1. Lindsay Trantum ACNP-BC VUMC Neuroscience ICU
DELIRIUM
Lindsay Trantum ACNP-BC
VUMC Neuroscience ICU

2. Objectives By the end of the presentation……
Identify the key features of delirium
Identify risk factors for delirium
Demonstrate understanding of the treatment plan for delirium

3. Delirium = Brain Dysfunction
Definition: DSM IV officially defines delirium as a disturbance of consciousness with inattention accompanied by a change in cognition or perceptual disturbance that develops over a short period of time (hours to days) and fluctuates over time
“The 6th vital sign”

4. Subtypes Hyperactive Hypoactive Mixed
characterized by agitation, restlessness, and emotional lability
Hypoactive
decreased responsiveness, withdrawal, and apathy
Mixed
Periods of hyperactivity and lethargy
Critical Care 2008; 12 (Suppl 3): S3

5. Incidence 60%-80% of mechanically ventilated patients
50%-70% of non-ventilated patients
Hypoactive delirium = 43.5%
Hyperactive delirium = 1.6%
Mixed delirium = 54.1%
(Girard, 2008)
Critical Care 2008; 12 (Suppl 3): S3

6. Outcomes 3 fold increase in 6 month mortality
1 in 3 delirium survivors develop permanent cognitive impairment
Associated with…..
New nursing home placement
Increased length of stay > 8.0 days
Increased mortality
Increased number of days on the ventilator
Ely EW, Shintani A, Truman B, Speroff T, Gordon SM, Harrell FE, Jr, Inouye SK, Bernard GR, Dittus RS. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA
Does Delirium Contribute to Poor Hospital Outcomes?A Three-Site Epidemiologic StudySharon K Inouye, MD, MPH,1 Julia T Rushing, MSt,2 Marquis D Foreman, PhD, RN,3 Robert M Palmer, MD, MPH,5 and Peter Pompei, MD

7. Outcomes Continued…. Associated with……. Depression/PTSD
Increased risk of aspiration
Increased need for re-intubation
Increased hospital cost: national burden $38 billion/year
(Ely, 2004); (Inouye, 1998)

8. Risk Factors I WATCH DEATH (many acronyms) Infection
Withdrawl (Etoh, Sedatives)
Acute Metabolic (renal/liver failure, electrolytes, etc)
Trauma
CNS Pathology
Hypoxia
Deficiencies (B12, thiamine, folate, niacin)
Endocrine (hyper/hypo)
Acute vascular
Toxins
Heavy metals

9. Pathophysiology Multi-factorial and poorly understood
Neurotransmitter imbalance
Dopamine (excess) & acetlycholine (depleation)
Results in neuroexcitability and unpredictable synapses
GABA, serotonin, endorphins and glutamate

10. Pathophysiology Inflammation
Inflammatory mediators cross blood-brain barrier and increase vascular permeability
Result = decrease cerebral blood flow (CBF)
Platelets, fibrin, neutrophils obstruct CBF
(Gunther, 2008)

11. Monitoring Step 1: RASS= Richmond Agitation Sedation Scale
RASS goal
Actual RASS
Minimize Sedation
Step 2: CAM-ICU = Confusion Assessment Method
Takes approximately 1 minute
Sensitivity/Specificity 95%

12. Targets 4 Key Features AND Feature 2: Inattention
Feature 1: Acute onset of mental status changes, or Fluctuating course.
AND
Feature 2: Inattention
AND
Feature 3: Disorganised thinking
Feature 4: Altered level of consciousness OR

13. CAM-ICU Worksheet

14. CAM-ICU Video

15. Management of Delirium
Environmental
Early mobility
Maintaining a day/night cycle
Minimize light/noise
Promoting sleep at night
Assessing for extubation
Daily sedation interruption
Correct hearing/visual deficits
Hearing aids
Glasses/magnifying glasses

16. Management of Delirium
Pharmacologic Options (intubated)
Sedation choices
Pain relief?
Morphine, fentanyl, dilaudid
Sedation?
Dexamedatomidine
Not for patients that need RASS -2 or greater
Propofol
Avoid benzodiazepines except in ETOH withdrawal

17. Management of Delirium
Pharmacologic Options (non-intubated)
Antipsychotics
Haldol mg q2h prn
Monitor daily EKG
Add Seroquel 25mg BID and titrate by 25mg q12h
Zyprexa
Dex
Benzodiazepines
Don’t use unless managing ETOH withdrawal

18. Delirium Timeline Usually seen within the first 24 to 48 hrs
Can last as long as 2 weeks or longer
Be patient

19. Questions????

20. Icudelirium.org Surgicalcriticalcare.net
Resources
Icudelirium.org
Surgicalcriticalcare.net

21. Delirium Review Article

22. References
Girard, Timothy; Pandharipande, Pratik; Ely, Wesley; (2008). Delirium in the Intensive Care Unit.; Critical Care. 12 (Suppl 3); S3
Gunther, Max, L.; Morandi, Alessandro; Ely, Wesley; (2008) Pathophysiology of Delirium in the ICU. Critical Care Clinics. 24: 45-6
Inouye, S. et al. (1998). Does delirium contribute to poor hospital outcomes? A three-site epidemiological study. Journal of General Internal Medicine. 13(4):
Ely, EW et al. (2004). Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA. 14; 291 (14):
Barr, J. et al. (2013). Clinical Practice Guidelines for the Management of Pain, Agitation and Delirium in Adult Patients in the Intensive Care Unit. Critical Care Medicine. Jan 41(1):
Cheatham, M.D. (Jan 4, 2011); Delirium Management Guidelines. Retrieved from