Bad, Mad, or Delirious

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Bad, Mad, or Delirious?

• Dealing with confusion in Intensive Care
• David Quayle PgC, RGN, FETC
• Charge Nurse, CTCC, JRH

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Acknowledgments

• Vanderbilt University, USA
• Pharmacy Department, John Radcliffe Hospital

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Delirium? What is it!

• 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 Diagnostic and Statistical Manual
  of Mental Disorders )

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Subtypes

• Hyperactive
• ICU Psychosis
• Hypoactive
• acute encephalopathy
• Mixed

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At Risk?

• On average ICU patients have greater than 10 risk
  factors for delirium which places them at a very
  high risk for this complication.

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• One of the most frequent forms of organ
  dysfunction experienced by critically ill
  patients
• Despite this prevalence, delirium (usually in the
  hypoactive state) remains unrecognized in 66 to
  84 of patients whether they be in the ICU,
  hospital ward, or AE

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• In a recent study Jason et al (2005) demonstrated
  that 48 of a cohort in ICU experienced at least
  1 episode of delirium
• http//ccforum.com/content/9/4/R375

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Delirium The Cost?

• Ely et al (2001) identified delirium as the
  strongest independent determinant of length of
  stay in the hospital
• Ely et al (2004) identified delirium as a cause
  of higher mortality
• Milbrant et al (2004) calculated that delirium
  was associated with an increase in the cost of
  care by 39 in ICU and 31 across the whole
  hospital stay
• Delirium may also predispose ICU survivors to
  prolonged neuropsychological deficits

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Our Perspective

• Self Harm
• Harm to other patients
• Harm to staff
• Concerns about the Use of Restraint (physical or
  chemical)
• Staff Discomfort
• Not Trained
• Using correct drugs?
• Using correct doses
• Over sedation?

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• The need to protect patients from self harm, to
  protect staff from incidents of aggressive
  behaviour from patients and the need to avoid
  increases in the levels of post operative
  morbidity and mortality, make a coordinated
  approach to the care of delirium a very high
  priority.

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How Do We Identify It?

• Richmond Aggitation Sedation Scale
• RASS
• ICU - Confusion Assessment Method
• ICU-CAM

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And
And / Or
4. Altered Level of Consciousness
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WHAT NOW?

• Is it Delirium? Assessment
• Hyper/ Hypo/ Mixed?
• Treatment Plan
• Restraint?

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BACCN Position Statement

• The purpose of restraint is to facilitate optimal
  care of the patient
• Use of restraint must not be an alternative to
  inadequate human or environmental resources
• Restraint should only be used when alternative
  therapeutic measures have proved to be
  ineffective to obtain the desired outcome.
• Decisions regarding the use or non-use of
  restraint must be made following a detailed
  patient assessment by the interdisciplinary team.
• Critical care areas must develop and implement
  protocol/ guidelines in order to assist nurses
  and others in this process.
• Whatever form of restraint is used there must be
  appropriate, continual assessment tools used and
  the findings acted upon
• Clear concise documentation of decisions, plans
  and treatment must be held within the patients
  record.
• The patient and their family should be engaged
  within the discussions to inform them of the
  reason for choice of the restraint method.
• Education for all staff regarding chemical,
  physical and psychological restraint must
  encompass training and competency programmes in
  critical care units

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Ethical Planning

• Nursing Care
• Environment
• Noise Levels
• Orientation
• Assessment
• Are they Delirious?
• Treatment
• Right drug, right time, right diagnosis

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Nursing care

• minimise risk factors
• repeated reorientation of patients
• provisions of stimulating activities for the
  patients throughout the day
• avoidance of night sedation
• early mobilization
• the earliest possible removal of invasive lines/
  catheters etc
• use of spectacles and hearing aids to facilitate
  effective communication
• early correction of dehydration
• effective pain control
• minimization of unnecessary noise/stimuli.

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Standard For The Night Environment on CTCC(based
on staff identified issues)

• Blinds to outside windows will be drawn by 22.00
• Main lights (not including night lights) will be
  switched off by 22.00
• Pre-prescribed night sedation will be given by
  22.00
• Radios will be switched off by 22.00
• Printing will not be done between 22.00 07.00
• All phone ringers will be set to low
• Patients will not be woken for a non essential
  wash
• Alarm limits will be checked at the beginning of
  the night shift adjusted to individually
  required parameters
• Alarms will be cancelled attended to within 20
  seconds of onset
• Alarm parameters will be adjusted when an alarm
  reoccurs for a known condition which is being
  attended to
• Alarms will be cancelled prior to undertaking a
  planned procedure (e.g. . removal of an arterial
  line, taking an ABG, etc)
• Routine medical examinations will take place
  before 22.00 after 07.00
• All main corridor light switches will be labelled
  to identify which switch controls which light
• Registrars ward round will be completed by 23.00
• Restocking will take place before 22.00 after
  07.00
• Patient care activities will be grouped into the
  fewest possible interventions based upon
  individual assessment
• Staff noise to be kept to a minimal level between
  22.00 07.00

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Treatment?

• Use an antipsychotic to treat the delirium PLUS a
  benzodiazepine for rapid control of agitation
• Neuroleptics are superior to benzodiazepines in
  treating delirium that has been caused by factors
  other than alcohol withdrawal or sedative
  hypnotics.
• Haloperidol is the preferred antipsychotic
  because it has fewer active metabolites, limited
  anticholinergic effects, less sedative and
  hypotensive effects and can be administered by
  different routes.
• Lorazepam is the benzodiazepine of choice due to
  its sedative properties, rapid onset and short
  duration of action it also has a low risk of
  accumulation.

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Treating Hyper Active Delirium

• ADMINISTRATION OF IV LORAZEPAM/ MIDAZOLAM
• Midazolam intravenously 0.5-2mg stat
• This can be repeated as often as required to
  attain appropriate sedation
• Give one dose and wait for the haloperidol to
  take effect if possible
• If available use Lorazepam intravenously 1-2mg
  stat
• This can be repeated up to a max of 2mg every 4
  hours
• Flumazenil should be available to rapidly reverse
  side effects if they occur
• Start Haloperidol intravenously at 0.5-5mg stat
• Observe the patient for 20-30mins
• If the patient remains unmanageable but has not
  had any adverse effects (e.g. hypotension,
  neuroleptic effects) DOUBLE the dose and continue
  monitoring
• Repeat the cycle until an acceptable response or
  unacceptable side effects occur
• Upper limits on doses have not been clearly
  established
• Haloperidol IV up to 100mg in 24 hours
• Haloperidol IV in conjunction with
  benzodiazepines up to 60mg in 24 hours.

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Treating Hypo Active Delirium

• Haloperidol IV/PO 0.5-5mg 2-3 times a day
• Regular treatment for a few days may be required
  to treat delirium.
• Reduce the dose gradually over the following few
  days.

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Alcohol Withdrawal?

• Benzodiazepines are the first line treatment
• Antipsychotics are not effective in treating
  delirium associated with alcohol withdrawal
• Take note of your patients history

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Any Other Factors?

• Drug therapy can contribute to the development of
  delirium
• Prompt cessation of medication that is no longer
  required can help to minimise the risk

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• Drugs that exhibit antimuscarinic activity are
  particularly associated with the development of
  delirium
• Establishing a day / night cycle is widely held
  to be important and many drugs are known to
  affect sleep pattern.

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In Conclusion

• Ethics Are we contributing?
• Environment
• Drugs
• Assessment
• 2 Step Approach
• RASS ICU-CAM
• Treatment Plan
• HyperActive Delirium
• HypoActive Delirium

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References

• BNF No 49 March 2005
• Bray et al. British Association of Critical Care
  Nurses position statement on the use of restraint
  in adult critical care units, BACCN, Nursing in
  Critical Care, 2004, Vol 9, No 5.
• Bourne RS and Mills GH. Sleep disruption in
  critically ill patients - pharmacological
  considerations. Anaesthesia 2004 59 374-84.
• Ely E.W. and Vanderbilt University.
  http//www.icudelirium.org/delirium/training-pages
  /trainingman.pdf. 2002
• Ely EW, Gautam S, Margolin R, Francis J, May L,
  Speroff T et al. The impact of delirium in the
  intensive care unit on hospital length of stay.
  Intensive Care Med 2001 271892-1900.
• Ely, E.W., Shintani, A., Truman, B., Speroff, T.,
  Gordon, S.M., Harrell, F.E., Inouye, S.K.,
  Bernard, G.R., Dittus, R.S. Delirium as a
  predictor of mortality in mechanically ventilated
  patients in the intensive care unit. JAMA.
  291(14) 1753-1762, 2004.
• Han L et al. Use of medications with
  anticholinergic effect predicts clinical severity
  of delirium symptoms in older medical inpatients.
  Arch Intern Med 2001 161 1099-1105.
• Jacobi J et al. Clinical practice guidelines for
  the sustained use of sedatives and analgesics in
  the critically ill adult. Crit Care Med 2002 30
  119-41.
• Jason WW Thomason, Ayumi Shintani, Josh F
  Peterson, Brenda T Pun, James C Jackson and E
  Wesley Ely. 2005. Intensive care unit delirium is
  an independent predictor of longer hospital stay
  a prospective analysis of 261 non-ventilated
  patients. http//ccforum.com/content/9/4/R375
• Mayo-Smith, M et al. 2004 Management of alcohol
  withdrawal delirium. Arch Intern Med (164)
  1405-1412
• Meagher D. Delirium Optimising Mangement, BMJ
  2001 322 144-9
• Milbrandt, E.B., Deppen, S., Harrison, P.L.,
  Shintani, A.K., Speroff, T., Stiles, R.A.,
  Truman, B., Bernard, G.R., Dittus, R.S., Ely,
  E.W. Costs Associated with Delirium in
  Mechanically Ventilated Patients. Crit. Care Med.
  32 (4)955-962,2004.
• NICE Guidance. 2005. Violence The short-term
  management of disturbed/violent behaviour in
  psychiatric in-patient settings and emergency
  departments
• Sessler et al, Am J Respir Crit Care Med 2002 and
  Ely et al JAMA 2003
• Skrobik Y, Bergeron N, Dumont M, Gottfried S
  (2004) Olanzapine vs Haloperidol treating
  delirium in a critical care setting Intensive
  Care Med 30444-449
• Truman B, Ely EW. Monitoring delirium in
  critically ill patients. Crit Care Nurse
• 2003 2325-36.

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Any Questions

• Please feel free to wake up and ask any questions
  that you may have!