DIAH MUSTIKA HW SpS,KIC Intensive Care Unit of Emergency Department Naval Hospital dr RAMELAN, Surabaya

Transcription

1 DIAH MUSTIKA HW SpS,KIC Intensive Care Unit of Emergency Department Naval Hospital dr RAMELAN, Surabaya

2 Encephalopathy is a common complication of systemic illness or direct brain injury. Acute confusional state, acute organic brain syndrome, acute cerebral insufficiency most commonly as delirium

3 Acute alteration of consciousness and higher cognitive function Develops over a short of period time Fluctuating course Precipitated by several diverse pathological process DSM IV TR Incidence 5%-40% in general hospitalized patient and 11%- 80% in critically ill

4 a. Disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with reduced ability to focus, to sustain, or to shift attention. b. A change in cognition (such as memory deficit, disorientation, or language disturbance) or the development of a perceptual disturbance that is not better accounted for by a preexistin, estabilished or evolving dementia. c. The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day. d. There is evidence from the history, physical examination, or laboratory findings thet the disturbance is caused by the direct physiologic condequences of a general medical condition. From American Psychiatric Association. Task Force on DSM-IV. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR, 4 th ed. Washington, DC: American Psychiatric Association; 2000

5 Age > 70 years Male Poor functional status Malnutrition Substance abuse Premorbid medical conditions or cognitive impairment Polypharmacy Physycal restraint Visual or hearing impairment Prior history of delirium

6 Vascular Infectious Inflammatory Neoplastic Legal and illegal drugs Recent surgery Ischemic stroke, transient ischemic attack, subarachnoid hemorrhage, intracerebral hemorrhage, epidural hematoma, subdural hematoma, cerebal venous thrombosis, myocardial infarction, pulmonary embolism, extreme hypertension/hypotension. Meningitis, encephalitis, cerebral abcess, neurosyphilis, Lyme disease, systemic sepsis, HIV infection and complications, pneumonia, urinary tract infection. CNS lupus erythematosus, Giant cell arteritis, neurosarcoidosis. Systemic cancer, paraneoplastic syndromes, CNS tumors, carcinomatous meningitis. Anticholinergics, narcotics, benzodiazepines, barbiturates, anesthetic, digitals, corticosteroids, antiparkinsonian, antiepileptics, immunosuppressants (tacrolimus), recreational drugs (abuse or withdrawal), over-the-counter medications, herbal preparations. Cardiac, orthopedic, CNS surgery, other invasive

7 Trauma Metabolic Endocrine Epileptic Nutritional Hereditary Miscellaneous Traumatic brain injury, multiple organ trauma, air or fat embolism. Liver failure, uremia, hypoglycemia, hyperglycemia, electrolyte abnormalities, hypercarbia, hypoxia. Thyroid, parathyroid, pituitary, adrenal gland dysfunction, uncontrolled diabetes, pancreatitis. Postictal conditions, status epilepticus (convulsive or nonconvulsive) Thiamine, B12, folic acid deficiencies Mitochondrial disorders (MELAS) Anaemia, dehydration, volume overload, burns, chronic obstructive pulmonary disease (COPD), migraine, sensory deprivation, sleep deprivation, posterior reversible encephalopayh syndrome, Reye syndrome.

8 Alteration of consciousness impairment of arousal : paradoxical agitation to sedation and stupor Attention impairment Fluctuation of symptomatology Hallucination, disorientation and perceptual distortion. Visual hallucination and illusions may result in attempt to dislidge to ET or IV lines Disorganized thinking

9 1. The Confusion Assessment Metod for the Intensive Care Unit (CAM-ICU) 2. The Intensive Care Delirium Screening Checklist

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11 History Clinical Examination : general and neurologic clinical examination Laboratory investigations Electrocardiogram Chest X ray Electroencephalogram Computed tomography of the brain

12 Primary prevention of delirium Identification of patient at high risk for developing delirium Early detection of syndrome Identification and treatment of underlying etiologies Environmental modifications, nonpharmacologic management Symptomatic pharmacologic management Mechanical Ventilation

13 Drugs Dose Comments Haloperidol Risperidone Olanzapine Quetiapine Younger patients 2-5 mg IV q2h Older patients mg IV q2h Younger patients mg PO/day Older patients mg PO q12h Younger patients mg PO/day Older patients mg PO at night Younger patients mg PO/day Older patients 12.5 mg PO at night Extrapyramidal side effect QTc prolongation Can induce delirium QTc prolongation Not to be used with age >70 years Increases glucose levels Less QTc prolongation QTc prolongation, but can be used following haloperidolinduced prolonged QTc Lorazepam mg IV/PO q8h Monitor sedation level and respiratory rate.

14 Encephalopathy is a index of acute CNS dysfunction Precipitated by multiple underlying disease should be actively treated Neurologic damage my progress to coma if untreated Effective management is multimodal and requires coordination of the team

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