ICU Delirium A Real Epidemic (or are we delirious)?
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1 ICU Delirium A Real Epidemic (or are we delirious)? CCCF: Toronto October 2014 Jesse Hall MD University of Chicago Section of Pulmonary and Critical Care Medicine
2 Faculty Disclosures Dr. Hall receives honoraria from the ACCP for board review course and SEEK receives honoraria from McGraw-Hill and Taylor-Francis publishing
3 10 Big Mistakes in Intensive Care Medicine (JLV, JBH, AS) 1-We focus too much on syndromes prominently ARDS, sepsis, acute kidney injury (AKI), and we spend much time redefining them. Even though we considered sepsis as a too vaguely defined entity, treatments were studied in prospective trials. Most were unsuccessful.. Better identification of patient populations is the key. Instead of general phenotypes (fever and tachycardia), we should uncover the basic cellular alterations characterizing critical illness, and by doing so better characterize the patients' status.
4 ICU delirium is our neurologic syndrome
5 J Crit Care 2011 Both the Confusion Assessment Method for the ICU (North America) and the Intensive Care Delirium Screening Check List (Europe) came into wide Application in
6 LOS, mortality, morbidity assoc with ICU delirium Ely, JAMA 2004
7 LOS, mortality, morbidity assoc with ICU delirium Ely, JAMA 2004
8 Cox Model HR Age 1.03 IADL 1.30 Comorbidity 1.21 Delirium day 1.10 For each day of delirium, 1-yr mortality increased by 10% Pisani MA et al., AJRCCM 180: 1092
9 Don t just stand there.. AJRCCM 2014
10 Don t just stand there.. AJRCCM 2014
11 What is the true incidence of delirium in the ICU? Case Mix Assessment Tool Sedation Practice 32% 81%
12 All cases of delirium are created equal, but some are more equal than others.
13 Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) Coma
14 A Day in the Life of RASS RASS Time
15 Sedatives and Delirium Ely EW, JAMA 291: 1753
16 Remarkably in > 10 yrs of reporting the incidence of delirium/coma, determining its association with outcomes, and even conducting interventional trials, we have not attempted to disentangle (within the limits of necessary patient care) the sedation-delirium problem
17 AJRCCM 2014
18 Patel et al 29% of patients scored as delirious had delirium absent when reassessed after sedation hold (up to 2 hrs) CAM-ICU 10.5 x more likely to dx delirium if done during sedation administration than after hold This rapidly reversible delirium showed reduced LOS, duration of MV, and improved survival as compared to persistent delirium AJRCCM 2014
19 AJRCCM 2014
20 AJRCCM 2014
21 AJRCCM 2014
22 Point 1 and its corollaries 1/4 to 1/3 of MV patients who would be scored by CAM-ICU as delirious have a rapidly reversible delirium demonstrable by sedation hold and their delirium does not associate with poor outcome Should be built into monitoring for delirium These patients should be stratified (excluded?) in intervention trials These patients not likely to yield fruitful results in mechanistic studies
23 Potential reversible causes of delirium that might not result in long-term brain dysfunction Drugs Hepatic encephalopathy Electrolyte disturbances Cerebral edema Hypothermia
24 The typical severely ill ARDS patient with exposures to both reversible and non-reversible insults Short-term coma/delirium near universal Extensive delirium testing in extreme AHRF not feasible Longterm neuropsychiatric dysfunction near universal Imaging studies not clear as to a macroscopic lesion (perhaps just volume loss VISIONS MRI data) Correlations not tight for hypoxemia, PPV exposures
25 Toward a better understanding of the brain in critical illness AJRCCM 2013
26 A bad brain-ventilator connection Murine model of high + low pressure MV with hippocampal apoptosis and Akt survival pathway studied Studies also done in vagotomized, haloperidol-treated, and local brain dopamine-blocked animals Findings MV triggers hippocampal apoptosis as a result of type 2 dopaminergic receptor activation in response to vagal signaling also causes alterations in dysbindin 1, a protein known to regulate cell surface D2R recycling in neurons Dysbindin 1 results confirmed in brain slices of humans who had undergone MV AJRCCM 2013
27 AJRCCM 2013
28 AJRCCM 2013
29
30 Point 2 For the pool of patients in whom we know delirium strongly associates with poor longterm outcome We need to better understand mechanisms linking brain injury to ICU diseases and interventions/environment, such as MV In addition to minimizing exposure to the injurious force (eg high lung vols/pressures) we need to consider interruption of adverse neural pathways or enhancement of neuroprotective pathways
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