Early catheter, line etc. removal
Minimize restraints and sedatives
Sedation Interval
Sleep protocol
Delirium bundle
37. First address complication of critical illness that may
lead to delirium (hypoxia, hypercapnia, hypoglycemia,
shock, electrolyte imbalances)
Any drug intended to improve cognition may have
adverse psychoactive effects thus paradoxically
exacerbating delirium.
Pharmacological treatment
38. Haloperidol recommended as drug of choice for treatment
of ICU delirium by SCCM
Blocks D2 dopamine receptors, resulting in amelioration
of hallucinations, delusions, unstructured thought patterns
SCCM guidelines-hyperactive delirium to be treated with
2 mg intravenously, followed by repeated doses (doubling
previous dose) every 15 to 20 minutes while agitation
persists
Haloperidol
39. Once agitation subsides scheduled doses (every 4 to 6
hours) may be continued for few days, followed by
tapered doses for several days.
Common doses for ICU patients range from 4 to 20
mg/day
Adverse effectsAdverse effects – extrapyramidal, prolonged QTc,– extrapyramidal, prolonged QTc,
torsades (3.8%), neuroleptic malignant syndrometorsades (3.8%), neuroleptic malignant syndrome
Haloperidol
40. Treating delirium – atypical antipsychotics
Olanzepine, quetiapine, risperidone
Alter multiple neurotransmitters
including DA, NA, serotonin, ACh,
histamine
Suggestion of decreased
extrapyramidal side-effects compared
to haloperidol
As effective as haloperidol
41.
42.
43.
44. Dexmedetomidine, novel α2- receptor agonist that does
not act on GABA receptors, may to be alternative
sedative agent less likely to cause delirium.
Pandharipande P. et al (2007) showed ICU patients
sedated with dexmedetomidine spent fewer days in
coma and more days neurologically normal than
lorazepam.
Benzodiazepines are not recommended for management
of delirium
Dexmedetomidine
45.
46.
47.
48.
49. Conclusion
Delirium is a frequent disease in the
ICU and associated with poor
outcomes.
Delirium is often under recognized, can
be monitored and rapidly identified.
New approaches to manage and prevent
delirium are emerging everyday.
Dexmedetomidine has a place in this
new strategies.