andersenpa Posted April 20, 2011 Share Posted April 20, 2011 Interesting to see this in the lay press: http://www.washingtonpost.com/national/health/hospitals-fight-a-form-of-delirium-that-often-strikes-icu-patients/2011/03/23/AF518nMD_story.html For the hospital based PAs here- what are your experiences with delirium? what are you doing to recognize/track/prevent/treat? It's a major morbidity in CTS patients. Easily 20-25% have some variant. We have used haldol, risperidone, olanzapine, and recently demedetomidine for prophylaxis and tx. What is everyone else's take? Davis? Dave C? Deborah212? Ventana? Link to comment Share on other sites More sharing options...
Moderator ventana Posted April 20, 2011 Moderator Share Posted April 20, 2011 I have never been totally assigned to the ICU - been on the floors and seen a lot of just "sundowning" and confusion, but have not experience in the realm of the ICU but I can completely understand as I think I would too go nuts if I slept even on night as a patient in an ICU How much of this might just be polypharmacy? Link to comment Share on other sites More sharing options...
andersenpa Posted April 20, 2011 Author Share Posted April 20, 2011 I have never been totally assigned to the ICU - been on the floors and seen a lot of just "sundowning" and confusion This is the same problem, just extending to the floor level of care. It can be more profound in the ICU due to the acuity but I think it is the same issue you encounter with sundowning. Link to comment Share on other sites More sharing options...
coloradopa Posted April 20, 2011 Share Posted April 20, 2011 Its a huge problem in our ICU. Every patient has CAM-ICU screening done twice per day. We use essentially the same meds you do. Usually start with either Risperidone or Olanzapine depending on NPO status. Haldol comes and goes. A lot of concerns over QT interval. We haven't used precedex specifically for that. We have moved away from Benzos. No easy solutions. Link to comment Share on other sites More sharing options...
andersenpa Posted April 20, 2011 Author Share Posted April 20, 2011 We started CAM-ICU a little over one yr ago and have made it a hospital wide policy (ie all wards/floors, not just ICU). Suprisingly with out cardiac pts and their predisposition to arrhythmias (and almost all of them on amiodarone) we have had no QT-related torsades events. There was a paper yrs ago for ortho hip pts receiving haldol low dose (0.5-1) q6 RTC for prophylaxes. Tried that for a while. Now using risperidone 0.5-1 qhs. Haldol PRN. Precedex on every case, starting at chest closure and through extubation. It's worked VERY well so far. Infusion only (0.4-0.8 mcg/kg/hr), no loading dose. Very few if any hypotension/brady events when not loading. Worth looking into if you have a significcant delirium problem. And I never ever use BZDs unless there is seizure activity or a hx of use for anxiolysis. Link to comment Share on other sites More sharing options...
maryfran123 Posted April 20, 2011 Share Posted April 20, 2011 This is a great site with alot of tools and information: http://www.mc.vanderbilt.edu/icudelirium/index.html Another good article: http://www.chestnet.org/accp/pccsu/delirium-icu-overview?page=0,3 We see a fair amount of delerium in our ICU and it is not just the elderly, although we DO have one of the highest percentage of elderly trauma patients in the state, actually higher than the national average. Even on the floors, I typically warn family members, especially if pt is > 55 that there is a chance the pt will develop delerium due to numerous factors so when it does occur they are less shocked/angry/surprised. I think the problem is multi-factorial: sleep-wake cycle disturbance which we try to control best we can, frequent re-orientation, "quiet" time is scheduled in our ICU from 2-4pm, many of our ventilated patients are on fentanyl gtts for pain. We use propofol for sedation as our primary agent then if need be switch to ativan. For acute delerium we use Haldol as it is still the recommended medication (SCCM includes this in their delerium info) If QT interval is a concern (i.e. hx of, potential drug interaction, etc) we will use geodon IM and also use scheduled seroquel. What I have learned relatively recently is that a number of these patients can develop long term cognitive issues and many suffer from PTSD/depression. This was quite surprising to me. I often wonder if delerium is going to become one of thos "preventable" complications we are hearing so much about now, similar to UTI's, VAP, DVT, etc where if they occur, payment is affected. Link to comment Share on other sites More sharing options...
maryfran123 Posted April 20, 2011 Share Posted April 20, 2011 Andersen, btw, we don't use much precedex because in our pt popluation we haven't had much success with it. Also, because of the limited time it can be used, for our severely injured traumas it is limited usefulness. Link to comment Share on other sites More sharing options...
coloradopa Posted April 20, 2011 Share Posted April 20, 2011 We started CAM-ICU a little over one yr ago and have made it a hospital wide policy (ie all wards/floors, not just ICU).Suprisingly with out cardiac pts and their predisposition to arrhythmias (and almost all of them on amiodarone) we have had no QT-related torsades events. There was a paper yrs ago for ortho hip pts receiving haldol low dose (0.5-1) q6 RTC for prophylaxes. Tried that for a while. Now using risperidone 0.5-1 qhs. Haldol PRN. Precedex on every case, starting at chest closure and through extubation. It's worked VERY well so far. Infusion only (0.4-0.8 mcg/kg/hr), no loading dose. Very few if any hypotension/brady events when not loading. Worth looking into if you have a significcant delirium problem. And I never ever use BZDs unless there is seizure activity or a hx of use for anxiolysis. We use Resperidone also as our baseline agent. Precedex is hit and miss. It seems to have a binary effect. Either it works or it doesn't. Starting it at closure is interesting but I can't see our Anesthesiologists using it. We use propofol as our primary agent. Change to Precedex for difficult extubation or hypotension. I've absolutely seen both bradycardia and hypotension with Precedex. Its somewhat dose related though. We've also had delerium on Precedex. So its not a cure all. I think that ICU PTSD is the next big issue. What can be done about it is a different question. Part of the problem is our physical plant. Dark no direct light into the room. Noisy environment. Hopefully this will be better in our new ICU in 3 years or so. Link to comment Share on other sites More sharing options...
rcdavis Posted April 20, 2011 Share Posted April 20, 2011 Big, BIG thing, I think is to try and normalize sleep cycle, external stimuli minimalized ( alamrs, etc). Day and night light and sound appropriate. Difficult with lvads, iapbs some resp. assist devices, these guys are simply loud. The older the greater the risk as you know. We are beginning to use more rispirdal and precedex David does. I am old school, and do not shrink from benzos and have even went through a throazine (!!!!) phase for the middle aged men ( 40-60) who seem much more violent in their delusions than other groups. Propofol helps, as does lorazepam drips. PTSD is a real event. Several years ago the it was noted that virtually every one on pump developed PET changes on pre and post op brain scans.. Felt to be attributed to micro emboli.. So far, no one has done similar studies ( that I know of) on the true sleep deprived, hyper stimulated ICU /sicu patient.. I think that the results , if done, will surprise us. Like David, in many units here is a paucity of sunlight. I had proposed getting "sun" lights in those rooms, but was ignored. I think that a significant issue with PTSD is inadequate pain control. And it is clear at there is true.y inadequate addressing of anxiety.. ( the conscious respiratory failure). Just as RSD seems to be avoided or decreased with aggressive pain and GABA stimulation control, I think unit PTSD can be decreased with AGGRESSIVE pain and anxiety control, and maximizing the diurnal / circadian rhythms, a giving steroids in AM only, and not QID ( hard to tell steroid psychosis from unit). Knock em out early, sedate them just this side of heavy, then bring them up gently with respiradol and benzos. get em out of the unit as fast as possible. Momet oz, when he was at Columbia, used to give his patients a walkman to wear during surgery.. With a looped tape of positive thoughts running throughout surgery. " you will wake up refreshed, you will have no pain, you will breath deeply.. Etc". After several studies which showed that the subconscious could be addressed even during stage z4 anesthesia, he started this, and found that post op time on respirator, blood pressure and pain issues were decreased... And Los in ICU was decreased by almost a full day! This will work for the planned surgical patient, but the acutely ill unplanned medical patients will remain a problem. The downside to major chemical intervention is daily evaluation of mental status... More later, am in-between patients and Link to comment Share on other sites More sharing options...
xxbowiexx Posted April 20, 2011 Share Posted April 20, 2011 Some great info guys, thank you. Could someone explain CAM-ICU? Link to comment Share on other sites More sharing options...
andersenpa Posted April 20, 2011 Author Share Posted April 20, 2011 This is a great site with alot of tools and information: http://www.mc.vanderbilt.edu/icudelirium/index.html Another good article: http://www.chestnet.org/accp/pccsu/delirium-icu-overview?page=0,3 We see a fair amount of delerium in our ICU and it is not just the elderly, although we DO have one of the highest percentage of elderly trauma patients in the state, actually higher than the national average. Even on the floors, I typically warn family members, especially if pt is > 55 that there is a chance the pt will develop delerium due to numerous factors so when it does occur they are less shocked/angry/surprised. I think the problem is multi-factorial: sleep-wake cycle disturbance which we try to control best we can, frequent re-orientation, "quiet" time is scheduled in our ICU from 2-4pm, many of our ventilated patients are on fentanyl gtts for pain. We use propofol for sedation as our primary agent then if need be switch to ativan. For acute delerium we use Haldol as it is still the recommended medication (SCCM includes this in their delerium info) If QT interval is a concern (i.e. hx of, potential drug interaction, etc) we will use geodon IM and also use scheduled seroquel. What I have learned relatively recently is that a number of these patients can develop long term cognitive issues and many suffer from PTSD/depression. This was quite surprising to me. I often wonder if delerium is going to become one of thos "preventable" complications we are hearing so much about now, similar to UTI's, VAP, DVT, etc where if they occur, payment is affected. Our intensivists went to Vanderbilt to meet with the Ely group. We have a multidisciplinary delirium panel at our hospital and one of our CTS PAs sits on the panel. The Vandy guys seem to be leading the charge nationally. Re precedex, the interesting thing about the time limit is that it hasn't been studied beyond 48 hrs- but it's still being used well into 3,4, 5 days etc. Personally we haven't used it beyond 2 -3 days b/c we haven't needed to (yet!).... Link to comment Share on other sites More sharing options...
andersenpa Posted April 20, 2011 Author Share Posted April 20, 2011 Some great info guys, thank you. Could someone explain CAM-ICU? Confusion Assessment Method Nurse screening tool it's on maryfran's Vanderbilt link http://www.mc.vanderbilt.edu/icudelirium/assessment.html Link to comment Share on other sites More sharing options...
maryfran123 Posted April 21, 2011 Share Posted April 21, 2011 RC..great points! I think that one of our key roles in the ICU as PA's is the continuity of care and attention to the smaller details. we provide. Too easy for residents to attribute all delerium to "sundowning" or "alcohol withdrawal" not realizing what a huge impact regualting someone's sleep with a scheduled med for several days, lights on during the day time, everything off after say 10pm, etc really makes as much of a difference in pt's recovery than any drug or test we can do. Agree with the pain control and ativan points, and remembering that decreasing anxiety is an adjunct to pain control. Have to look up that M. Oz study, sound pretty interesting!! Link to comment Share on other sites More sharing options...
deborah212 Posted April 21, 2011 Share Posted April 21, 2011 Zyprexa was my first choice for infection/hospital induced delirium in the elderly. It's amazing was 2.5 mg of Zydis can do. However, psychiatry recently made me aware that Zyprexa has a higher incidence of anticholinergic symptoms compared to Haldol. Have any of you seen this? Has made me second guess my order of antipsychotics as would hate to have to put a foley into an 88 yo male with BPH because of iatrogenic urinary retention. Even worse if he then tried to yank that foley out. Edit: My experience of course is just on the floor, not in the ICU with myriad of other delirium inducing concerns and acuity. Link to comment Share on other sites More sharing options...
crieman Posted April 21, 2011 Share Posted April 21, 2011 I think that everyone is different in how the react to haldol or zyprexa but we generally start with zyprexa. Serequel is starting to overtake zyprexa however since it's the only one that has really been studied recently and shown to make a difference. Our new intensivists swear by it. It's overwhelmingly obvious that benzos are the root of evil in the ICU and their only place is seizure control. We are moving to the CAM-ICU as well. I can honestly say that our new intensivists have made a HUGE difference in length of stay in the ICU and a lot of it was discontinuing all of the versed drips. Link to comment Share on other sites More sharing options...
andersenpa Posted April 21, 2011 Author Share Posted April 21, 2011 I think that everyone is different in how the react to haldol or zyprexa but we generally start with zyprexa. Serequel is starting to overtake zyprexa however since it's the only one that has really been studied recently and shown to make a difference. Our new intensivists swear by it. It's overwhelmingly obvious that benzos are the root of evil in the ICU and their only place is seizure control. We are moving to the CAM-ICU as well. I can honestly say that our new intensivists have made a HUGE difference in length of stay in the ICU and a lot of it was discontinuing all of the versed drips. I agree re: bzds. Davis, if your group hasn't you guys should look at the bzd data on delirium. Significant stuff. Link to comment Share on other sites More sharing options...
maryfran123 Posted April 21, 2011 Share Posted April 21, 2011 I don't want to speak for Davis and but I'm assuming he is aware of the benzo data same as I am. I'm short on time so in brief, speaking primarily from a trauma perspective there are indications for benzos as an adjunct for treating pts in the ICU other than seizures, for example alcohol withdrawal/DT's which is common in our pt population. In addition, when you have a pt that requires the max dose of propofol(up to 50mcg/kg/min at our place) in addition to a narcotic gtt to keep them adequately sedated you have no choice after some point to switch them to a benzo, be it a drip or atc dosing. And yes, we do use adjuncts such as seroquel, haldol, etc in these patients. I think it becomes dangerous when we make statements as pure "dogma" that something should never be used except for x, y, z because lets be honest, the atypical antipsychotics we are mentioning in these post have black box warnings re: increased morbidity and mortality when used in the elderly. I think we need to be aware of the research, practiced evidence based medicine but as we all know, there are pts that fall outside the norms and alot of what we do is mixed with "art" and risk/benefit treatment assessment. Link to comment Share on other sites More sharing options...
andersenpa Posted April 21, 2011 Author Share Posted April 21, 2011 there are indications for benzos as an adjunct for treating pts in the ICU other than seizures, for example alcohol withdrawal/DT's which is common in our pt population.In addition, when you have a pt that requires the max dose of propofol(up to 50mcg/kg/min at our place) in addition to a narcotic gtt to keep them adequately sedated you have no choice after some point to switch them to a benzo, be it a drip or atc dosing. And yes, we do use adjuncts such as seroquel, haldol, etc in these patients. I think it becomes dangerous when we make statements as pure "dogma" that something should never be used except for x, y, z because lets be honest, the atypical antipsychotics we are mentioning in these post have black box warnings re: increased morbidity and mortality when used in the elderly. I think we need to be aware of the research, practiced evidence based medicine but as we all know, there are pts that fall outside the norms and alot of what we do is mixed with "art" and risk/benefit treatment assessment. True. I would guess that the majority of sedation in most ICUs is for mechanical ventilation. This is the population I was referring to. I have heard of people using rate limits on propofol; aside from the TG load I haven't heard of other downsides except myocardial depression which at prolonged HIGH doses. There needs to be a major reorganization of thinking on benzo use in ICUs, and it needs to be put in the third/fourth/fifth line of the armamentarium the same way we think about demerol, aminoglycosides and amphotericin et al. Near the bottom of the list in their respective categories. Link to comment Share on other sites More sharing options...
crieman Posted April 21, 2011 Share Posted April 21, 2011 We exhaust all avenues before going with a benzo. Granted, there are those times that you will end using them but even with alcohol w/d we are doing more scheduled beer than ativan because length of stay is (don't quote me) about 2 days less than with ativan. Let's face it, we're not going to cure the alcoholism. We have a guy right now though that exhausted our "stash" of beer and we had to resort to ativan. Link to comment Share on other sites More sharing options...
crieman Posted April 21, 2011 Share Posted April 21, 2011 Zyprexa was my first choice for infection/hospital induced delirium in the elderly. It's amazing was 2.5 mg of Zydis can do. However, psychiatry recently made me aware that Zyprexa has a higher incidence of anticholinergic symptoms compared to Haldol. Have any of you seen this? Has made me second guess my order of antipsychotics as would hate to have to put a foley into an 88 yo male with BPH because of iatrogenic urinary retention. Even worse if he then tried to yank that foley out. Edit: My experience of course is just on the floor, not in the ICU with myriad of other delirium inducing concerns and acuity. I've sure found quite a few folks (elderly) who simply get better after discontinuing Levaquin. I try really hard to find the cause of delerium before starting more drugs that can actually cause delerium. Zyprexa is a great drug but I've seen people head in the opposite direction pretty quick. All of them elderly. Link to comment Share on other sites More sharing options...
deborah212 Posted April 22, 2011 Share Posted April 22, 2011 There is a definite entity of fluroquinolone induced delirium- I've seen it it in one patient as young as 50 but had MS at baseline. Amazing to see before and after discontinuation. I've sure found quite a few folks (elderly) who simply get better after discontinuing Levaquin. Link to comment Share on other sites More sharing options...
coloradopa Posted April 23, 2011 Share Posted April 23, 2011 We exhaust all avenues before going with a benzo. Granted, there are those times that you will end using them but even with alcohol w/d we are doing more scheduled beer than ativan because length of stay is (don't quote me) about 2 days less than with ativan. Let's face it, we're not going to cure the alcoholism. We have a guy right now though that exhausted our "stash" of beer and we had to resort to ativan. Precedex is starting to have some pretty interesting results for DTs. I've had good luck with it in a few cases. I think that benzos have their place. People say don't use them, but they definitely have their place and in some cases it should be your first line drug. Take today. Walked into a patient that absolutely fell off a cliff. Couple of days post op with Gram negative rod sepsis. Overnight got intubated and vas cath placed. When I walked in she was on 50 mcg/min Norepi, 10 mcg Epi and 0.03 mcg Vaso (plus 100 of Neo). Full on ARD on 100% Fio2 with crappy compliance, pH 7.02. MAP was 50. I walked in and started pushing Bicarb. Used the entire stock in the Omni-cell. Got the pH to 7.19 which helped my pressors start working. Even then I ended up on 100 mcg of Norepi at one point. I finally got dialysis going at was able to make some headway. The point here is that when I walking in the patient was staring at me scared out of her wits. They were trying to use Precedex without success. What are my other options? Propofol isn't going to help my pressure much. I told the nurse to hang an Ativan drip, and set it to stun. Then I went back to saving the patients life. Will they have ICU delerium, possibly but if they live then I can sort it out later. Bottom line if you have someone with profound septic shock benzo's are going to have the least hemodynamic effects. First choice for me in these cases. Link to comment Share on other sites More sharing options...
rcdavis Posted April 23, 2011 Share Posted April 23, 2011 Holy crap. I hate gns. I don't shy away from benzos, especially in the agitated delirious PT..not the pleasantly confused, but the grab his tube and hit you pt that you may not want for whatev to knock out with propofol. David, did you try xigris? I know, I know... But with this patient you don't have much left, and she is leaking endotheially .. You may not have anything to lose. By the time you read this, she is either dead of diffuse dic and hemorrghaing and dying. I would try it. Link to comment Share on other sites More sharing options...
coloradopa Posted April 24, 2011 Share Posted April 24, 2011 Holy crap. I hate gns. I don't shy away from benzos, especially in the agitated delirious PT..not the pleasantly confused, but the grab his tube and hit you pt that you may not want for whatev to knock out with propofol. David, did you try xigris? I know, I know... But with this patient you don't have much left, and she is leaking endotheially .. You may not have anything to lose. By the time you read this, she is either dead of diffuse dic and hemorrghaing and dying. I would try it. Actually I thought about this when I got there. Problem is the patient had an epidural in. I pulled the epidural and started Xigris about 2 hours later. Normal Coags. Came in today. PT was off the Epi and on 20 of levo plus Vaso. The CVVHD made a big difference. Meds function much better with a normal pH. Got her off APRV onto conventional ventilation. Actually off ARDs-NET. Not out of the woods yet but doing much better. Not sure if it was the Xigris, dialysis, antibiotics or what but a little more hopeful. Link to comment Share on other sites More sharing options...
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