Thread by @laxswamy

Highlights from an ICU delirium talk I give to the residents, please share your thoughts & feedback! Image credit: deliriumcarenetwork.com/art.html

Delirium: An acute change in attention, awareness and cognition caused by a medical condition that cannot be better explained by a pre- existing neurocognitive disorder. Often reversible.

Drugs don’t work to treat it... but they can precipitate it.

Patients often have altered arousal- from reduced responsiveness at a near- coma level (hypoactive) to hypervigilance & severe agitation (hyperactive)

Hypoactive delirium is a/w worse outcomes, including ⬆️mortality, ⬆️length of stay, ⬆️falls and institutionalization, lower QOL.

Citation: Garrett RM. Reflections on delirium – A patient’s perspective. Journal of the Intensive Care Society. 2019;20(3):258-262. doi:10.1177/1751143719851352

Terminology is confusing!
Delirium: formal clinical syndrome (phenotype)
Acute encephalopathy: rapidly developing (hours to days) diffuse pathobiological process, may manifest as delirium or coma

I do NOT say: Acute brain failure, Acute confusional state, Organic brain syndrome

Delirium is COMMON:
Inpatient: ~23%
Post-surgical: >20% in high risk patients, emergency surgery
Acute stroke: 25%
Palliative care: ranging from 60-90% close to death
ICU: ~30% for all ICU; 50-70% for mechanical ventilation

Citation: theatlantic.com/video/archive/…

Patient risks for delirium:
Age, visual and hearing impairment
Cognitive impairment (dementia, developmental delay)
Frailty, poor nutrition
Medical comorbidities (CV, renal)
Depression / other psych illness
Substance use including alcohol, opiates
Prior delirium

Iatrogenic risks:
Critical illness (esp sepsis), electrolytes, AKI, liver dysfunction, seizure, CHF
Mechanical ventilation
Major surgery/trauma
Substance use/withdrawal, deep sedation, benzos, antihistamines, opioids
Hypoglycemia
Psych stress, sleep deprivation, untreated pain

There are some models to predict delirium, for ex below. But mostly I think you can assume many ICU patients are at high risk for the reasons above. evidencio.com/models/show/608

What is actually happening in the brain? I like the ✨Bioenergetic Insufficiency Model✨
Citation: Wilson, J.E., Mart, M.F., Cunningham, C. et al. Delirium. Nat Rev Dis Primers 6, 90 (2020). doi.org/10.1038/s41572…

Bioenergetic Model
🔸Resp failure → brain hypoxia
🔸Shock = reduced blood flow: hypoxia, hypoglycemia
🔸🧠microcapillary dysfunction → same
🔸Impaired neurovascular coupling, local ischemia/hypoglycemia
🔸Systemic hypoglycemia
🔸Insulin resistance
🔸Impaired glucose management

Citation: Einar Brünniche, “Memory images of acute, alcoholic delirium”, 1919. Source: Psychiatry in pictures. The British Journal of Psychiatry. 2007;190(6):a22.
h/t @marktuttle

Delirium Outcomes:
🔸20% of patients have persistent delirium at 6 months.
🔸A/w many poor outcomes, including⬆️ post- discharge mortality as well as new institutionalization and dementia
🚨Outcomes worse in: elderly, frail, hypoactive delirium, long duration & severe delirium

Citation: Garrett RM. Reflections on delirium – A patient’s perspective. Journal of the Intensive Care Society. 2019;20(3):258-262. doi:10.1177/1751143719851352

Assessing Delirium - two main instruments, the CAM ICU and the Intensive Care Delirium Screening Checklist (ICDSC)

CAM ICU: Acute onset & fluctuating course, inattention, disorganized thinking, level of consciousness; sensitivity 80%, specificity 96%

Intensive Care Delirium Screening Checklist (ICDSC): yes/no to Altered LOC; Inattention; Disorientation; Hallucination, delusions; Agitation; Inappropriate speech; Sleep–wake disturbances; Symptom fluctuation → 4 or more is positive

Whichever instrument is used, ideally you have the results presented for every patient in the chart right there with vital signs, sedation scores, etc so they can be clearly discussed and universally understood on rounds. That requires significant multidisciplinary support!

Preventing Delirium:
🔸Early recognition of high-risk pts
🔸Light sedation, avoid benzos
🔸Early mobilization- PT/OT
🔸Promote day/night
🔸Environmental awareness & orientation
🔸Remove devices
🔸Reduce interventions - POC glucose, lab draws
🔸Avoid restraints
🔸FAMILY VISITS

What about meds? MIND-USA: largest RCT to examine 💊 for the treatment of ICU delirium
Haldol, ziprasidone, placebo in 566 ICU pts w delirium: no significant effect!
⚠️Evidence does NOT support haldol or 2nd gen antipsychotics for delirium prevention⚠️
nejm.org/doi/full/10.10…

Potential Therapies:
Dexmedetomidine: 3 multicenter RCTs support use: ⬇️delirium than GABA agents (benzos, propofol).
Delirium resolved 16h (40%) earlier & extubation ~17h earlier among patients treated w Dexmedetomidine than in those who rec'd placebo.

'Using dexmedetomidine for delirium in mechanically ventilated adults where agitation is precluding weaning/extubation (conditional recommendation, low quality of evidence' - @SCCM sccm.org/getattachment/…

Quetiapine: small RCT (n=36) ICU pts rec’d seroquel vs placebo. Need more data. What is your experience?

ICU Delirium: Treatment
🔸Address multiple delirium triggers
🔸Correct physiological disturbances
🔸Treat symptoms of delirium including distress
🔸Communicate with patient and caregivers
🔸Address current and future risks linked with delirium

Use the ABCDEF bundle! Credit: sccm.org/ICULiberation/…
@SCCM

More from the ABCDEF bundle. Don't worry about the details on the graphs, but notice how the lines go down with increased bundle performance.

More of the @SCCM guidelines in the next few slides. Links above.

@SCCM

@SCCM

@SCCM

Some of my thoughts on delirium & COVID-19

Thanks for reading, apologies for the long format and looking forward to your feedback so I can improve my teaching! 🙏🏾

tl;dr: benzos are bad