ICU Delirium: Recognition, Management and Long-Term Outcomes

Transcription

1 ICU Delirium: Recognition, Management and Long-Term Outcomes Sandy Staveski RN, PhD, CPNP-AC/PC, CNS Assistant Professor, Nurse Scientist Cincinnati Children s Hospital Medical Center Research in Patient Services, Heart Institute University of Cincinnati College of Nursing (Affiliate Faculty) Vice President Nursing, Pediatric Cardiac Intensive Care Society Photos with permission

2 Disclosures Patient Services Research Scholars Award (PS2): Delirium after Pediatric Cardiac Surgery

3 Delirium - Definition Global encephalopathic process/generalized cerebral dysfunction Acutely developing and fluctuating syndrome that encompasses a number of neuropsychiatric symptoms including: Disturbance in consciousness, attention, cognition, or perception Disorientation, thought disorder, memory problems Language disorders Sleep disturbances Delusions, mood labiality, psychomotor changes, and hallucinations American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders, DSM-5; Turkel & Huft, 2014

4 Pathogensis of Delirium Circulating cytokines and locally acting chemokines Impaired cerebral blood flow Impaired oxidative metabolism Metabolic dysregulation Abnormal neurotransmitter release and complex neurotransmitter interactions Final common pathway in the production of delirium Dopamine and GABA levels increase Reduction in acetylcholine synthesis and function van der Mast, 1998; Seaman et al., 2006; Rooij et al., 2007; Turkel et al., 2013; Turkel & Hanft, 2014;

5 Delirium - Three Synergistic Events Underlying disease process Highly abnormal critical care environment Side-effects of treatment Silver et al., 2015

6 Types of Delirium Hypoactive Significant deficiency of dopamine or excess of acetylcholine or GABA Apathy, depressed level of consciousness, withdrawal from their environment or a being good patient" Hyperactive Excess of dopaminergic activity and acetylcholine antagonism Agitation, restlessness, emotional instability, psychosis Refractory agitation in children likely a marker for delirium in children Mixed fluctuates between hypoactive and hyperactive Schiveld et al., 2006; Smith et al., 2013

7 Delirium - Presentation Overlap of behavioral cues in pain, sedation, withdrawal syndrome, and delirium

8 Outcomes of Adult Intensive Care Survivors Numerous studies link delirium with increased mortality, longer length of intensive care unit stay (LOS), longer duration of mechanical ventilation, long-term cognitive impairment, depression, and post-traumatic stress disorder in adult intensive care survivors Schieveld et al., 2013; Pasani et al, 2007; McNicoll et al., 2003; Milbrandt et al., 2004; Ely et al., 2001: Ely et al., 2004; Hopkins & Jackson, 2006; Girand et al., 2010

9 Predisposing Factors for Delirium - Adult Cardiac Surgery Associated with age (elderly), weight, use of betablockers, higher opioid exposure, longer aortic cross-clamp time, atrial fibrillation, prior stroke/transient ischemic attack, abnormal serum albumin, & pre-operative cardiac/neurologic burdens increased the risk delirium in adult cardiac surgery patients Tse et al., 2015; Brown et al., 2016; Crocker et al., 2016; Andrejaitiene & Sirinskas, 2011; Rudolph et al., 2016

10 Mainstays of Adult Delirium Treatment Stepwise approach Early recognition through routine delirium screening Use of delirium screening improved physician s recognition of delirium in an adult medical intensive care unit Treatment of underlying conditions Nonpharamacologic interventions (such as promotion of normal sleep/wake cycle, exposure to natural light, early mobilization) Pharmacological treatment Devlin et al, 2007

11 Search for Reversible, Treatable Causes

12 Delirium - Multidisciplinary Pediatric ICU Little is known of children s naturalistic course following an episode of delirium. Prevalence of delirium 4-29% Associated with prolonged LOS, developmental delay, mechanical ventilation, and age Increased costs associated with delirium approximately $9200/day, $20,000/day for 2-3 days, and $76,000 for > 3 days Pediatric multidisciplinary intensivists reported that delirium screening was not routinely performed. Smeets et al., 2010; Silver et al., 2015; Traube et al., 2016; Kudchadkar et al., 2015; Guerra et al., 2016; Meyburg et al., 2016

13 DAS-Guidelines: Therapy of Delirium in Children Suggests a combination of symptomatic pharmacological, non-pharmacological, psychological and social interventions, as well as differential diagnoses regarding potential causes for critically-ill children Baron et al., 2015

14 Identifying Delirium in Children in Multidisciplinary PICUs Early, routine delirium screening is our best tool Given the long-term implications associated with delirium in adults such as long-term cognitive deficits, depression, and PTSD - further study is warranted to explicate diagnostic and therapeutic strategies

15 Delirium Screening Tools for Children Pediatric Confusion Assessment Method for the ICU & Preschool Confusion Assessment Method for the ICU (> 6 months to 5 years) Cornell Assessment of Pediatric Delirium (CAPD) High quality research needed to determine diagnostic accuracy CAPD recommended by European Society of Pediatric and Neonatal Intensive Care Smith et al., 2011; Smith et al., 2016; Traube et al., 2014; Harris et al., 2016; Daoud et al., 2014; Luetz et al.,

16 Preverbal Children Very young pose unique diagnostic challenges Understanding preverbal children s orientation and cognition essential to identify delirium Regulation of normal state and attention Moving closer with 2 validated tools Further study is warranted Schieveld, Herms & Oomen, 2016; Smith et al., 2016

17 Nonpharmacologic Interventions Importance of environmental nursing interventions Reassurance and re-orientation by someone familiar to the child Calendars and clocks for older children Personalized photos and toys Day/night cycling, exposure to natural light Regular, routine schedule in children and clustering care in infants Minimizing noise Turkel & Hanft, 2014

18 Atypical Antipsychotic Therapy Off-label informed consent Quetiapine atypical antipsychotic has demonstrated efficacy and favorable safety profile in off-label use in adults. short-term use safe in general PICU patients however 3 patients had episodes of prolonged QTc However, is it safe in children with heart disease? Olanzapine and risperidone safe to control symptoms Meta-analysis of 9 studies of atypical antipsychotics found no difference when compared to placebo Joyce et al., 2015; Turkel & Hanft, 2014; Turkel et al., 2012; Jensen et al., 2015; Groves et al., 2016; Brahmbhatt & Whitgob, 2016

19 Atypical Antipsychotics Do the benefits outweigh the risks? Cautious/judicious consideration of atypical antipsychotics especially in the very young or children with arrhythmias Do we consider other medications? Melatonin

20 Pediatric Cardiac Surgery ICU Delirium Studies Elective surgery (all comers; however 58% CHD) Short-lasting vs. long-lasting delirium Measureable effect on outcomes (LOS, mechanical ventilation) Highlights the need for routine screening with a validated tool Case study of recurrent delirium after Norwood & BDG Treated with olanzapine Madden et al., 2011; Meyburg et al., 2016

21 Pediatric Cardiac Surgery ICU Delirium Studies Dexmedetomidine use with children with CHD Lower post-operative opioid use, reduced stress response, lower risk of delirium but may increase bradycardia and hypotension risk Lower risk of delirium was not evaluated using validated delirium screening tool Systematic review of Dexmedetomidine studies highlighted the unique characteristics of population such as ventricular dysfunction, single ventricle physiology, rises in PaCo2 and potential withdrawal syndrome that deserve consideration Tobias et al., 2011

22 Non-pharmacologic interventions in PCICU: QI project in infants < 1 year old Implementation of neonatal delirium score loosely used pediatric anesthesia emergence delirium scale Kangaroo care Early parent holding Select parents sleeping in same bed Winch et al., 2016

23 Recognizing Delirium After Pediatric Cardiac Surgery 296 PCICU healthcare providers from 71 PCICUs in 13 countries 58% completion rate 173 respondents One random respondent from each participating institution

24 Participant Characteristics Participant Characteristics n=173 Age (years) Mean (SD), Range 39.6 (9.1), Gender (female) n (%) 116 (67%) Role -MD -RN -Pharmacist 81 (47%) 91 (53%) 1 (0.6%) Years in post-op management Mean (SD), Range 9.8 (7.5), 0-35 Attended delirium lecture n (%) -Yes -No 67 (39%) 106 (61%)

25 Personal experience percentage of postoperative delirium Overall Sample n=173 Mean SD Range Median IQR MD (n=81) RN (n=91) Random Sample n= MD (n=45) RN (n=26)

26 Postoperative Delirium Screening Overall Sample n = 173 Random Sample n=71 Always all patients screened 12 (7%) 6 (8.5%) Sometimes some patients screened 32 (18.5%) 13 (18%) Never no patients screened 129 (74%) 52 (73%)

27 Who makes confirmatory delirium diagnosis? Overall Sample (n=173) Random Sample (n=71) CICU attending physician 132 (76.3%) 66 (85.9%) CICU medical trainee 15 (8.7%) 8 (11.3%) CICU nurse practitioner 21 (12.2%) 11 (15.5%) Neurology attending 34 (19.7%) 18 (25.3%) Neurology trainee 8 (4.6%) 2 (2.8%) Neurology nurse practitioner 4 (2.3%) 1 (1.4%) Psychiatry attending 75 (43.4%) 28 (39.4 %) Psychiatry trainee 15 (8.7%) 6 (8.5%) Psychiatry nurse practitioner 7 (4.1%) 1 (1.4%) Psychology 16 (9.3%) 8 (11.3%) Other 9 (5.2%) 2 (2.8%)

28 Satisfaction with Delirium Management Overall Sample (n=173) Random Sample (n=71) No 165 (95.4%) 58 (81.7%) Yes 8 (4.6%) 13 (18.3%)

29 Where do we as a society PCICU healthcare providers start? Conduct more research on delirium Educate our teams on delirium and its clinical presentation Implement routine delirium screening with a validated tool

30 Implementing Delirium Screening Change in CICU culture Change is hard! Requires planning, persistence, and champions Multi-faceted education and training approach Critical need for interdisciplinary education Short in-services, pocket guides, case studies On-line training, one-on-one training Real-time feedback Interdisciplinary rounds Targeting pain, sedation, withdrawal, and delirium management Flaigle et al., 2016; Brummel et al., 2013

31 Thank you!