Canadian Practices for the Treatment of Delirium Lisa Burry, BScPharm, PharmD
Disclosures & Acknowledgements Conflicts of interest: None Acknowledgements: our patients and the clinical staff that supported our numerous projects
2002 Canadian Survey Findings 29% used sedation-analgesia protocol 86% developed locally 49% used sedation scale Monitoring: Q1h 29% Q4h 38% 40% practiced daily interruption All patients 38%; some patients 62% CAM-ICU 2001 ICDSC 2001 3.7% used delirium assessment tool 48% used haloperidol in 25-75% of patients
Methods Design Setting Prospective observational study to describe actual utilization of psychoactive prescriptions and strategies 51 medical-surgical ICUs Time frame February 2008 April 2009 Inclusion 1) Consecutive mechanically ventilated patients, 2) 16 years 3) Admitted to participating ICUs during a 2 week study period Exclusion Data collection None Data collected from initiation of mechanical ventilation until extubation, 24h after tracheostomy, death, or max of 30 days Hospital, ICU and patient demographics, pain-sedation-delirium assessment tools & scores, medication history, daily ICU drug exposure, physical restraint use, clinical outcomes, adverse events (e.g. accidental device removal)
Opioids > 80%; Benzos > 60% Physical restraints used on 53% patients Objective delirium screening rarely performed 41/712 patients (5.8%) & 148/3620 patient ICU days (4.1%)
Initiated on: mean 4.8 days (SD 4.3) Duration of antipsychotic Rx: mean 4.0 days (SD 3.1) 143 prescriptions Haloperidol 33% Quetiapine 22% Olanzapine 20% Risperidone 11% Prescribed as: 34% fixed interval, 38% PRN, 27% fixed + PRN
Factors Associated with Antipsychotic Rx Use Adjusted OR (95% CI)* Duration of mechanical ventilation 1.13 (1.08, 1.18) Any documented episode of agitation based on sedation scale assessment 1.88 (1.03, 3.44) Daily interruption on any day of ICU admission 1.71 (1.02, 2.89) Use of physical restraints 2.22 (1.31, 3.77) * Controlling for age, admission type, and APACHE II score
Delirium recognition and sedation practices in critically ill patients: a survey on the attitudes of 1015 Brazilian critical care physicians. Salluh JI1, Dal-Pizzol F, Mello PV, Friedman G, Silva E, Teles JM, Lobo SM, Bozza FA, Soares M; Brazilian Research in Intensive Care Network. PURPOSE: The aim of the study was to characterize the practices of Brazilian ICU physicians toward sedation and delirium. MATERIALS AND METHODS: A cross-sectional survey was conducted among a convenience sample of critical care physicians between April and June 2008. RESULTS: One thousand fifteen critical care physicians responded. A significant rate of the respondents (42.7%) estimated that more than 25% of patients under mechanical ventilation have delirium, but 53.5% occasionally assessed patients for delirium. Thirteen percent used specific delirium scales, with the Confusion Assessment Method for intensive care unit (ICU) being the most applied. Delirium was often treated with haloperidol (88.1%); however, atypical antipsychotics (36.3%) and benzodiazepines (42.3%) were also used. CONCLUSIONS: Despite the recent advances in knowledge of sedation and delirium, most of them are still not translated into clinical practice. Significant variation in practice is observed among ICU physicians and represents a potential target for future research and educational interventions. J Crit Care. 2009 Dec;24(4):556-62
14 Canadian and 2 US sites PS vs. PS+ DSI Standardized weaning 1: time to extubation 2: LOS, Rx doses, workload, delirium
Delirium in Critically Ill Mechanically Ventilated Patients Enrolled in the SLEAP RCT n=423 Patients 214 PS+DI, 209 PS Assessed (n=420) No Delirium Data (n=3) 31 Always ICDSC score A or B 7.4% Delirium (n=226) 53.8% No Delirium (n=163) 38.8% Median duration: 2 days + on 1 st screen: 47.8% Sub-syndromal Delirium (n=146) Never Delirious (n=17) In press, Critical Care Medicine
Duration of Mechanical Ventilation and Lengths of Stay median Days MV ICU LOS Hospital LOS MV (13 vs. 7 days, P<.0001) LOS ICU (12 vs. 8 days, P<.0001) LOS Hospital (24 vs. 15 days, P<.0001) P<.0001 In press, Critical Care Medicine
Delirium Interventions Ever Delirious (n=226) Never Delirious (n=163) P Midazolam equivalents (mg) Dose/pt/day Infusion, days 104 (356) 5 (3,9) 57 (123) 3 (2,6) <.0001 <.0001 Fentanyl equivalents (mcg) Dose/pt/day Infusion, days 1497 (3564) 6 (3,10) 1150 (2234) 3 (2,7) <.0001 <.0001 Antipsychotic 36.7% 12.9% <.0001 Physical restraints Study days, median (IQR) 86.3% 5 (2,9) 76.7% 2 (1,6).01 <.0001 In press, Critical Care Medicine
A Prospective Evaluation of Psychoactive Medications and Delirium in Canadian Critically Ill Adults: Interim Results L. Burry, S. Mehta, D. Williamson, M. Perreault, I. Mantas, D. Fergusson, O. Smith, A. Day, M. Anan, A. Cho, S. Dupuis, E. Fan, L. Rose Presented Oct 1 st 2014
Methods Design Prospective observational study, July 2011 to June 2012 Setting Objective Inclusion 6 Adult medical-surgical ICUs (5 academic and 1 large community hospital) To describe incidence of delirium + sub-syndromal delirium (SSD), exposure to benzos, sedatives, opioids, anticholinergics, and potentially deliriogenic environmental factors, and clinical outcomes Patients admitted to study ICUs for 24 hours Exclusion Data collection Relevant definition 1) Unable to communicate in English or French 2) Always comatose (score A or B on ICDSC*) Demographics, daily ICDSC (score 0-8), exposure to drugs and environmental factors, clinical outcomes Delirium = ICDSC 4 out of possible 8 points SSD = ICDSC 1-3 and never 4 Comatose = ICDSC A or B *Bergeron et al. Int Care Med 2001;27(5): 859-864
Study Population 521 Enrolled Never Delirious ICDSC = 0 n=89 (17%) SSD only ICDSC = 1-3, never 4 n=172 (33%) Delirious ICDSC 4 n=260 (50%) Mean duration of delirium: Delirium = 3.3 days (SD 3.0) SSD + Delirium = 7.6 days (SD 5.2) Delirium only ICDSC 4 n=51 Delirium + SSD ICDSC = 1-3 & 4 n=209
Demographics No Delirium n=89 SSD n=172 Both SSD & Delirium n=209 Delirium n=51 P Age years, mean 56 59 61 64 0.04 APACHE II, mean 17 19 20 21 <.0001 Admission category, % Surgical Medical 46 51 34 61 25 67 18 77 0.006 Reason for ICU admit, % Respiratory Cardiovascular Gastrointestinal Sepsis 37 15 18 3 36 15 13 15 39 10 11 14 29 12 6 20 Comorbidities, % Dementia Hypertension Alcohol Tobacco 0 46 14 20 0.6 48 14 17 5 46 20 28 6 55 23 20 0.007 0.71 0.25 0.06
Outcomes No Delirium n=89 SSD n=172 Both SSD & delirium n=209 Delirium n=51 P MV 63 % 76 % 91% 77% <0.0001 Days MV, median (IQR) 1 (0.5, 2.0) 2 (1.2, 4.8) 7 (2.8, 13.6) 2 (0.9, 3.6) <0.0001 Reintubation 2% 5% 23% 8% <0.0001 Tracheostomy 2% 8% 22% 0% <0.0001 Days ICU stay, median (IQR) Days Hospital stay, median (IQR) ICU mortality 3 (2.1, 4.0) 11 (6.0, 18.4) 4 (2.8, 6.9) 16 (8.1, 31.9) 10 (6.2, 17.6) 28 (16.3, 52.6) 4 (3.0, 7.3) 13 (7.2, 34.8) 1% 9% 12% 24% <0.0001 <0.0001 0.0003 Hospital mortality 6% 22% 23% 35% 0.0002
ICU Drug Exposures (1) No Delirium n=89 SSD n=172 Both SSD & Delirium n=209 Delirium n=51 Opioid use 75% 85% 91% 94% 0.001 P Total fentanyl dose (mg), median (IQR) 0.8 (0.3, 1.5) 1.2 (0.5, 3.5) 2.5 (0.9, 7.7) 0.5 (0.1, 2.2) <0.0001 Benzodiazepine use 61% 63% 83% 73% <0.0001 Total midazolam dose (mg), median (IQR) 5 (3, 25) 10 (4, 58) 62 (12, 259) 21 (4, 93) <0.0001 Low anticholinergic* (LAC) active drugs 76% 86% 93% 96% <0.0001 #LAC drugs, mean (SD) 1.2 (1.0) 1.6 (1.2) 2.5 (1.5) 2.2 (1.3) <0.0001 High anticholinergic* (HAC) active drugs 41% 38% 41% 31% 0.64 # HAC drugs, mean (SD) 0.5 (0.6) 0.4 (0.6) 0.5 (0.6) 0.4 (0.6) 0.79 * Duran Eur J Clin Pharmacol (2013) 69:1485-1496
ICU Drug Exposures (2) No Delirium n=89 SSD n=172 Both SSD and Delirium n=209 Delirium n=51 P Beta blocker use, % 31.5 33.1 52.2 54.9 <0.0001 Corticosteroid use, % 47.2 40.7 49.3 31.4 0.081 Nicotine replacement, % 0 5.2 8.2 5.9 0.016 Antipsychotic use, % 7.9 28.5 61.2 60.8 <0.0001 Antidepressant use, % 13.5 13.4 16.3 9.8 0.6422 Polypharmacy, mean max # of meds (SD) 12.3 (4.7) 14.1 (4.4) 17.3 (5.6) 15.2 (4.6) <0.0001
Environmental Exposures No delirium N = 89 SSD N = 172 Both SSD and delirium N = 209 Delirium N =51 Not mobilized, % 57.3 58.7 50.2 58.8 0.34 No TV, % 69.7 66.9 56.5 70.6 0.05 More patients with delirium than without had physical restraints applied 63% vs. 11%, p<0.0001 No window, % 20.2 12.2 9.6 5.9 0.03 No clock, % 24.7 26.2 27.3 19.6 0.72 Single room, % 70.8 80.8 78.5 82.4 0.25 Isolation, % 7.9 19.2 24.9 25.5 0.007 Epidural in-situ, % 4.5 7.0 4.8 0 0.24 Chest tube in-situ, % 13.5 16.9 23.0 11.8 0.10 P
Summary Poor utilization of delirium screening tools in Canadian ICUs. ~ 50% of patients experienced delirium & their outcomes were clinically & statistically different than those without delirium. Similar to international reports We identified polypharmacy & substantial exposure to psychoactive drugs (drugs previously linked to delirium) Poor-modest use of non-drug strategies (e.g. mobilization) & high utilization of physical restraints Next steps Results from multivariable analysis to determine if drug (or dose) independently risk of delirium and adjustments for survival Methods to improve compliance with screening and management
Thank you! lburry@mtsinai.on.ca