ABCDE ICU Delirium Bundle From Diagnosis to Treatment Timothy D. Girard, MD, MSCI ICU Delirium and Cognitive Impairment Study Group Division of Allergy, Pulmonary, & Critical Care Medicine Center for Health Services Research Vanderbilt University School of Medicine VA Tennessee Valley GRECC Nashville, Tennessee

Disclosures Grant monies –NIH Honoraria (for non-promotional presentation) –Hospira, Inc. Research product/procedure/technique –None

What’s ahead 1.ABCDEs of critical care 2.Delirium diagnosis 3.Delirium management

1 1 ABCDEs of Critical Care

A A Awakening trials B B Breathing trials C C Coordination D D Delirium management E E Exercise & mobility

Patients Receiving Mechanical Ventilation (%) Control (n=60) Protocol (n=68) Adjusted p<. 001 Time (Days) Kress JP, et al. N Engl J Med 2000;342: Ventilator time reduced by 2 days Awakening – Daily Interruption of Sedatives

Patients Liberated from Mechanical Ventilation (%) 10 Intermittent SBTs (n=33) Daily SBTs (n=31) Pressure support vent (n=37) Intermittent mandatory vent (n=29) Weaning Time (Days) Esteban A, et al. N Engl J Med 1995;332: Breathing – Spontaneous Breathing Trials

Ely EW, et al. N Engl J Med 1996;335: Patients Receiving Mechanical Ventilation (%) Control (n=151) Protocol (n=149) p<.001 Weaning Time (Days) Breathing – SBT Protocols Ventilator time reduced by 2 days

Days before Weaning Begins Days after Intubation 7 SBTs begin (Esteban 1995) Intubation SBTs begin (Ely 1996) Sedation

Duration of Mechanical Ventilation 0 Days Patients Successfully Extubated (%) SAT+SBT (n=167) Control (n=168) Girard TD, et al. Lancet 2008;371: Ventilator time reduced by 3 days

0 Days Patients Discharged from the ICU (%) SAT+SBT (n=167) Control (n=168) p=.01 ICU Length of Stay Girard TD, et al. Lancet 2008;371:126-34

0 Days Patients Discharged from the Hospital (%) SAT+SBT (n=167) Control (n=168) p=.04 Hospital Length of Stay Girard TD, et al. Lancet 2008;371:126-34

Patients Alive (%) Days Control (n=168) SAT+SBT (n=167) One-Year Survival p=.01 NNT=7 Girard TD, et al. Lancet 2008;371:126-34

Hospital Days Patients with Functional Independence (%) Early PT/OT (n=49) Control (n=55) p=.05 Schweickert WD, et al. Lancet 2009;373: Return to Functional Independence

Outcome*Early PT/OTControlp Independent functional status at discharge, % 59%35%0.02 Barthel Index score at discharge 75 [7.5-95]55 [0-85]0.05 ICU-acquired paresis at discharge 31%49%0.09 Ventilator-free days 23.5 [ ]21.1 [0-23.8]0.05 ICU delirium, days 2.0 [0-6.0]4.0 [ ]0.03 ICU length of stay, days5.9 [ ]7.9 [ ]0.08 Hospital length of stay, days 13.5 [ ]12.9 [ ]0.93 In-hospital mortality18%25%0.53 *Median [IQR] or % Schweickert WD, et al. Lancet 2009;373: Secondary Outcomes

2 2 Delirium Diagnosis

ConsciousnessCognition

“a disturbance of consciousness that is accompanied by a change in cognition that cannot be better accounted for by a preexisting or evolving dementia” – American Psychiatric Association di-'lir-E-&m

Bergeron, ‘01 Skrobik, ‘04 Ouimet, ‘07 Pandharipande, ‘07 Ely, ‘01 McNicoll, ‘03 Ely, ‘04 McNicoll, ‘05 Micek, ‘05 Thomason, ‘05 Actual Prevalence of Delirium Medical ICUs (40%-80%) Mixed ICUs (10%-40%) Plaschke, ‘07 Pisani, ‘07 Lat, ‘09 Guenther, ‘09 Riker, ‘09 Girard, ‘08

Recognition of Delirium in the ICU Spronk PE, et al. Intensive Care Med 2009;35: MDs recognized 28%RNs recognized 35%

HypoactiveMixedHyperactive % Delirium Subtypes in the ICU Peterson JF, et al. J Am Geriatr Soc 2006;54:479-84

1 2

Which diagnostic method? 41% - none 37% - clinical assessment 14% - Confusion Assessment Method-ICU 2% - Delirium Rating Scale 2% - Mini Mental State Examination 1% - Delirium Screening Checklist 14% - Confusion Assessment Method-ICU 01% - Delirium Screening Checklist Patel R, et al. Crit Care Med 2009;37:825-32

Feature 1 Feature 3 Feature 2 Feature 4 and and either or Ely EW, et al. JAMA 2001; 286: Confusion Assessment Method-ICU Acute onset of changes or fluctuations in the course of mental status Acute onset of changes or fluctuations in the course of mental status Inattention Altered level of consciousness Altered level of consciousness Disorganized thinking

Bergeron N, et al. Intensive Care Med 2001; 27: Intensive Care Delirium Screening Checklist (ICDSC) Altered level of consciousness Inattentiveness Disorientation Hallucination-delusion-psychosis Psychomotor agitation or retardation Inappropriate speech or mood Sleep/wake cycle disturbance Symptom fluctuation ≥4 = delirium

Symptoms Rating (0, 1, or 2) Disorientation Inappropriate behavior Inappropriate communication Illusions/hallucinations Psychomotor retardation Total score Gaudreau JD, et al. J Pain Symptom Manage;29: Nursing Delirium Screening Scale (NuDESC) ≥2 = delirium

CAM-ICU % Luetz A, et al. Crit Care Med 2010;38: Validity of ICU Delirium Assessment Tools Nu-DESCDDS ICDSC* Sensitivity Specificity *Van Eijk MM, et al. Crit Care Med 2009;37:1881-5

Brain Road Map 3. How did they get there? Drugs 1. Where is the patient going? Target RASS 2. Where is the patient now? Current RASS Current CAM-ICU © Brian Sloan via Flickr

3 3 Delirium Management

Toxic Situations CHF, shock, dehydration CHF, shock, dehydration Deliriogenic medications Deliriogenic medications New organ failure, eg, liver, kidney New organ failure, eg, liver, kidney Hypoxemia Infection or Immobilization Nonpharmacologic efforts Hearing aids, eye glasses, reorientation, noise reduction, sleep, ambulation K+ or Electrolyte problems What to THINK When Delirium Is Present

Study Day Daily Dose of Benzodiazepines ABC Trial - Benzodiazepines Control Protocol

No Drug Lorazepam Dose (mg) Log scale Original scale Probability of Delirium (%) Pandharipande PP, et al. Anesthesiology 2006;104:21-6 Benzodiazepines and Delirium

Duration of Delirium ControlSAT+SBT Days p=.50 Girard TD, et al. Lancet 2008;371:126-34

Effect of Wake Up and Breathe on Coma Girard TD, et al. Unpublished data from the ABC Trial.

Effect of Wake Up and Breathe on Delirium Girard TD, et al. Unpublished data from the ABC Trial.

Daily Risk of Delirium in MENDS Pandharipande PP, et al. Crit Care 2010;14:R38 p=0.02

Daily Risk of Delirium in SEDCOM p<0.001 Riker RR, et al. JAMA 2009;301:

Which drug for delirium? 86% - haloperidol 37% - atypical antipsychotics 35% - benzodiazepines 13% - propofol 8% - opiates 5% - dexmedetomidine Patel R, et al. Crit Care Med 2009;37:825-32

Antipsychotics – Delirium and Coma Day Patients without Delirium or Coma (%) Girard TD, et al. Crit Care Med 2010;38: Haloperidol (n=35) Ziprasidone (n=32) Placebo (n=36) p=0.66

Quetiapine – Resolution of Delirium Day Patients with Delirium (%) Devlin JW, et al. Crit Care Med 2010;38: Quetiapine (n=18) Placebo (n=18) 8 p=0.001

Reade MC, et al. Crit Care 2009;13:R75 Dexmedetomidine in Agitated Patients Hours Patients Intubated (%) p=.001 Dexmedetomidine Haloperidol

Modifying the Impact of ICU-Associated Neurological Dysfunction MIND-USA

Photo by Chris Hartlove for The New York Times Reduce immobility Promote consciousness

Outcome*Early PT/OTControlp Independent functional status at discharge, % 59%35%0.02 Barthel Index score at discharge 75 [7.5-95]55 [0-85]0.05 ICU-acquired paresis at discharge 31%49%0.09 Ventilator-free days 23.5 [ ]21.1 [0-23.8]0.05 ICU delirium, days 2.0 [0-6.0]4.0 [ ]0.03 ICU length of stay, days5.9 [ ]7.9 [ ]0.08 Hospital length of stay, days 13.5 [ ]12.9 [ ]0.93 In-hospital mortality18%25%0.53 *Median [IQR] or % Schweickert WD, et al. Lancet 2009;373: Secondary Outcomes

Looking back 1.ABCDEs of critical care 2.Delirium diagnosis 3.Delirium management