Thread by @virenkaul

I'm not a big #tweetorial person, more a #bitesized learning guy.
But important topic + healthy peer pressure =
Let's talk about #Delirium in the ICU (#DICU)!
For the most part, this is applicable to most patients.

Q: Do you regularly assess for #DICU?

What does delirium look like?
<5% "hyperactive": EASY TO JUDGE these pts
95%: "hypoactive" or mixed: somnolent, not accepting feeds, withdrawn:
EASY TO MISS these pts

What's the big deal?
Vent time 🔼 8d
Hosp LOS 🔼 by 8d
Cognitive impairment at D/C: 50%, long term: 33%

WHAT is delirium:
😣 Altered level of consciousness (hyper/hypoactive) +
🙄 Inattention

With either:
😇 Change in cognition (who, you?, what is life?) OR
🤓 Change in perception

Easy to miss in a patient that isn't "belligerent" or "climbing out of the bed". It can be SUBTLE!

#DICU predisposed:
Elderly 🧓
Dementia
Depression / other underlying mental health disorders
Poly💊🧓

#DICU precipitated by:
Meds 💉
🆕 Surroundings
Major illness🏥
ICU admission
Emergent surgery / trauma😷

Which is MOST, if not all, our ICU patients!

*Blue: Modifiable*

CAM-ICU is > 90% sensitive and specific for assessing #DICU!
2 - 3 minutes to perform.

Check this worksheet by @AACNme out!

Caveat:
- Patient RASS needs to be > - 3 to perform CAM-ICU
- Even RASS - 2 can OVERESTIMATE #DICU (77% vs 23% if RASS -1/0)
- Repeat measurements

Hey, wait!

Before you decide your patient has #DICU,
Consider the differential:
🧠 CNS/psych path/lesions: bleed/stroke/seizure/dementia/depression
💥 Tox/metabolic causes: Na/substance/withdrawal/Glu/Meds (BZD)/O2
🤒 Infections: meningoenceph/UTI/sepsis
👹 Organ failures

With all this in mind, which patients should be considered by PREVENTION of delirium in the ICU?

There are risk predictors, but most ICU patients have critical illness,
IMO they are ALL at risk.

They all DESERVE delirium prevention.

Meds: Data DOES NOT support using antipsychotics!
Su (2016): Dex reduces delirium vs placebo (77% vs 32%): bit.ly/2UZVJOA

Nocturnal (9:30 PM to 6:15 AM) Dexmedetomidine allowed more patients to stay delirium free: 80% vs 54% for placebo.

n = 50, but still a neat idea.

W/ some data supporting improvement in sleep physiology, we may have a new tool, but more to come!

bit.ly/2Fm1cex

#Melatonin agnosists (melatonin, ramelteon) have shown promise in delirium prevention too, likely from beneficial effect on the #sleep - wake cycle. 3 positive RCTs + minimal downside. Personally, I've had good results too! Slide adapted from @PulmCrit

What's really effective in preventing delirium?

💉 STOP offending meds (BZDs, antihistaminics, etc)
😴 SLEEP at NIGHT!
🏃‍♀️Mobility during day
💩 5Ps: Poop (constipation), Pee (urinary retention), Pain, Positioning, Presence (meaningful contact: TALK TO THEM!)

#DICU

Wondering why I even asked about checking for delirium if am advocating preventive measures on EVERYONE?

Early identification⏭️Aggressive removal of offenders⏭️Rx⏭️ Monitor response!

I hear a why!
Rapidly reversed (<2 hours) sedative related delirium outcomes = no delirium!

Coming to Rx:

Antipsychotics don't seem to work (see slide)
Early, tiny bit of data for using Dex (it's the new star!): DahLIA study
MIND-USA (2018): no diff in delirium free days: Haldol vs ziprasidone vs placebo. H/T @timothygirard for nicely done study, sharing his insight!

What DOES work for Rx:

MULTIMODAL NON PHARM measures! Significant data in support H/T PADIS by @SCCM
#ABCDEF bundle (bit.ly/2V001Wc) shown in study to reduce delirium
Also better compliance with bundle, IMPROVED HOSPITAL MORTALITY!

#ABCDEF:

A: Assess, manage, prevent pain
B: Both sedation vacation + breathing trials
C: Choose sedatives / analgesics well (🚫fent gtt for everyone)
D: Delirium mgmt
E: Early mobility
F: Family engagement / empowerment

PS: #whiteboard teaching on my rounding delirium checklist

So. before you tuck in for the 🌃, or as you are working your way through your morning ☕️;

Which of our ICU patients will you be assessing for and working hard to prevent delirium in? #DICU #Delirium #ICUliberation #ABCDEF #Prevent

Thank you to everyone shared their experience yesterday! @laxswamy and @ETSshow for making me take a full on plunge into tweetorializing, and esp @timothygirard for taking time out to review my slides!

The full presentation is here, in case: bit.ly/2JTiJxF