#4 Delirium w/ Dr Wes Ely

NeurologyHumanitiesGuest Episode
Written By Nick Mark

What is consciousness? Plum and Posner define this as Arousal & Content

  • Arousal:   “Arousal Assessment” – i.e. the RASS (Richmond Agitation & Sedation Scale)

The Richmond Agitation & Sedation Scale (RASS)

  • b.     Content: “Delirium Tool” – i.e. CAM-ICU (see below)

The CAM-ICU tool

  • We use both RASS & CAM-ICU to assess arousability & likelihood of delirium

  • These tools can be used anywhere in the hospital, in modified versions – they are not unique to the ICU!

What is delirium?

  • Global brain dysfunction… trillions of neurons, trillions of glial cells not functioning correctly

    • Phenotypically: inability to maintain attention (inattentiveness)

  • Test: CASABLANCA, SAVEAHAART, etc… see if patient can listen to what you are saying & squeeze or blink when the letter “A” is stated

    • May have hallucinations, disorganized thought

    • A form of organ dysfunction independently associated with mortality, increased length of stay and increased incidence of dementia / long-term disability.

  • Rates of delirium across ICUs

    • ~70% in intubated patients

    • ~40% in non-intubated patients

  • Approaching delirium in the critically ill

    • Delirium is associated with a reduction in brain volume

    • Follow the “Dr. Dre” or “DR-DR-E”

      • DR = Disease Remediation – how can I cure or otherwise mitigate the effects of the underlying disease process

        • Treat pain

        • Treat hypoxemia/hypoxia

        • Improve perfusion

      • DR = Drug Removal – what drugs are contributing to this patient’s delirium or risk for delirium

        • Excessive sedatives or analgesics?

        • Un-necessary antipsychotics?

        • Medications with untoward side effects?

        • Polypharmacy?

      • E = Environment – What can be added or removed from the patient’s surroundings to improve their delirium or mitigate their risk for delirium?

        • Glasses?

        • Hearing Aids?

        • Incorporate family whenever possible!!

        • Family can provide an element of therapy that we simply cannot!

        • Facilitate diurnal variation (lights, TV, radio, activity during the day vs darkness, quiet, etc. at night)

  • The A-F Bundle

    • An approach to ICU liberation that has been validated in over 20,000 patients which, per SCCM

      • Decreases likelihood of hospital death within seven days by 68%

      • Reduces delirium an coma days by 25-50%

      • Cuts ICU readmissions by 50%

      • Reduces discharges to nursing and rehab facilities by 40%

    • What is the A-F Bundle?

      • Assess, Prevent & Manage Pain

        • Consider whether pain is being effectively managed, what should be added, what can be removed

      • Both spontaneous awakening trials and spontaneous breathing trials

        • Wake up and breathe!

      • Choice of analgesia and sedation

        • Avoiding overuse of sedatives & GABAergic drugs

      • Delirium: assess, prevent & manage

        • Assess the CAM-ICU & run the “Dr. Dre”

      • Early mobility & exercise

        • Get your patients moving! There is data to support this!

      • Family engagement and empowerment

        • Again – family needs to be involved, and can provide an element of treatment that we simply cannot provide as doctors, nurses, therapists, etc.

  • Nuts & Bolts

    • Patients that are admitted to the ICU and receive RSI drugs (paralytics, sedatives, etc.) and are initially placed on the ventilator are at the “arc” of their illness

      • This is the time to start thinking about what medications or interventions can be removed in the next 24 hours!

      • Example: stop a sedative or analgesic, if it works out great – if not restart at half the dose!

    • “If you aren’t escalating care… you should be deescalating.”

    • What medications can you reach for to “treat” delirium?

      • MIND-USA (2018)- Haloperidol vs Ziprasidone vs Placebo for Delirium Treatment in Critical Illness: Neither the atypical or typical anti-psychotic outperformed placebo

      • AID-ICU (2022): Treatment of delirium in the ICU with haloperidol did not improve number of days alive and out of the hospital at 90 days versus placebo, however, there was a non-statistically significant trend identified with respect to mortality that favored the use of haloperidol

      • Unfortunately, there is no data that suggests antipsychotics reduce the duration of brain dysfunction (i.e. delirium) in these patient populations

    • Hyperactive delirium: anti-pyschotics or an alpha-2-agonist can be helpful when a patient poses a threat to themselves or others

      • These drugs don’t suppress the respiratory drive – okay to use with non-invasive positive-pressure ventilation

      • Alpha-2-agonists: dexmedetomidine, guanfacine, clonidine

      • Dexmedetomidine:

    • Anti-psychotics: haloperidol (typical), ziprasidone (atypical), quetiapine (atypical)

    • Use the lowest dose, know why you are doing it, and how/when you are going to stop the agent

    • Pain in the critically ill

      • Opioids are associated with increasing an incidence of delirium

      • However, this does NOT cross-over into the burn intensive care unit

      • Consider NSAIDs, acetaminophen, lidocaine patches, nerve blocks, epidurals when appropriate

  • Non-pharmacologic interventions

    • Consider eye-covers and/or ear-covers (after checking with the patient, family!)

Follow Dr. Ely: @WesElyMD on Twitter & TikTok!

See the complete infographic below:

Critical Care Time infographic about how to prevent, diagnose, and treat delirium in the ICU

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Nick Mark
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