PREVENZIONE E TERAPIA DEL DELIRIUM NEI REPARTI DI CURA INTENSIVA. Giuseppe Natalini Terapia Intensiva Fondazione Poliambulanza Brescia
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1 PREVENZIONE E TERAPIA DEL DELIRIUM NEI REPARTI DI CURA INTENSIVA Giuseppe Natalini Terapia Intensiva Fondazione Poliambulanza Brescia
2 TERAPIA FARMACOLOGICA
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4 Quetiapina Devlin JW. Efficacy and safety of quetiapine in critically ill patients with delirium: A prospective, multicenter, randomized, double-blind, placebo-controlled pilot study Crit Care Med 2010; 38:419-27
5 ...meglio prevenire...
6 PREVENZIONE FARMACOLOGICA
7 Wang W et al. Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery: a randomized controlled trial. Crit Care Med 2012; 40:731-9
8 Girard TD. Feasibility, efficacy, and safety of antipsychotics for intensive care unit delirium: The MIND randomized, placebocontrolled trial. Crit Care Med 2010; 38: Page VJ. Effect of intravenous haloperidol on the duration of delirium and coma in critically ill patients (Hope-ICU): a randomised, double-blind, placebocontrolled trial. Lancet Respir Med 2013; 1:515 23
9 ...anche la prevenzione farmacologica...
10 LA SEDAZIONE
11 van den Boogaard M. Development and validation of PRE-DELIRIC (PREdiction of DELIRium in ICu patients) delirium prediction model for intensive care patients: observational multicentre study. BMJ 2012;344:e420 alfa-2 agonisti: buona alternativa (dexmedetomidina, clonidina?) Pandharipande PP. JAMA. 2007; 298: Maldonado JR. Psychosomatics 2009; 50: Riker RR. JAMA 2009; 301: Shehabi Y. Anesthesiology 2009; 111: Rubino AS. Interact Cardiovasc Thorac Surg 2010; 10:58-62 oppioidi: solo a dose analgesica Dubois MJ. Intensive Care Med 2001; 27: Ouimet S. Intensive Care Med 2007; 33:66 73 Pandharipande PP. J Trauma 2008; 65:34-41 Pisani MA. Crit Care Med 2009; 37: Agarwal V. J Burn Care Res 2010; 31:706-15
12 Conclusione: farmaci e delirium Prevenzione: forse anziani con bassa gravità Terapia: aloperidolo per trattare episodi acuti (quetiapina?) Sedativo di prima scelta (per il delirium): dexmedetomidina Oppioidi: solo per analgesia
13 PREVENZIONE NON FARMACOLOGICA
14 Strategia di riorientamento HR 0.50 [95% CI: ] (p=0.03) Colombo R. A reorientation strategy for reducing delirium in the critically ill. Results of an interventional study. Minerva Anestesiol 2012; 78:
15 Rispetto del sonno notturno Van Rompaey B. The effect of earplugs during the night on the onset of delirium and sleep perception: randomized controlled trial in intensive care patients. Crit Care 2012; 16:R73
16 Terapia fisica ed occupazionale precoce Schweickert WD. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009; 373:
17 Zaal IJ. Intensive care unit environment may affect the course of delirium. Intensive Care Med 2013: 39:481-88
18 Balas MC. Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle. Crit Care Med 2014; 42: Khan BA. Effectiveness of Implementing a Wake Up and Breathe Program on Sedation and Delirium in the ICU. Crit Care Med 2014; 42:791-5
19 Prevenzione non farmacologica Nei gruppi di controllo i pazienti erano sottoposti a condizioni di disorientamento e depersonalizzazione, inutilmente immobilizzati nel letto, tenuti inutilmente svegli, senza privacy...
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22 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th edition.2013.
23 Maldonado JR. Am J Geriatr Psychiatry 2013; 21:
24 Girard TD. Associations of markers of inflammation and coagulation with delirium during critical illness. Intensive Care Med 2012; 38:
25 Delirium e ARDS Hsieh SJ. The association between Acute Respiratory Distress Syndrome, delirium, and in-hospital mortality in Intensive Care Unit patients. Am J Respir Crit Care Med 2015; 191:71-8
26 INFIAMMAZIONE E VENTILAZIONE
27 Pelosi P. The lung and the brain: a dangerous cross-talk. Critical Care 2011, 15:168
28 Dreyfuss D. Ventilator-induced Lung Injury. Lessons from experimental studies. Am J Respir Crit Care Med 1998; 157: Slutsky AS. Ventilator-Induced Lung Injury. N Engl J Med 2013;369:
29 Ranieri MV. Effect of mechanical ventilation on inflammatory mediators in patients with acute respiratory distress syndrome. JAMA. 1999;282:54-61 Pintado MC et al. Individualized PEEP setting in subjects with ARDS: A randomized controlled pilot study. Respir Care 2013 ;58:
30 Amato MBP. Driving pressure and survival in the Acute Respiratory Distress Syndrome. N Engl J Med 2015; 372:747-55
31 paziente passivo + flusso inspiratorio costante Ranieri VM. Pressure time curve predicts minimally injurious ventilatory strategy in an isolated rat lung model. Anesthesiology 2000; 93:1320-8
32 SONNO E VENTILAZIONE
33 60% dei pazienti ventilati ha disturbi del sono dovuti alla ventilazione meccanica Bergbom-Engberg I. Assessment of patients experience of discomforts during respirator therapy. Crit Care Med 1989; 17: Ozsancak A. Sleep and mechanical ventilation. Crit Care Clin 2008; 24:517-31
34 Il problema della PSV Meza S. Susceptibility to periodic breathing with assisted ventilation during sleep in normal subjects. J Appl Physiol 1998; 85:
35 ACV vs PSV Parthasarathy S. Effect of ventilator mode on sleep quality in critically ill patients. Am J Respir Crit Care Med 2002; 166:1423-9
36 PSV con basso volume corrente Cabello B. Sleep quality in mechanically ventilated patients: Comparison of three ventilatory modes. Crit Care Med 2008; 36:
37 insufficienza respiratoria acuta su cronica Toublanc B. Assist-control ventilation vs. low levels of pressure support ventilation on sleep quality in intubated ICU patients. Intensive Care Med :
38 insufficienza respiratoria acuta su cronica Andrejak C. Does using pressure-controlled ventilation to rest respiratory muscles improve sleep in ICU patients? Respir Med 2013; 107:534-41
39 impostazione PSV sulla meccanica respiratoria Fanfulla F. Effects of different ventilator settings on sleep and inspiratory effort in patients with neuromuscular disease. Am J Respir Crit Care Med 2005; 172:619-24
40 Come migliorare il sonno durante la ventilazione meccanica 1) ventilazione assistita-controllata: prima scelta - spt malattie polmonari croniche 2) PSV: - ottimale: scegliere PEEP e supporto su PEEPi e sforzo inspiratorio del paziente (40-80%) - supporto inspiratorio: volume corrente max 7-8 ml/kg peso ideale, limitare asincronie e apnee Meza S. Susceptibility to periodic breathing with assisted ventilation during sleep in normal subjects. J Appl Physiol 1998; 85: Parthasarathy S. Effect of ventilator mode on sleep quality in critically ill patients. Am J Respir Crit Care Med 2002; 166: Fanfulla F. Effects of different ventilator settings on sleep and inspiratory effort in patients with neuromuscular disease. Am J Respir Crit Care Med 2005; 172: Toublanc B. Assist-control ventilation vs. low levels of pressure support ventilation on sleep quality in intubated ICU patients. Intensive Care Med : Bosma K. Patient-ventilator interaction and sleep in mechanically ventilated patients: pressure support versus proportional assist ventilation. Crit Care Med 2007;35: Cabello B. Sleep quality in mechanically ventilated patients: Comparison of three ventilatory modes. Crit Care Med 2008; 36: Andrejak C. Does using pressure-controlled ventilation to rest respiratory muscles improve sleep in ICU patients? Respir Med 2013; 107:534-41
41 Conclusioni: trattare e prevenire il delirium in Terapia Intensiva - approccio farmacologico al delirium al momento poco efficace - efficace la prevenzione non farmacologica (rivoluzione culturale) - ottimizzare la cura delle cause di delirium: infezioni, ventilazione, ecc. per curare bene il delirium non bisogna curare il delirium
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