1. A New Frontier in Critical Care: Saving the Injured Brain
E. Wesley Ely, MD, MPH
Professor of Medicine and Critical Care
Vanderbilt University, Nashville, TN
VA TN Valley Health Care System GRECC

2. Disclosures: ICU Physician Vanderbilt - Abbott, Hospira, Orion - NIH and VA U.S. Federal Funding - Author of PAD Guidelines of SCCM 2013

3. Agitation Pain Delirium
SAG Guidelines for sustained use of sedatives and analgesics in the critically ill adult
Jacobi, CCM 2002

4. Quote of the Day #1
Dr. Swenson explained, "I'll tell you the truth. What I have discovered…is not what I expected. It is something greater, much more ambitious than anything we had hoped for…in science: Never be so focused on what you are looking for that you overlook the thing you actually find."
Ann Patchett , State of Wonder

5. Agitation Pain Delirium
Barr J, et al. PAD Guidelines. Crit Care Med. 2013;41:

6. Barr J et al, CCM 2013;41:

8. Airplane Draft ICU Liberation - 3 Columns

9. 50-70% Cognitively Impaired © rustyrhodes via Flickr
Wolters Intensive Care Med 2013; 39: 376
Jackson AJRCCM 2010; 182: 183
Girard Crit Care Med 2010; 38: 1513

10. Functionally Impaired
60-80%
Functionally Impaired
Marcel Oosterwijk via Flickr
Latronico Lancet Neurol 2011; 10: 931

11. ICU Survivorship Family Hobbies Work
Iwashyna Annals of Int Med 2010; 153:204-5

12. “
After 5 months I felt better and returned to work but was fired 10 weeks later... it didn't surprise me because I was struggling terribly. I couldn't organize my work; committed many errors in documentation; frequently lost things; forgot meetings, and did not manage my time well
“The time I spent seems like it was in a huge, empty gray space, sort of like a monstrous underground parking garage with no cars, only me, floating or seeming to float, on something. Every once in a while I would get to an edge of something horrible and once I remember I thought, "if I just let go, then this horror will be over.””
© Travis Smith via Flickr

13. “ http://www.icudelirium.org/testimonials.html
When I returned to work, the work I did before seemed foreign and unfamiliar. I became isolated and excluded from everyone. No one wanted to be around me. My wife of more than 36 years told me that I was just “feeling sorry” for myself, and I just needed to get on with my life. I nearly ended my life a few times. Then after five years of this hell, Oct CBS News ran a report about people just like me. From that report I found your website. I cried for long time; it has changed my wife’s opinion about me. For the first time in the past five years, I think believe I have a future.
“The time I spent seems like it was in a huge, empty gray space, sort of like a monstrous underground parking garage with no cars, only me, floating or seeming to float, on something. Every once in a while I would get to an edge of something horrible and once I remember I thought, "if I just let go, then this horror will be over.””
© Travis Smith via Flickr

14. Cognitive Impairment: Sepsis25
Before Sepsis
After Sepsis
p<0.001 20
Mild Cognitive Impairment
Moderate/Severe Cog Impairment 15
% survivors
cognitively impaired 10
Prospective cohort study of patients enrolled in the health and retirement study, an ongoing cohort of 27,000 community dwelling americans >50 years old. Every two years patients are assessed with good follow-up rates north of 90%. The GRAND IDEA put forth by this paper of ours was that there is a tripling of risk post sepsis (the main admission criteria for ICU patients) of moderate to severe cognitive impairment. That is, a HUGE increase in Demential like illness post ICU, and if delirium is the main risk factor for this, then modifying delirium could have a huge impact on a rising population of demented Americans.
1520 episodes of sepsis in 1194 patients over the 7 year study period
84% had normal cognition at baseline; 7.8% were mildly imparied and 8.7% were moderate/severely impaired
This modeling used in this study used within-person variation over time in cognitive function to estimate the impact of severe sepsis and to control for characteristics that did not change over time--in effect the patients served as their on controls over time. Thus, in the LR analysis, patients who developed severe sepsis were at 3.5 ( ) times the risk of developing moderate to severe cognitive impariment vs. those non-septic patients.
Severe sepsis was highly associated with progression to moderate/severe CI (OR 3.55; CI )
Patients NOT mechanically ventilated had a 4.4x great odds for developing moderate to severe CI after SS (CI ) 5
-3 years
-1 year
+1 year
+ 3 years
Iwashyna T, JAMA 2010;304:

15. Ely EW, JAMA 2004;291:

16. Delirium Duration & Mortality4
0 vs 1
HR 1.7
<0.001
0 vs 2
HR 2.69
0 vs 3
HR 3.73
p<.001 3
Relative Hazard of Death 2 1
NOTES: Crossing CI of HR from Cox regression happens based on a mathematical formula of Cox regression. Cox regression does not have an intercept in its equation, and lacking intercept does not provide a reference category when CI is shown graphically. For this reason, when a graph is drown, we need to pick an arbitral reference category where CI crosses on X axis, and typical default for this is to use median value of X. For example, HR is set to 1 at the median value (eg delirium duration =2 days), and HR shows relative increase or decrease from HR=1 (delirium duration = 2 days) when showing effect at non-median values.
Table 3. Multivariable analysis of cumulative number of delirium days
Number of Delirium
Days (p .001,
Overall)
30–Day Mortality
(p .02, Nonlinear Effect)a
Remaining Intubated
(p .001, Overall)
Remaining in Intensive Care Unit
(p .02, Overall)
HR 95% CI p HR 95% CI p HR 95% CI p
0 vs. 1 day – – –
0 vs. 2 days – – –
0 vs. 3 days – – –
HR, hazard ratio; CI, confidence interval. 1 2 3 4 5 6
Days of Delirium
Shehabi Y, et al. CCM 2010; 38:2311–2318

18. NEJM 2013;369:
Editorial by M. Herridge

19. Delirium and Brain Atrophy
Figure 2. Representative example of lateral ventricle size in 46-yr-old female and 42-yr-old female intensive care unit (ICU) survivors with no preexisting cognitive impairment: Axial T1-weighted brain images in two ICU survivors. A, Relatively normal ventricular volume (see arrow) in a 46-yr-old female who did not experience delirium in the ICU. Patient had a history of respiratory and heart failure. She was admitted to a medical ICU due to acute respiratory distress syndrome and was subsequently intubated and managed through the ICU without ever developing delirium. B, Enlarged ventricles (see arrow) in a 42-yr-old female who did develop delirium in the ICU. Patient was admitted to the hospital after reporting fever and dyspnea with a chest radiograph and other laboratory data confirming community acquired pneumonia and acute respiratory distress syndrome. The patient was admitted to the ICU and mechanically ventilated, experiencing 12 days of delirium and then resolution. There was no preexisting history of neurological impairment, and surrogate questioning for preexisting cognitive impairment was also negative.
(A) 46 year old, no delirium (B) 42 year old, 12 days of delirium
Gunther M et al. CCM 2012;40:

20. The Picture of Dementia Following ICU Care

21. Global Cognitive Scores by Age

22. Global Cognitive Scores by Age and Comorbidity

23. Delirium and Executive Function

24. Confirmed: Delirium Risk Factor for Long-Term Cognitive Problems after ICU Stay
1,101 survivors of critical illness, 37% with delirium
Studied only survivors and used self report
Multivariable analysis with adjustment for gender, admission dx, severity of illness (both APACHE IV and cumulative SOFA)
Delirium independent predictor of mild (O.R. 2.41, C.I ) and severe (3.1, ) LTCI 1 year
Limitations:
Only survivors so mortality analysis does not uproot ours
Biostats – dichotomous delirium ever/never, did use CAM-ICU twice daily but did NOT use duration of delirium (said was not possible)
LONG-TERM COGNITIVE IMPAIRMENT – no baseline incorporated so can’t tell is delirium was a causal factor or a marker of poor baseline.
Used self-report off of EQ-6D, which is a 3-level multiple choice question, which is “minimal compared to extensive neuropsychological testing.”
Adjustment with Cumulative SOFA interesting. They tested sensitivity analysis and it didn’t change things.
Findings nicely supportive of NEJM BRAIN-ICU and also actually supportive of Lancet RM (negative with delirium not predicting HRQOL)
Wolters AE, Crit Care 2014 June epub

25. If delirium is not screened for using a validated delirium screening tool it is missed ~75% of time.
Inouye SK Arch Intern Med. 2001;161:
Devlin JW Crit Care Med. 2007;35:
Spronk PE Intensive Care Med. 2009;35:
van Eijk MM Crit Care Med. 2009;37:

26. Take Home Message

27. “We recommend routine monitoring for delirium in adult ICU patients”
2013 PAD Guidelines:
“We recommend routine monitoring for delirium in adult ICU patients”
Grade 1B Recommendation
Crit Care Med. 2013;41:

28. Don’t forget about Dr. DRE
Diseases
Sepsis, COPD, CHF
Drug Removal
SATs and stopping benzodiazepines/ narcotics
Environment
Immobilization, sleep and day/night, hearing aids, glasses, noise
Medical Intensive Care Unit

29. So let’s focus on potentially modifiable aspects of care such as potent medications, delirium, and improving care and clinical outcomes…

30. Building blocks of managing Pain, Agitation & Delirium
ABCDEs:
Building blocks of managing
Pain, Agitation & Delirium E D C B A

31. “Faced with the choice between changing one's mind and proving that there is no need to do so, almost everyone gets busy on the proof.”     John Kenneth Galbraith 

32. Awake and Breathing Coordination
Duration of mechanical ventilation
Duration of coma
Mortality
Choose light sedation & avoid benzos
Duration of mechanical ventilation
Mortality
Delirium
Delirium monitoring & management
 Delirium detection
Early Mobility & Environment
Duration of delirium
Disability
ICU Length of Stay
Rehospitalization/Mortality
Morandi et al Curr Opin Crit Care 2011;17:43-9
Vasilevskis et al Crit Care Med 2010;38:S683-91
Vasilevskis et al Chest 2010;138:
Zaal et al, ICM 2013;39:481-88
Colombo et al, Minerva Anest 1012;78:

34. New Order Set: Benzodiazepine Use
Median dose - Lorazepam equivalents (mg)
Adjusted Ratio of Medians: 0.71 (95% CI: -1.31, -0.10)
Dale CR & Treggiari M, Ann ATS 2014 epub
Treggiari M et al. Crit Care Med 2009;37:

35. Probability of Delirium over Time
Adjusted OR of delirium: 0.67 (95% CI: 0.49, 0.91)
Dale CR & Treggiari M, Ann ATS 2014 epub
Treggiari M et al. Crit Care Med 2009;37:

36. 1.5 year prospective QI (before/after) study of 296 ICU patients.
Balas M, CCM 2014 epub

37. VENTILATOR FREE DAY RESULTS
Days
Significant improvement in ventilator free days
Pre Median 21 IQR 0 to 25
Post Median 24 IQR 7 to 26
Balas M CCM 2014

38. DELIRIUM RESULTS
p=0.003
Balas M CCM 2014

39. p=0.07 %
Balas M CCM 2014

40. 28 DAY MORTALITY RESULTS
p=0.07
p=0.04
Balas M CCM 2014

41. ADJUSTED ANALYSIS
Controlling for age, sex, mechanical ventilation, APACH II score, Charlson Comorbidity Index
Delirium anytime - OR 0.55 ( ); p=0.03
OOB anytime in ICU - OR 2.11 ( ) p=0.003
Balas M CCM 2014

42. Hopkins QI Project = Reduced Delirium
via less benzodiazepines and more mobility
Outcome
Pre-QI (n=27)
Post-QI (n=30) p
Days with any benzodiazepine use**
150 (50%)
118 (26%)
.002
Days alert (RASS -1 to +1)
88 (30%)
311 (67%)
<.001
PT/OT in MICU
19 (70%)
28 (93%)
.040
Number of PT/OT treatments in ICU
1 (0-3)
7 (3-15)
Days without delirium
61 (21%)
243 (53%)
.003
Days of delirium in ICU
107 (36%)
125 (28%)
Days of Coma
129 (43%)
86 (19%)
** Benzodiazepine dose (median midazolam eq) from 47mg down to 15 mg/day
Needham DM Arch Phys Med Rehabil 2010; 91:

43. “I had never before understood how much good nursing care contributes to patients’ safety and comfort, especially when they are very sick or disabled.  This is a lesson all physicians and hospital administrators should learn.  When nursing is not optimal, patient care is never good.” Dr. Bud Relman
Remember: Monitoring of delirium in critical illness, while not a feat resting solely in the hands of nurses, will succeed only under the guidance of nursing leadership and via the day-to-day actions of nurses intersecting with the other critical INTER-disciplinary members of our ICU teams at every bed in ICUs across the land.

44. Pain, Agitation, and Delirium Are Interrelated
Barr J, et al. Crit Care Med. 2013;41:

45. “Pain should be routinely monitored in all adult ICU patients”
2013 PAD Guidelines:
“Pain should be routinely monitored in all adult ICU patients”
Grade 1B Recommendation
Crit Care Med. 2013;41:

46. Pain, Agitation, and Delirium Are Interrelated
Barr J, et al. Crit Care Med. 2013;41:

47. Targeted Level of Consciousness
Choose Target RASS
Assess Actual RASS
Modify treatment so Actual = Target

48. Grade 1B Recommendation *Light sedation = RASS 0 to -2
2013 PAD Guidelines:
“We recommend either daily sedation interruption or a light level* of target sedation be routinely used…”
Grade 1B Recommendation
*Light sedation = RASS 0 to -2
Crit Care Med. 2013;41:

49. Awake and Breathing Coordination
Duration of mechanical ventilation
Duration of coma
Mortality
Choose light sedation & avoid benzos
Duration of mechanical ventilation
Mortality
Delirium
Delirium monitoring & management
 Delirium detection
Early Mobility & Environment
Duration of delirium
Disability
ICU Length of Stay
Rehospitalization/Mortality
Morandi et al Curr Opin Crit Care 2011;17:43-9
Vasilevskis et al Crit Care Med 2010;38:S683-91
Vasilevskis et al Chest 2010;138:
Zaal et al, ICM 2013;39:481-88
Colombo et al, Minerva Anest 1012;78:

50. 2 days Liberating from Ventilator SBT reduced weaning time by = 100 80
p<.001 60
Patients on Ventilator (%) 40
Control (n =151) 20
Protocol (n =149) 30 20 10 15 5 25
Time (Days)
Ely EW, et al. N Engl J Med 1996;335:1864-9

51. 2 days Liberating from Sedation SAT reduced ventilator time by = 10080 60
Patients on Ventilator (%) 40
Control (n=60)
Adjusted p<.001 20
Protocol (n=68) 5 10 15 20 25 30
Time (Days)
Kress JP, et al. N Engl J Med 2000;342:1471-7

52. Quote of the Day #2
“I came awake on the fifth day. My first memory is that of floating up from the ocean bottom, my eyes still waterlogged and with what felt like scuba gear stuffed in my mouth and throat. I couldn’t speak. As I broke to the surface, I understood that I was still in the ICU at Our Lady, but I heard nothing of what anybody said.
Abraham Verghese , Cutting for Stone
Ann Patchett , State of Wonder

53. SAT + SBT = 4 day shorter ICU/hosp LOS

54. ABC Trial: One-Year Survival
100
NNT=7 80
ABC approach (n=167) 60
Patients Alive (%) 40
Control (n=168) 20
p=.01 60
120
180
240
300
360
Days
Girard TD, et al. Lancet 2008;371:126-34

55. Sedation Interruption in SLEAP
Mehta S, JAMA 2012;308:

56. Benzodiazepine Use in Trials *
Study
Control
Treatment
Kress NEJM 2000
90 mg/day
53 mg/day
Girard ABC Lancet 2007
84 mg/day
54 mg/day
Mehta SLEAP JAMA 2012
82 mg/day
102 mg/day
OSCILLATE NEJM 2013
141 mg/day
199 mg/day
* All values converted and expressed as mean midazolam dose per patient, median for ABC study were 8 mg and 5 mg, respectively

57. From Canadian Authors of SLEAP… n=712 and 3,620 patient-days
“We found that nearly all patients were managed with continuous-infusion opioids and sedatives. We also found that actual practice was different from what we expected because the available clinical tools – such as protocols and assessment scales – were not necessarily applied at the bedside.”
Burry LD, Can J Anesth May 2014 epub
Data collected

58. SPICE Study – first 48 hours mean 50 mg/d benzos
Pratik wrote: I just read the Shehabi SPICE study (AJRCCM 2012) showing early deep sedation is associated with mortality (apart from delayed extubation) in detail and recommend it as reading for those who have not. Its got some neat data about sedation practices (albeit in Australia/NZ) that still supports low implementation of targeted sedation and of SATs (20% in Australia). There are also some nice descriptive data about prevalence of delirium over time.
In this study early deep sedation (first 48 hours) was not associated with delirium. Some of you may be asked about this on the podium one day so I thought I’d share a few thoughts. Also these delirium results are different from the diurnal sedation paper we just published in CCM (Seymour et al.) but they are answering different questions tham we did.
1.       They defined deep sedation of RASS -3 to -5 so its not just coma
2.       Delirium was measured only in patients who were RASS -2 to +1. So some cases Im sure got missed at -3 and then in the more positive range of the RASS
3.       All sedatives were lumped together in the delirium analysis since they chose the risk factor of deep sedation irrespective of how you got there. They did separate out the sedatives for the liberation from MV outcome and found that midazolam but not propofol was associated with the outcome.
4.       There may have been some missing delirium assessments even in the RASS -2 to +1 range- perhaps those were the aberrant UTAs that show up which almost always tend to be CAM positive. They clearly mention the number of missing values on day 1 on the study but not during the outcome phase.
Pratik
Shehabi AJRCCM 2012;186:724-31

59. Awake and Breathing Coordination
Duration of mechanical ventilation
Duration of coma
Mortality
Choose light sedation & avoid benzos
Duration of mechanical ventilation
Mortality
Delirium
Delirium monitoring & management
 Delirium detection
Early Mobility & Environment
Duration of delirium
Disability
ICU Length of Stay
Rehospitalization/Mortality
Morandi et al Curr Opin Crit Care 2011;17:43-9
Vasilevskis et al Crit Care Med 2010;38:S683-91
Vasilevskis et al Chest 2010;138:
Zaal et al, ICM 2013;39:481-88
Colombo et al, Minerva Anest 1012;78:

60. No Sedation: ICU Length of Stay
100 80
Control (n=58) 60
Patients Remaining in ICU (%) 40
Intervention (n=55) 20
9.7 days
ICU stay reduced by 7 14 21 28
Days
Strom T, et al. Lancet 2010;375:475-80

61. Grade 2B Recommendation
2013 PAD Guidelines:
“We suggest that sedation strategies using non-benzodiazepines (propofol or dexmedetomidine) may be preferred over sedation with benzodiazepines (midazolam or lorazepam)”
Grade 2B Recommendation
Crit Care Med. 2013;41:

62. Buffalos to Beer to Brain Cells Cliff the mailman and philosopher
Cliff: “Well you see, Norm, it's like this . . A herd of buffalo can only move as fast as the slowest buffalo. And when the herd is hunted, it is the slowest and weakest ones at the back that are killed first. This natural selection is good for the herd as a whole, because the general speed and health of the whole group keeps improving by the regular killing of the weakest members.”
sitcom CHEERS

63. Buffalos to Beer to Brain Cells
“In much the same way, Norm, the human brain can only operate as fast as the slowest brain cells. Now, as we know, excessive intake of alcohol kills brain cells. But naturally, it attacks the slowest and weakest brain cells first. In this way, regular consumption of beer eliminates the weaker cells, making the brain a faster and more efficient machine. And that, Norm, is why you always feel smarter after a few beers.”
sitcom CHEERS

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

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

66. Pain, Agitation, and Delirium Are Interrelated
Barr J, et al. Crit Care Med. 2013;41:

67. Awake and Breathing Coordination
Duration of mechanical ventilation
Duration of coma
Mortality
Choose light sedation & avoid benzos
Duration of mechanical ventilation
Mortality
Delirium
Delirium monitoring & management
 Delirium detection
Early Mobility & Environment
Duration of delirium
Disability
ICU Length of Stay
Rehospitalization/Mortality
Morandi et al Curr Opin Crit Care 2011;17:43-9
Vasilevskis et al Crit Care Med 2010;38:S683-91
Vasilevskis et al Chest 2010;138:
Zaal et al, ICM 2013;39:481-88
Colombo et al, Minerva Anest 1012;78:

68. Cardinal Symptoms of Delirium and Coma
Morandi A, et al. Intensive Care Med. 2008;34:

69. Ely EW, JAMA 2001;286:

70. Ely EW, JAMA 2003;289:
The Miraculous Haul of Fishes, by Henry Tanner, who was the first African American to become a member of the National Academy of Design. This from 1927 confirmed his reputation as the foremost biblical painter of his day. Probably from Luke 5:1-11 (maybe from John’s story, but details make Luke more likely).

71. CAM-ICU Sensitivity and Specificity
Over a dozen studies have now compared the 30 second CAM-ICU evaluation to Geriatric psychiatrists’ 30 to 45 minute evaluations:
Sensitivity 80% to 95%
Specificity 90% to 97%
Inter-rater reliability, kappa = 0.96 ( )
Delirium prevalence rates in mechanically ventilated ICU patients consistently 60% to 80%
Ely EW, JAMA 2001;286:
Gusmao-Flores Crit Care 2012;16:R115

72. Don’t forget about Dr. DRE
Diseases
Sepsis, COPD, CHF
Drug Removal
SATs and stopping benzodiazepines/ narcotics
Environment
Immobilization, sleep and day/night, hearing aids, glasses, noise
Medical Intensive Care Unit

73. SLEEP
Consider reading these citations: Patel J et al, Anesthesia 2014;69: Watson P et al, CCM 2013;41: Weinhouse G, CO-Anesthesiology 2014;27:epub Kamdar B et al, Anesthesia 2014;69: Kamdar B et al, CCM 2013;41:800-09

74. Hopkins Sleep Protocol Associated with Reductions in Delirium
Environmental
Non-Pharmacologic
Pharmacologic
No overhead pages
No TV
Dim hall lights
Grouping Care Activities
Mobilization
Lights on, blinds open
Decrease naps
No caffeine after 3pm
Ear plugs
Eye masks
Soothing Music
Avoiding Benzos, Opiates & trazodone as sleep aides
Zolpidem if CAM –
Haloperidol if CAM +
Following QI intervention, fewer patients developed delirium
(Adjusted OR 0.46, 95% CI , p=0.02)
Intervention patients had more days of ‘normal’ brain function
(Adjusted OR 1.64, 95% CI , p=0.03)
Kamdar B CCM 2013;41:800-09

75. Average ICU has background noise of
crowded restaurant, louder next to patient’s head
Noise spikes of >85dBA at least every 8 minutes
Darbyshire JL CCM 2013;17:R187

76. Sleep Promotion In ICU Reduces Delirium Prevalence
SLEEP Program %
Weeks
Rummelhard D, Schelle-Chaple H (UCSF) CCM 2012

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

78. Brain Road Map (A framework for bedside rounds)
1. Where is the patient going?
Target RASS
2. Where is the patient now?
Current RASS
Current CAM-ICU
© Brian Sloan via Flickr
3. How did they get there?
Drugs

79. Awake and Breathing Coordination
Duration of mechanical ventilation
Duration of coma
Mortality
Choose light sedation & avoid benzos
Duration of mechanical ventilation
Mortality
Delirium
Delirium monitoring & management
 Delirium detection
Early Mobility & Environment
Duration of delirium
Disability
ICU Length of Stay
Rehospitalization/Mortality
Morandi et al Curr Opin Crit Care 2011;17:43-9
Vasilevskis et al Crit Care Med 2010;38:S683-91
Vasilevskis et al Chest 2010;138:
Zaal et al, ICM 2013;39:481-88
Colombo et al, Minerva Anest 1012;78:

80. The Iconic Picture of Early Mobility
Point prevalence study in Germany showed <10% walking
“Yes ‘n How many deaths will it take, Till he knows that too many people have died?” Dylan, Times They Are A-Changin’
Needham DM, JAMA 2008;300:
Nydahl P et al, CCM 2014;42:
Clemmer T, CCM 2014;42:

81. Mobilization = Less Delirium
Variable
Intervention
(n=49)
Control
(n=55)
P-value
ICU/Hosp Delirium Days
2 days
4 days
0.03
Time in ICU with Delirium
33%
57%
0.02
Time in Hosp. with Delirium
28%
41%
0.01
Schweickert et al, Lancet 2009;373:

82. Minimum Criteria for Consulting PT/OT and Initiating Early Exercise
M – Myocardial Stability
No evidence of active myocardial ischemia
Stable heart rate and cardiac rhythm
O – Oxygenation adequate on
FIO2<0.6
PEEP<10 cm H2O.
V – Vasopressor(s) Minimal
No increase dose of any vasopressor infusion for at least 2 hours*
E – Engages to Voice
Patient response to verbal stimulation (RASS > -3)

83. Mobilizing the Brain with Sudoku & Scrabble

84. RETURN to Land of the Living
Returning to Everyday Tasks Utilizing Rehabilitation Networks

85. RETURN – Cognitive Rehabilitation
Intervention
Control 18 14
Executive Function 10 6 2
Enrollment
3 Month Follow-Up
Jackson et al, Critical Care Med. 2012

86. Building blocks of managing Pain, Agitation & Delirium
ABCDEs:
Building blocks of managing
Pain, Agitation & Delirium E D C B A

87. Airplane Draft ICU Liberation - 3 Columns

88. abcdef… F = FAMILY Family rounding Family visitation
Family importance to reducing delirium
Good EOL planning
Good transitions of care, IMPACT project

89. Jiro Dreams of Sushi - Tokyo
Excellence
Aristotle: “We are what we repeatedly do Excellence is not an act, but a habit”
Jiro Dreams of Sushi - Tokyo

90. “ “
I survived and that is the main thing. And I am so grateful to God that I survived and am now off all oxygen and consider myself all well except that I can’t remember to take my medications...
-SB
© Cappi Thompson via Flickr

91. The ICU Delirium and Cognitive Impairment Study Group at the Loveless Café, Nashville TN

92. ICU Delirium and Cognitive Impairment Study Group: selected local members
Pratik Pandharipande
Jim Jackson
Jin Han
Ed Vasilevskis
Chris Hughes
Alessandro Morandi
Paula Watson
Lorraine Ware
Gordon Bernard
Bob Dittus
Ted Speroff
Wes Ely
Leanne Boehm
Joyce Okahashi
Cayce Strength
Brenda Pun
Lauren Hardy
Amy Lipsey
Ryan Black
Jessica McCurley
Michael Santoro
Carrie Jones
Morgan Crawford
Mayur Patel
Tim Girard
John Gore
Baxter Rogers
Stephan Heckers
Cathy Fuchs
Heidi Smith
Ty Berutti
Brad Strohler
Elizabeth Card
Jennifer Thompson
Ayumi Shintani
Stephanie Hamilton