Transcript Awakening and Breathing (AB) - SEDATION
Learning Objectives
• Describe current guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit • Use validated scales to measure sedation, pain, agitation, and delirium in critically ill patients • Compare the benefits and limitations of available sedatives and analgesics in the acute care, procedural, and surgical settings
Goals for Sedation and Analgesia
• Prevent pain and anxiety • Decrease oxygen consumption • Decrease the stress response • Patient-ventilator synchrony • Avoid adverse neurocognitive sequelae – Depression – PTSD – Dementia – Anxiety Rotondi AJ, et al.
Crit Care Med
. 2002;30:746-752
.
Weinert C.
Curr Opin in Crit Care
. 2005;11:376-380.
Kress JP, et al.
Am J Respir Crit Care Med
. 1996;153:1012-1018.
American College of Critical Care Medicine
Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult • Guideline focus – Prolonged sedation and analgesia – Patients older than 12 years – Patients during mechanical ventilation • Assessment and treatment recommendations – Analgesia – Sedation – Delirium – Sleep • Update expected in 2012 Jacobi J, et al.
Crit Care Med
. 2002;30:119-141.
American College of Critical Care Medicine (ACCM) Guidelines
• Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult • Pertains to patients older than 12 years during mechanical ventilation • Areas of focus – Assessment for pain, delirium – Physiological monitoring – Pharmacologic tools • Most recommendations rated as grade B or C Jacobi J, et al.
Crit Care Med.
2002;30:119-141.
Assessing Pain: FACES Scale 0 –10
• • Other Scales Behavioral Pain Scale (BPS) 3-12 – Payen JF, et al.
Crit Care Med.
2001;29(12):2258-2263.
Critical Care Pain Observation Tool 0-8 – Gélinas C, et al.
Am J Crit Care.
2006;15:420-427.
Wong DL, et al.
Wong’s Essentials of Pediatric Nursing.
6th ed. St. Louis, MO: Mosby, Inc; 2001. p.1301.
Managing Pain in the ICU: Opioids
Clinical Effects
• Analgesia • Sedation Fentanyl
Adverse Effects
• Respiratory depression • Hypotension • Bradycardia • Constipation • Tolerance • Withdrawal symptoms • Hormonal changes Morphine Remifentanil Benyamin R, et al.
Pain Physician
. 2008;11(2 Suppl):S105-120.
What Is the ABCDE Bundle?
We Need Coordinated Care
• Many tasks and demands on critical care staff • Great need to align and support the people, processes, and technology already in ICUs • ABCDE bundle is multicomponent, interdependent, and designed to: – Improve clinical team collaboration – Standardize care processes – Break the cycle of oversedation and prolonged ventilation Vasilevskis EE, et al.
Chest.
2010;138(5):1224-1233.
What Is the ABCDE Bundle?
Awakening and Breathing Trial coordination Coordination/Choice of Sedation Delirium Monitoring and Management Early Mobility Vasilevskis EE, et al.
Chest.
2010;138(5):1224-1233.
AB
CDE
Awakening Breathing Coordination/Choice of Sedation Delirium Monitoring and Management Early Mobilization
ICU Sedation: The Balancing Act
Patient Comfort and Ventilatory Optimization Undersedation
• • • • • •
Patient recall Device removal Ineffectual mechanical ventilation Initiation of neuromuscular blockade Myocardial or cerebral ischemia Decreased family satisfaction w/ care G O A L Oversedation
•
Prolonged mechanical ventilation
• • •
Increase length of stay
•
Increased risk of complications - Ventilator-associated pneumonia Increased diagnostic testing Inability to evaluate for delirium
Jacobi J, et al.
Crit Care Med.
2002;30:119-141.
Improper Sedation
30.6% 15.4% 54.0%
• • • Continuous sedation carries the risks associated with oversedation and may increase the duration of mechanical ventilation (MV) 1 MV patients accrue significantly more cost during their ICU stay than non-MV patients 2 – $31,574 versus $12,931,
P
< 0.001
Sedation should be titrated to achieve a cooperative patient and daily wake-up, a JC requirement 1,2 Undersedated 3 Oversedated On Target 1. Kress JP, et al.
N Engl J Med.
2000;342:1471-1477.
2. Dasta JF, et al.
Crit Care Med.
2005;33:1266-1271.
3. Kaplan LJ, Bailey H.
Crit Care
. 2000;4(suppl 1):P190.
Assessing Agitation and Sedation
• Sedation-Agitation Scale (SAS) – Riker RR, et al
. Crit Care Med
. 1999;27:1325-1329.
– Brandl K, et al.
Pharmacotherapy
. 2001;21:431-436.
• Richmond Agitation-Sedation Scale (RASS) – Sessler CN, et al.
Am J Respir Crit Care Med
. 2002;166(10):1338-1344.
– Ely EW, et al.
JAMA
. 2003;289:2983-2991.
80 70 60 20 10 0 50 40 30
Systematic Implementation of Pain and Sedation Tools: Montpellier France
P < 0.01
63 42 Pain Post implemenation n = 130 Control n = 100 P < 0.01
29 Significant Patient Characteristics/Metrics/Outcomes Pre Post P-value
65 0.01
Mechanical Ventilation, hrs* Duration CIVS, hrs*
120 84 48 0.03
12 Agitation Duration CIVI Opioid, hrs*
96 60 0.02
Nosocomial infection†
17 (17) 11 (8) *Data presented in median hrs; †Data presented as n (%) CIVS; Continuous intravenous infusion sedation < 0.05
Chanques G, et al.
Crit Care Med
. 2006;34(6):1691-1699.
Daily Sedation Interruption Decreases Duration of Mechanical Ventilation
• Hold sedation infusion until patient awake and then restart at 50% of the prior dose • “Awake” defined as any 3 of the following: – Open eyes in response to voice – Use eyes to follow investigator on request – Squeeze hand on request – Stick out tongue on request • Fewer diagnostic tests to assess changes in mental status • No increase in rate of agitated-related complications or episodes of patient-initiated device removal • No increase in PTSD or cardiac ischemia Kress JP, et al.
N Engl J Med.
2000;342:1471-1477.
ABC Trial: Objectives
• To determine the efficacy and safety of a protocol linking:
spontaneous awakening trials (SATs) & spontaneous breathing trials (SBTs)
– Ventilator-free days – Duration of mechanical ventilation – ICU and hospital length of stay – Duration of coma and delirium – Long-term neuropsychological outcomes Girard TD, et al.
Lancet.
2008;371:126-134.
ABC Trial: Main Outcomes
Outcome*
Ventilator-free days Time-to-Event, days Successful extubation, days ICU discharge, days Hospital discharge, days Death at 1 year, n (%) Days of brain dysfunction Coma Delirium * Median, except as noted
SBT
12 7.0
13 19 97 (58%) 3.0
2.0
SAT+SBT
15 5 9 15 74 (44%) 2.0
2.0
P-value
0.02
0.05
0.02
0.04
0.01
0.002
0.50
Girard TD, et al.
Lancet.
2008;371:126-134.
ABC Trial: 1 Year Mortality
Girard TD, et al.
Lancet
. 2008;371:126-134.
Despite Proven Benefits of Spontaneous Awakening/Daily Interruption Trials, They Are Not Standard of Practice at Most Institutions
• • • •
Canada
– 40% get SATs (273 physicians in 2005) 1
US
– 40% get SATs (2004-05) 2
Germany
– 34% get SATs (214 ICUs in 2006) 3
France
– 40–50% deeply sedated with 90% on continuous infusion of sedative/opiate 4 1. Mehta S, et al.
Crit Care Med.
2006;34:374-380.
2. Devlin J.
Crit Care Med.
2006;34:556-557.
3. Martin J, et al.
Crit Care
. 2007;11:R124.
4. Payen JF, et al.
Anesthesiology.
2007;106:687-695.
Barriers to Daily Sedation Interruption
(Survey of 904 SCCM members) Increased device removal Poor nursing acceptance Compromises patient comfort Leads to respiratory compromise Difficult to coordinate with nurse No benefit Leads to cardiac ischemia Leads to PTSD #1 Barrier #2 Barrier #3 Barrier 0 10 20 30 40 Number of respondents (%) 50 60 70
Clinicians preferring propofol were more likely use daily interruption than those preferring benzodiazepines (55% vs 40%,
P
< 0.0001) Tanios MA, et al.
J Crit Care
. 2009;24:66-73.
Awakening and Breathing (AB) Safety Screens
Awakening Trial
• No active seizures • No active alcohol withdrawal • No active agitation • No active paralytic use • No myocardial ischemia (24h) • Normal intracranial pressure
Breathing Trial
• No active agitation • Oxygen saturation ≥ 88% • FiO 2 ≤ 50% • PEEP ≤ 8 cm H 2 O • No myocardial ischemia (24h) • Normal intracranial pressure • No significant vasopressor or inotrope use Girard TD, et al.
Lancet
. 2008;371(9607):126-134.
AB
C
DE
Awakening Breathing Coordination/Choice of Sedation Delirium Monitoring and Management Early Mobilization
Characteristics of an Ideal Sedative
• Rapid onset of action allows rapid recovery after discontinuation • Effective at providing adequate sedation with predictable dose response • Easy to administer • Lack of drug accumulation • Few adverse effects • Minimal adverse interactions with other drugs • Cost-effective • Promotes natural sleep Ostermann ME, et al.
JAMA.
2000;283:1451-1459.
Jacobi J, et al.
Crit Care Med
. 2002;30:119-141.
Dasta JF, et al.
Pharmacother.
2006;26:798-805.
Nelson LE, et al.
Anesthesiol
. 2003;98:428-436.
Consider Patient Comorbidities When Choosing a Sedation Regimen
• Chronic pain • Organ dysfunction • CV instability • Substance withdrawal • Respiratory insufficiency • Obesity • Obstructive sleep apnea
GABA Agonist Benzodiazepine Midazolam
Clinical Effects Adverse Effects
• Sedation, anxiolysis, and amnesia • Rapid onset of action (IV) • May accumulate with hepatic and/or renal failure • Anterograde amnesia • Long recovery time • Synergy with opioids • Respiratory depression • Delirium Olkkola KT, Ahonen J.
Handb Exp Pharmacol.
2008;(182):335-360.
Riker RR, et al; SEDCOM Study Group.
JAMA
. 2009;301(5):489-499.
GABA Agonist Benzodiazepine Lorazepam
Clinical Effects
• Sedation, anxiolysis, and amnesia • Commonly used for long term sedation
Adverse Effects
• Metabolic acidosis (propylene glycol vehicle toxicity) • Retrograde and anterograde amnesia • Delirium Olkkola KT, Ahonen J.
Handb Exp Pharmacol.
2008;(182):335-360.
Wilson KC, et al.
Chest
. 2005;128(3):1674-1681.
GABA Agonist Propofol
Clinical Effects Adverse Effects
• Sedation • Hypnosis • Anxiolysis • Muscle relaxation • Mild bronchodilation • Decreased ICP • Decreased cerebral metabolic rate • Antiemetic • Pain on injection • Respiratory depression • Hypotension • Decreased myocardial contractility • Increased serum triglycerides • Tolerance • Propofol infusion syndrome • Prolonged effect with high adiposity • Seizures (rare) Ellett ML.
Gastroenterol Nurs
. 2010;33(4):284-925.
Lundström S, et al.
J Pain Symptom Manage.
2010;40(3):466-470.
a 2
Agonist Clonidine
Clinical Effects
• Antihypertensive • Analgesia • Sedation • Decrease sympathetic activity • Decreased shivering
Adverse Effects
• Bradycardia • Dry mouth • Hypotension • Sedation Kamibayashi T, et al.
Anesthesiol
. 2000;93:1345-1349.
Bergendahl H, et al.
Curr Opin Anaesthesiol
. 2005;18(6):608-613. Hossmann V, et al.
Clin Pharmacol Ther
. 1980;28(2):167-176.
a 2
Agonist Dexmedetomidine
Clinical Effects Adverse Effects
• Antihypertensive • Sedation • Analgesia • Decreased shivering • Anxiolysis • Patient arousability • Potentiate effects of opioids, sedatives, and anesthetics • Decrease sympathetic activity • Hypotension • Hypertension • Nausea • Bradycardia • Dry mouth • Peripheral vasoconstriction at high doses Kamibayashi T, et al.
Anesthesiol.
2000;93:1345-1349.
Bhana N, et al.
Drugs
. 2000;59(2):263-268.
Comparison of Clinical Effects
Benzodiazepines Propofol Opioids
a
2 Agonists Haloperidol X X X
Sedation Alleviate anxiety 1,2 Analgesic properties 1-4 Promote arousability during sedation 2-4 Facilitate ventilation during weaning 2-4 Control delirium 1-4
X X X X X X X X X X X
1. Blanchard AR.
Postgrad Med.
2002;111:59-74.
2. Kamibayashi T, et al.
Anesthesiol.
2000;95:1345-1349.
3. Maze M, et al.
Anesthetic Pharmacology: Physiologic Principles and Clinical Practice.
Churchill Livingstone; 2004.
4. Maze M, et al.
Crit Care Clin.
2001;17:881-897.
Comparison of Adverse Effects
Benzodiazepines Propofol Opioids
a
2 Agonists Haloperidol
Prolonged weaning 1 Respiratory depression 1 Hypotension 1-3 Constipation 1 Deliriogenic Tachycardia 1 Bradycardia 1
X X X X X X X X X X * X X X X
morphine fentanyl
X X X X
1. Harvey MA.
Am J Crit Care.
1996;5:7-18.
2. Aantaa R, et al.
Drugs of the Future.
1993;18:49-56.
3. Maze M, et al.
Crit Care Clin.
2001;17:881-897.
*Excluding remifentanil
Maximizing Efficacy of Targeted Sedation and Reducing Neurological Dysfunction (MENDS)
• Double-blind RCT of dexmedetomidine vs lorazepam • 103 patients (2 centers) – 70% MICU, 30% SICU patients (requiring mechanical ventilation > 24 hours) – Primary outcome: days alive without delirium or coma • Intervention – Dexmedetomidine 0.15–1.5 mcg/kg/hr – Lorazepam infusion 1–10 mg/hr – Titrated to sedation goal (using RASS) established by ICU team • No daily interruption Pandharipande PP, et al.
JAMA.
2007;298:2644-2653.
MENDS: Dexmedetomidine vs Lorazepam
P
= 0.011
P
= 0.086
P
< 0.001
• • • Dexmedetomidine resulted in more days alive without delirium or coma (
P
= 0.01) and a lower prevalence of coma (
P
< 0.001) than lorazepam Dexmedetomidine resulted in more time spent within sedation goals than lorazepam (
P
= 0.04) Differences in 28-day mortality and delirium-free days were not significant Dexmedetomidine n = 52 Lorazepam n = 51
Delirium/Coma-Free Days Delirium-Free Days Coma-Free
Pandharipande PP, et al.
JAMA.
2007;298:2644-2653.
Days
MENDS Delirium: All Patients
Pandharipande PP, et al
. Crit Care
. 2010;14:R38.
SEDCOM: Dexmedetomidine vs Midazolam
• Double-blind, randomized, multicenter trial comparing long-term (> 24 hr) dexmedetomidine (dex, n = 244) with midazolam (mz, n = 122) • Sedatives (dex 0.2-1.4 μg/kg/hr or mz 0.02-0.1 mg/kg/hr) titrated for light sedation (RASS -2 to +1), administered up to 30 days • All patients underwent daily arousal assessments and drug titration Q 4 hours
Outcome Midazolam (n = 122) Dexmedetomidine (n = 244)
Time in target sedation range, % ( primary EP ) 75.1
77.3
Duration of sedation, days Time to extubation, days Delirium prevalence Delirium-free days Patients receiving open-label midazolam 4.1
5.6
93 (76.6%) 1.7
60 (49%) 3.5
3.7
132 (54%) 2.5
153 (63%)
P-
Value
0.18
0.01
0.01
0.001
0.002
0.02
Riker RR, et al.
JAMA.
2009;301:489-499.
100
Reduced Delirium Prevalence with Dexmedetomidine vs Midazolam
SEDCOM
Dexmedetomidine versus Midazolam,
P
< 0.001
80 60
Midazolam Dexmedetomidine
40 20 0
Sample Size
Baseline
118 229
1
109 206 Riker RR, et al.
JAMA.
2009;301:489-499.
2
92 175
3 Treatment Day
77 134
4
57 92
5
42 60
6
44 34
SEDCOM Trial:
Safety Outcomes Outcome
Bradycardia Bradycardia needing treatment Tachycardia Hypertension requiring intervention Hyperglycemia Infections
Midazolam (n = 122)
18.9% 0.8% 44.3% 29.5% 42.6% 19.7%
Dexmedetomidine (n = 244)
P-
Value
42.2% 4.9% 25.4% 18.9% 56.6% 10.2% 0.001
0.07
0.001 0.02
0.02
0.02
Riker RR, et al.
JAMA.
2009;301:489-499.
Arm
MIDEX PRODEX MDZ Dex
P-value
Propofol Dex
P-value
MIDEX and PRODEX Trials
• • • • 2 phase 3 multicenter RCTs Dexmedetomidine vs midazolam (MDZ) or propofol ~ 250 patients per arm, MV > 24 hours Daily interruption of sedation, SBT
Time at RASS Target
56.6% 60.7% 0.15
64.7% 64.6% 0.97
Median MV, h
164 123 0.03
118 97 0.24
ICU LOS, h
243 211 185 164
Arousability (total VAS)
30.0
49.7
< 0.001
40.1
51.3
< 0.001
Hypo tension
11.6% 20.6% 0.007
13.4% 13.0%
Brady cardia
5.2
14.2
< 0.001
10.1% 13% Jakob SM, et al.
JAMA
. 2012;307(11):1151-1160.
Analgosedation
• Analgesic first (A-1), supplement with sedative • Acknowledges that discomfort may cause agitation • Remifentanil-based regimen – Reduces propofol use – Reduces median MV time – Improves sedation-agitation scores • Not appropriate for drug or alcohol withdrawal Park G, et al.
Br J Anaesth.
2007;98:76-82. Rozendaal FW, et al.
Intensive Care Med.
2009;35:291-298.
Analgosedation
• 140 critically ill adult patients undergoing mechanical ventilation in single center • Randomized, open-label trial – Both groups received bolus morphine (2.5 or 5 mg) – Group 1: No sedation (n = 70 patients) - morphine prn – Group 2: Sedation (20 mg/mL propofol for 48 h, 1 mg/mL midazolam thereafter) with daily interruption until awake (n = 70, control group) • Endpoints – Primary Number of days without mechanical ventilation in a 28-day period – Other Length of stay in ICU (admission to 28 days) Length of stay in hospital (admission to 90 days) Strøm T, et al.
Lancet
. 2010;375:475-480.
Analgosedation Results
• Patients receiving no sedation had – More days without ventilation (13.8 vs 9.6 days,
P
= 0.02) – Shorter stay in ICU (HR 1.86,
P =
0.03) – Shorter stay in hospital (HR 3.57,
P
= 0.004) – More agitated delirium (N = 11, 20% vs N = 4, 7%,
P
= 0.04) • No differences found in – Accidental extubations – Need for CT or MRI – Ventilator-associated pneumonia Strøm T, et al.
Lancet
. 2010;375:475-480.
ABC
D
E
Awakening Breathing Coordination/Choice of Sedation Delirium Monitoring and Management Early Mobilization
Cardinal Symptoms of Delirium and Coma
Morandi A, et al.
Intensive Care Med
. 2008;34:1907-1915.
ICU Delirium
• Develops in ~2/3 of critically ill patients • Hypoactive or mixed forms most common • Increased risk – Benzodiazepines – Extended ventilation – Immobility • Associated with weakness • Undiagnosed in up to 72% of cases Vasilevskis EE, et al.
Chest
. 2010;138(5):1224-1233.
Patient Factors
Increased age Alcohol use Male gender Living alone Smoking Renal disease
Less Modifiable DELIRIUM Environment
Admission via ED or through transfer Isolation No clock No daylight No visitors Noise Physical restraints Van Rompaey B, et al.
Crit Care.
2009;13:R77.
Inouye SK, et al.
JAMA
.1996;275:852-857.
Skrobik Y.
Crit Care Clin
. 2009;25:585-591.
More Modifiable Predisposing Disease
Cardiac disease Cognitive impairment (eg, dementia) Pulmonary disease
Acute Illness
Length of stay Fever Medicine service Lack of nutrition Hypotension Sepsis Metabolic disorders Tubes/catheters Medications: - Anticholinergics - Corticosteroids - Benzodiazepines
Mechanisms for Delirium in the Critically Ill Are Numerous and Not Clearly Understood
•
Neurotransmitter imbalance
• Neuroinflammation • Blood brain barrier permeability • Impaired oxidative metabolism • Microglial activation • Abnormal levels of large neutral amino acids (eg, tryptophan) and their metabolism (eg, kynurenine pathway) Maldonado JR.
Crit Care Clin
. 2008;24(4):789-856.
Pandharipande PP.
Intensive Care Med.
2009;35(11):1886-1892.
Adams-Wilson JR, et al.
Crit Care Med.
2012 (in press)
Sequelae of Delirium
During the ICU/Hospital Stay
• Increased mortality • Longer intubation time • Average 10 additional days in hospital • Higher costs of care
After Hospital Discharge
• Increased mortality • Development of dementia • Long-term cognitive impairment • Requirement for care in chronic care facility • Decreased functional status at 6 months Bruno JJ, Warren ML.
Crit Care Nurs Clin North Am
. 2010;22(2):161-178.
Shehabi Y, et al.
Crit Care Med
. 2010;38(12):2311-2318.
Rockwood K, et al.
Age Ageing
. 1999;28(6):551-556.
Jackson JC, et al.
Neuropsychol Rev.
2004;14:87-98.
Nelson JE, et al.
Arch Intern Med.
2006;166:1993-1999.
Delirium Duration and Mortality
Kaplan-Meier Survival Curve
P
< 0.001
Each day of delirium in the ICU increases the hazard of mortality by 10% Pisani MA.
Am J Respir Crit Care Med
. 2009;180:1092-1097.
Worse Long-term Cognitive Performance
• Duration of delirium was an independent predictor of cognitive impairment – An increase from 1 day of delirium to 5 days was associated with nearly a 5-point decline in cognitive battery scores • Patient testimony
“One quite literally loses one’s grip on what is true and what is false because the true and the false are mixed together in a mess of experience.
”
Girard TD, et al.
Crit Care Med.
2010;38:1513-1520.
Misak CJ
. Am J Respir Crit Care Med
. 2004;170(4):357-359.
Risk Factors Specific for ICU Delirium
• Dementia 1,2,3 • Hypertension history 4,5 • Alcoholism 3,4 • Severity of illness 1,4,6,7,8 • Age (?pos
6,8 /neg 2,3,4,9 ) • Benzodiazepine use 4,10 • Coma (medical vs. pharmacologic) 4,9 • Morphine use ( ?data unclear ) 1. Pisani MA, et al.
Crit Care Med.
2009;37:177-183 2. Pisani MA, et al.
Arch Intern Med.
2007;167:1629-1634. 3. Van Rompaey B, et al.
Crit Care.
2009;13:R77.
4. Ouimet S, et al.
Intensive Care Med.
2007;33:66-73.
5. Dubois MJ, et al.
Intensive Care Med.
2001;27:1297-1304. 6. Pandharipande PP, et al.
Anesthesiology.
2006;104:21-26. 7. Pisani MA, et al.
Crit Care Med.
2009;37:177-183. 8. Pandharipande PP, et al.
Intensive Care Med.
2009;35:1886-1892. 9. Ely EW, et al.
Crit Care Med.
2007;35:112-117.
10. Pandharipande PP, et al.
J Trauma.
2008;65:34-41 .
Delirium After Stroke
• Increased 12-month mortality risk • Stroke patients +/- delirium • Will delirium treatment change outcome?
Shi Q, et al.
Stroke
. 2012;43(3):645-649.
Delirium Assessment Tools
• Confusion Assessment Method for the ICU (CAM ICU) – Ely EW, et al.
Crit Care Med
. 2001;29:1370-1379.
– Ely EW, et al.
JAMA
. 2001;286:2703-2710.
• Intensive Care Delirium Screening Checklist (ICDSC) – Bergeron N, et al.
Intensive Care Med
. 2001;27:859-864.
– Ouimet S, et al.
Intensive Care Med.
2007;33:1007-1013.
Confusion Assessment Method (CAM-ICU)
1. Acute onset of mental status changes or a fluctuating course and 2. Inattention and 3. Altered level of consciousness or 4. Disorganized thinking
= Delirium
Ely EW, et al.
Crit Care Med
. 2001;29:1370-1379.
Ely EW, et al.
JAMA
. 2001;286:2703-2710.
Intensive Care Delirium Screening Checklist
1. Altered level of consciousness 2. Inattention 3. Disorientation 4. Hallucinations 5. Psychomotor agitation or retardation 6. Inappropriate speech 7. Sleep/wake cycle disturbances 8. Symptom fluctuation Score 1 point for each component present during shift • Score of 1-3 = Subsyndromal Delirium • Score of ≥ 4 = Delirium Bergeron N, et al.
Intensive Care Med
. 2001;27:859-864.
Ouimet S, et al.
Intensive Care Med.
2007;33:1007-1013.
Pediatric CAM-ICU
146 paired assessments Mean age = 12.2 years 2 critical care clinicians vs. pediatric psychiatrist Sensitivity = 83% (95% CI, 66-93%) Specificity = 99% (95% CI, 95-100%) Inter-rater reliability
κ
= 0.96
Smith HA, et al.
Crit Care Med.
2011;39(1):150-157.
Predicting Delirium in the ICU
PRE-DELIRIC • Development of model – 1613 ICU patients – Delirium defined as +CAM-ICU or haloperidol use – 10 variables • Age • APACHE-II score • Admission group • Coma • Infection • Validation of model – 549 ICU patients – Area under ROC • PRE-DELIRIC • Nurses 0.85
0.59
• Physicians 0.59
• • • • • Metabolic acidosis Use of sedatives Use of morphine Urea concentration Urgent admission Pooled ROC 1 - Specificity van den Boogaard M, et al.
BMJ
. 2012;344:e420.
Delirium Assessment
Implementation Strategies •
Case-based scenarios 1
– Before-and-after case studies – This strategy increased usage of the ICDSC by 70% and accuracy of assessment by 54% – http://www.biomedcentral.com/content/supple mentary/cc6793-S2.doc •
Spot-checking
2,3 – Systematically uses expert raters – Identifies areas for fine tuning education 1. Devlin JW, et al.
Crit Care.
2008;12(1):R19.
2. Pun BT, et al.
Crit Care Med.
2005;33(6):1199-1205.
3. Soja SL, et al.
Intensive Care Med
. 2008;34(7):1263-1268.
Helpful Approach to Delirium Management 1. Stop 2. THINK 3. Lastly medicate
Stop and THINK
Do any meds need to be stopped or lowered?
• Especially consider
sedatives
• Is patient on minimal amount necessary? – Daily sedation cessation – Targeted sedation plan • Do sedatives need to be changed?
T oxic Situations
• CHF, shock, dehydration • Deliriogenic meds (tight titration) • New organ failure (liver/kidney)
H ypoxemia I nfection/sepsis (nosocomial) I mmobilization N onpharm interventions
• Hearing aids, glasses, reorient, sleep protocols, music, noise control, ambulation
K + or electrolyte problems
Delirium Nonpharmacologic Interventions
• Early mobility – the only nonpharmacologic intervention shown to reduce ICU delirium 1 • Other interventions: – Environmental changes (eg, noise reduction) – Sensory aids (eg, hearing aids, glasses) – Reorientation and stimulation – Sleep preservation and enhancement Schweickert WD, et al.
Lancet.
2009;373:1874-1882.
Sleep Abnormalities in the ICU
• More time in light sleep • Less time in deep sleep • More sleep fragmentation There is little evidence that sedatives in the ICU restore normal sleep Friese R.
Crit Care Med.
2008;36:697-705.
Weinhouse GL, Watson PL.
Crit Care Clin.
2009;25:539-549.
Boosting Sleep Quality in ICU
• Optimize environmental strategies – Day/night variation, reduce night interruptions, noise reduction • Avoid benzodiazepines (↓ SWS & REM) • Consider dexmedetomidine (↑ SWS) • GABA receptor agonists (eg, zolpidem) • Sedating antidepressants (eg, trazodone) or antipsychotics • Melatonin – Pilot: may improve sleep quality of ICU COPD patients Weinhouse GL, Watson PL.
Crit Care Clinics.
2009;25:539-549.
Faulhaber J, et al.
Psychopharmacology.
1997;130:285-291.
Shilo L, et al.
Chronobiol Int.
2000;17:71-76.
Effect of Common Sedatives and Analgesics on Sleep
There is little evidence that administration of sedatives in the ICU achieves the restorative function of normal sleep • Benzodiazepines ↑ Stage 2 NREM ↓ Slow wave sleep (SWS) and REM • Propofol ↑ Total sleep time without enhancing REM ↓ SWS • Analgesics Abnormal sleep architecture • Dexmedetomidine ↑ SWS Weinhouse GL, et al.
Sleep.
2006;29:707-716.
Nelson LE, et al.
Anesthesiology.
2003;98:428-436.
Contribution of Sedative-Hypnotic Agents to Delirium Via Modulation of the Sleep Pathway
Differences in BOLD activities/NREM sleep (fMRI) Sanders RD, Maze M
. Can J Anesth
. 2011;58:149-156.
A Multicomponent Intervention to Prevent Delirium in Hospitalized Older (Non-ICU) Patients
• 852 patients ≥ 70 years old on general medicine service, no delirium at time of admission • Intervention – Standardized protocol for management of 6 delirium risk factors (n = 426) • Usual care – Standard hospital services (n = 426) • Primary Outcome – Delirium incidence and prevalence Inouye SK, et al.
N Engl J Med.
1999;340:669-676.
Elder Life Program
Targeted Risk Factor Cognitive impairment Sleep deprivation Immobility Visual impairment Hearing impairment Dehydration Standardized Intervention Orientation & therapeutic activity protocol
(discuss current events, word games, reorient, etc)
Sleep enhancement & nonpharm sleep protocol
(noise reduction, back massages, schedule adjustment)
Early mobilization protocol
(active ROM, reduce restraint use, ambulation, remove catheters)
Vision protocol
(glasses, adaptive equipment, reinforce use)
Hearing protocol
(amplification devices, hearing aids, earwax disimpaction)
Dehydration protocol
(early recognition of dehydration & volume repletion) Inouye SK, et al.
N Engl J Med.
1999;340:669-676.
Results
Outcome Incidence of delirium, N (%) Total days of delirium Episodes of delirium Intervention 42 (9.9) 105 62 Control 64 (15) 161 90 P-value 0.02
0.02
0.03
• ↓ delirium incidence in patients with intermediate baseline risk • Improved orientation score with targeted intervention (
P
= 0.04) • Reduced rate of sedative use for sleep (
P
= 0.001) • 87% overall adherence to protocol Inouye SK, et al.
N Engl J Med.
1999;340:669-676.
Survey: First-Choice Delirium Treatment Options
• Delirium should always be managed with a medication: 85% • Use ≥ 2 medications to treat delirium: 68%
40 30 20 10 0 90 80 70 60 50 Characteristics of Haloperidol Use (always or frequently)
• Oral: 23%; IV 93% • As needed: 93%; Scheduled: 61%; Infusion: 0% • ≤ 4 mg/d: 47%; 5-10 mg/d: 56%; 11-20 mg/d: 38%; ≥ 21 mg/d: 9% Haloperidol Atypical Antipsychotic Benzodiazepine Dexmedetomidine Devlin JW, et al.
Ann Pharmacother.
2011;45(10):1217-1229.
Dopamine Antagonist Haloperidol
Clinical Effects Adverse Effects
• Hypnotic agent with antipsychotic properties 1 – For treatment of delirium in critically ill adults 1 • Does not cause respiratory depression 1 • Dysphoria 2 • Adverse CV effects include QT interval prolongation • Extrapyramidal symptoms, neuroleptic malignant syndrome (rare) 1 • Metabolism altered by drug-drug interactions 2 1. Harvey MA.
Am J Crit Care.
1996;5:7-16.
2. Crippen DW.
Crit Care Clin.
1990;6:369-392.
But…Use of Haloperidol Is an Independent Predictor for Prolonged Delirium
Pisani MA, et al.
Crit Care Med.
2009;37:177-183.
Atypical Antipsychotics
• Receptor adherence is variable between agents • Use has increased substantially • Possible safety benefits – Decreased extrapyramidal effects – Little effect on the QTc interval (except ziprasidone) – Less hypotension/fewer orthostatic effects – Less likely to cause neuroleptic malignant syndrome • Possible limitations – No IV formulations available – Little published experience in ICU patients – Troublesome reports of adverse events but most associated with prolonged use in non-delirium patients Devlin JW, et al.
Harv Rev Psychiatry.
2011;19:59-67.
Use of Atypical Antipsychotic Therapy Is Increasing
90 80 70 60 50 40 30 20 10 0 2001 2007 Ely EW, et al.
Crit Care Med.
2004;32:106-112.
Patel RP, et al.
Crit Care Med.
2009;37:825-832.
The MIND Study
Haloperidol n = 35 Ziprasidone n = 32
• Modifying the INcidence of Delirium (MIND) • Randomized and double-blind • Multisite (6 centers) • 103 MV patients • PO/IM delivery of study drug • Doses – Haloperidol – Ziprasidone 5-20 mg 40-160 mg
Placebo n = 36
Girard TD, et al.
Crit Care Med.
2010;38(2):428-437.
MIND Study Results
Outcome* Delirium/coma-free days Haloperidol (n = 35)
14 [6-18]
Ventilator-free days
8 [0-15]
Length of stay
ICU Hospital
Mortality, % Extrapyramidal side effects
12 [5-16] 14 [10-NA † ] 11 Daily EPS score
Cognition at discharge
Mean T-score 0 [0-0.2] 27 [25-31] *Median [interquartile range] except as noted
Ziprasidone (n = 32)
15 [9-18] 12 [0-19] 10 [4-15] 14 [10-NA 12 0 [0-0] 28 [24-35] † ]
Placebo (n = 36)
13 [2-17] 12 [0-23] 8 [5-13] 16 [9-NA † ] 17 0 [0-0] 33 [23-36]
P
0.65
0.33
0.70
0.67
0.80
0.56
0.50
Girard TD, et al.
Crit Care Med.
2010;38(2):428-437.
Prophylactic Haloperidol
• RCT of short-term low-dose IV haloperidol • Patients – N = 457 – Age > 65 years – ICU after noncardiac surgery • Intervention – Haloperidol 0.5 mg IV bolus then Infusion 0.1 mg/h for 12 hrs – Placebo • Primary endpoint – Incidence of delirium within the first 7 days after surgery Wang W, et al.
Crit Care Med
. 2012;40(3):731-739.
Prophylactic Haloperidol
7 day delirium incidence (%) Mean time to delirium onset (days) Mean time delirium-free (days) Median ICU LOS (hours) All-cause 28-day mortality (%)
Haloperidol (n = 229)
15.3
6.2
6.8
21.3
0.9
Placebo (n = 229)
23.2
5.7
6.7
23.0
2.6
P-value
0.031
0.021
0.027
0.024
0.175
Wang W, et al.
Crit Care Med
. 2012;40(3):731-739.
Quetiapine vs. Placebo
Delirium + Haloperidol PRN Quetiapine (n = 18) Placebo (n = 18) • Randomized, double-blind, placebo-controlled • Multisite (3 centers) • 36 ICU patients • PO delivery of study drug • Quetiapine dose: 50-200 mg q12h • Primary outcome: time to first resolution of delirium (ie, first 12-hour period when ICDSC ≤ 3) Devlin JW, et al.
Crit Care Med.
2010;38(2):419-427.
Patients with First Resolution of Delirium
Log-Rank
P
= 0.001
Placebo Quetiapine Day During Study Drug Administration
Quetiapine added to as-needed haloperidol results in faster delirium resolution, less agitation, and a greater rate of transfer to home or rehabilitation.
Devlin JW, et al.
Crit Care Med
. 2010;38:419-427.
Impact of Quetiapine on the Resolution of Individual Delirium Symptoms
Median ICDSC and individual delirium symptoms similar at study baseline
Quetiapine Placebo Median time to symptom resolution Inattention Disorientation Symptom fluctuation 3 hrs 2 hrs 4 hrs 8 hrs 10 hrs 14 hrs Agitation 5 hrs 1 hrs Time with each symptom [median (IQR)] Inattention 47 (0-67)% 78 (43-100)% Hallucinations Symptom fluctuation 0 (0-17)% 47 (19-67)% 28 (0-43)% 89 (33-100)% P value Log rank 0.10
0.10
0.004
0.04
Comparison of Proportions 0.02
0.10
0.04
Devlin JW, et al.
Crit Care.
2011;15(5):R215.
Rivastigmine for Delirium?
Time (days after inclusion)
• FDA approved for dementia of Alzheimer’s or Parkinson’s • Cholinesterase inhibitor • Result − Mortality (vs placebo): 22% vs 8%,
P
= 0.07
− Delirium (vs placebo): 5 vs 3 days,
P
= 0.06
• Conclusion: − Need RCTs for delirium as endpoint − Don’t use rivastigmine for ICU delirium http://www.accessdata.fda.gov. Accessed March 2012.
Van Eijk MM, et al.
Lancet
. 2010;376(9755):1829-1837.
Impact of Pain-Sedation-Delirium Protocol on Subsyndromal Delirium
Significant Patient Characteristics/Metrics/Outcomes 60 Protocol n = 561 PRE protocol n = 572 55 50 40 30 20 10 P = 0.01
5,9 7,5 0 Duration of MV P = 0.009
5,3 6,3 ICU LOS P < 0.001
27 Hospital LOS Delirium † Subsyndromal Delirium † Protocol
(34.2) (24.6)
Lorazepam equivalents, mg*
2.75 ± 7.94
PRE
(34.7) (33) 5.79 ± 31.78
MSO4 equivalents, mg*
22.3 40.1
± 103.5 239.2
*Data presented in mean; † Data presented as n (%) Subsyndromal delirium; max ICDSC 1-2 in ICU ±
P-value
0.9
0.009
0.02
< 0.001
Skrobik Y, et al.
Anesth Analg
. 2010;111(2):451-463.
Before Considering a Pharmacologic Treatment for Delirium…
• Does your patient have delirium?
– Assessed with scale?
• Which type of delirium?
– Hyperactive – Hypoactive – Mixed hyperactive-hypoactive • Have the underlying causes of delirium been identified and reversed/treated?
• Have non-pharmacologic strategies been optimized?
Inouye SK, et al.
N Engl J Med.
1999;340:669-676.
Antipsychotic Therapy Rule Out Dementia
• Antipsychotic drugs are not approved for the treatment of dementia-related psychosis – No drug is approved for dementia-related psychosis • Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death • Physicians considering antipsychotics for elderly patients with dementia-related psychosis should discuss this increased risk of mortality with their patients, patients’ families, and caregivers Antipsychotics. http://www.canhr.org/ToxicGuide/Media/Articles/FDA%20Alert%20on%20Antipsychotics.pdf. Accessed March 2012.
ABCD
E
Awakening Breathing Coordination/Choice of Sedation Delirium Monitoring and Management Early Mobilization
Early Mobilization Patient Selection
• Inclusion criteria − Medical ICU − Adults (≥ 18 years of age) − On MV < 72 h, expected to continue for at least 24 h − Met criteria for baseline functional independence (Barthel Index score ≥ 70) • Exclusion criteria − Rapidly developing Neuromuscular disease Cardiopulmonary arrest Irreversible disorders with estimated 6-month mortality > 50% Raised intracranial pressure Absent limbs Enrolment in another trial Schweickert WD, et al.
Lancet.
2009;373:1874-1882.
Early Mobilization Trial Design
• 104 sedated patients with daily interruption – Early exercise and mobilization (PT & OT; intervention; n = 49) – PT & OT as ordered by the primary care team (control; n = 55) • Primary endpoint: number of patients returning to independent functional status at hospital discharge – Ability to perform 6 activities of daily living – Ability to walk independently • Assessors blinded to treatment assignment • Secondary endpoints – Duration of delirium during first 28 days of hospital stay – Ventilator-free days during first 28 days of hospital stay Schweickert WD, et al.
Lancet.
2009;373:1874-1882.
Perform Safety Screen First
• Patient responds to verbal stimulation (ie, RASS ≥ -3)* • FIO 2 ≤ 0.6 • PEEP ≤ 10 cmH 2 O • No dose of any vasopressor infusion for at least 2 hours • No evidence of active myocardial ischemia (24 hrs) • No arrhythmia requiring the administration of new antiarrhythmic agent (24 hrs) Pass Fail *Range of motion may be started in comatose patients, but not considered Early Exercise/Mobility Exercise/Mobility Therapy Too Ill for Exercise/Mobility Schweickert WD, et al.
Lancet.
2009;373:1874-1882.
Early Mobilization Protocol: Result
• Return to independent functional status at discharge – 59% in intervention group – 35% in control group (
P
= 0.02) Schweickert WD, et al.
Lancet.
2009;373:1874-1882.
Early PT and OT in Mechanically Ventilated ICU Patients
All Patients P = 0.93
16 14 PT/OT with DSI n = 49 DSI alone n = 55 13,5 12,9 12 P = 0.08
10 P = 0.02
7,9 8 P = 0.02
6,1 5,9 6 4 4 3,4 2 2 0 Duration of ICU Delirium Mechanical Ventilation ICU LOS Hospital LOS
Schweickert WD, et al.
Lancet
. 2009;373(9678):1874-1882.
Protocol for Early Mobility Therapy Acute Respiratory Failure Patients
Morris PE, et al.
Crit Care Med
. 2008;36(8):2238-2243.
Early Mobility Therapy Results
Primary Endpoint: more protocol patients received PT than did usual care (80% vs. 47%,
P
≤ 0.001) Days to first out of bed Ventilator days ICU LOS days Hospital LOS days
Usual Care* (n = 135)
11.3 10.2
6.9
14.5
Protocol* (n = 145)
5.0
8.8
5.5
11.2
P-Value
0.001
0.163
0.025
0.006
*Values adjusted for BMI, Acute Physiology and Chronic Health Evaluation II, and vasopressors Morris PE, et al.
Crit Care Med
. 2008;36(8):2238-2243.
Early Mobility Resources
• Agency
for Healthcare Research and Quality (AHRQ)
website has a description of LDS Hospital’s (Salt Lake City, UT) Early Mobility Program implementation process. Helpful points on how to get started: – http://www.innovations.ahrq.gov/content.aspx?id=2442 • Overview of the implementation of a Early Mobility Quality Improvement Program in the ICUs at Johns Hopkins University in Baltimore, MD – Needham DM, Korupolu R. Rehabilitation Quality Improvement in an Intensive Care Unit Setting: Implementation of a Quality Improvement Model.
Top Stroke Rehabil
. 2010;17(4):271-281.
• This
video
highlights the patient’s perspective; watch the patient ambulating in the ICU while mechanically ventilated – http://www.youtube.com/watch?v=0jycOFVE624 (Full version: 9 minutes) – http://www.youtube.com/watch?feature=player_detailpage&v=aobZTnhMK1g (Shorter version: 2 minutes) • Dale Needham, MD, PhD, talks about the Early Mobility Program at Johns Hopkins University (2.5 minutes) – http://www.youtube.com/watch?v=D53gygWRhLM
Benefits of ABCDE Protocol
Morandi A, et al
. Curr Opin Crit Care
. 2011;17:43-49.
Liberation and Animation Summary of RCT Literature
Ely EW, et al.
N Engl J Med
. 1996;335(25):1864-1869.
Kress JP, et al.
N Engl J Med.
2000;342(20):1471-1477.
SBT SAT Girard TD, et al.
Lancet
. 2008;371(9607):126-134.
Strøm T, et al.
Lancet.
2010;375(9713):475-480.
Pandharipande PP, et al.
JAMA.
2007;298(22):2644-2653.
Riker RR, et al.
JAMA.
2009;301(5):489-499.
Remove (A+B) Remove Sedation Sedation Choice Sedation Choice Schweickert WD, et al.
Lancet
. 2009;373(9678):1874-1882. Early Mobility
Post-Intensive Care Syndrome
• SCCM Task Force on Long-Term Outcomes • “Post-intensive care syndrome (PICS) was agreed upon as the recommended term to describe new or worsening problems in physical, cognitive, or mental health status arising after a critical illness and persisting beyond acute care hospitalization. • The term could be applied to either a survivor or family member- PICS F.” Needham DM, et al.
Crit Care Med.
2012;40(2):502-509.
PICS Consequences
Post Intensive Care Syndrome (PICS) Family (PICS-F) Survivor (PICS) Mental Health Anxiety/ASD PTSD Depression Complicated Grief Mental Health Anxiety/ASD PTSD Depression Needham DM, et al.
Crit Care Med.
2012;40(2):502-509.
Desai SV, et al.
Crit Care Med
. 2011;39(2):371-379.
Davidson JE, et al.
Crit Care Med
. 2012;40(2):618-624.
Cognitive Impairments Executive Function Memory Attention Physical Impairments Pulmonary Neuromuscular Physical Function
PICS Checklist: Have We….
• Limited sedation? • Changed goals from "arouseable" to "cognitively engaged“ • Promoted early physical and cognitive activity to engage the brain?
• Treated pain first and used benzodiazepines only when necessary?
• Limited drugs that block memory (exception: AWS)?
• Assessed and treated pts with alcohol dependency? • Encouraged family involvement (for both the health of the pt and the family)?
• Performed a thorough medication reconciliation?
PICS Checklist: Have We….
• Communicated with the pt and family to support psychological well being?
• Offered pt care conferences when indicated?
• Translated/interpreted when indicated?
• Maintained glycemic control without causing hypoglycemia?
• Encouraged uninterrupted sleep at night and for at least 2 hours in the afternoon?
• Assured that the pt who has dentures and glasses wears them when conscious?
• Assessed for delirium? • Noted the presence of delirium in the progress notes for coding and communication?
• Considered maintaining a pt diary of key events to share with the family?
PICS Hand-Off Checklist
• Have we coordinated care prior to transfer?
– Referred cognitive issues to speech therapy/OT (taught pt/family cognitive recovery exercises) – Referred psychiatric issues to psych consult (taught pt/family coping strategies) – Referred physical issues to PT (promoting physical activity that engages the brain) – Discussed with family lasting effects of illness and the possible need for continued care (assured them that this is common, and will take time to resolve) – Recorded current physical, cognitive and psychological issues, informed next provider?
Introducing ABCDE in the ICU: Practical Advice for Implementing Protocols
How to Identify Barriers
• The ABCDE supporting: – People – Processes – Technology Bundle focuses on aligning and • These are three key areas to evaluate when identifying barriers to adoption and implementation
People: Who Is on Your Team?
• Nurses • Doctors • Pharmacists • Respiratory therapists • PT/OT • Administration
Processes: What Does Your Team Have in Place?
• What do you do well? (ABCDEs) • Where do you need help?
• What is in motion?
• What has not started?
What Is the Role of Technology?
• Computerized charting • Computerized order entry • Keep it simple • Size of the institution • Measure outcomes
General Barriers to Changing the ICU Culture
• Tendency to maintain the status quo • Resistance of independent groups to alter their behaviors and relinquish some autonomy • Perceived disproportionality of outcomes from the proposed change to the efforts required for change • Lack of significant prioritization • Insufficient personal accountability for completing change • Inadequate knowledge about clinical outcomes Hatler CW, et al.
Am J Crit Care.
2006;15:549-555.
Nursing-Implemented Sedation Protocol: Barnes Jewish Pilot United States
25 20 15 10 5 Protocol n = 162 Routine n = 159 P = 0.003
4.8
2.3
P = 0.13
5.7
7.5
P < 0.001
14 20 Significant patient characteristics/metrics/outcomes Protocol Routine P value
CIVS† 66 (40) 66 (42) Duration CIVS, hrs* Bolus † 3.5 ± 4 118 (72) 5.6 ± 6.4
127 (80) Reintubated † Trached † 14 (8.6) 10 (6.2) 21 (13) 21 (13.2) *Data presented in median; † Data presented as n (%) CIVS: continuous intravenous infusion sedation 0.9
0.003
0.14
0.2
0.04
0 Duration of MV ICU LOS Hospital LOS
Single center, prospective, trial of 332 consecutive ICU patients requiring mechanical ventilation randomized to protocolized sedation (n = 162) or routine care (n = 159) at Barnes Jewish Hospital from 8/97 to 7/98. Protocol used goal orientated sedation to target Ramsay with bolus requirements before initiation of continuous infusion and uptitration of opioids and benzodiazepines.
Brook AD, et al.
Crit Care Med
. 1999;27(12):2609-2615.
25 20 15 10 5
Nursing-Implemented Sedation Protocol: Bocage University Hospital France
Protocol n = 197 Control n = 226 P = 0.001
8 4.2
P = 0.004
5 11 P = 0.003
21 17 Significant patient characteristics/metrics/outcomes
Daily midazolam, mg* Duration midazolam, hrs** Reintubated† VAP diagnosis †
Protocol
44 ± 31 3 11 (6) 12 (6)
Control
92 *Data presented in mean; ** Data presented in median † Data presented as n (%) ± 59 5 29 (13) 34 (15)
P value
0.001
0.18
0.01
0.005
0 Duration of MV ICU LOS Hospital LOS
Single center, prospective, before-after trial of 423 ICU patients requiring mechanical ventilation for > 48 hours before (n = 226) and after (n = 197) implementation of sedation protocol at Bocage University Hospital from 5/99 to 12/03. Protocol used goal orientated sedation to target Q3hr Cambridge scale with bolus requirements before initiation of continuous infusion and uptitration of midazolam Quenot JP, et al.
Crit Care Med
. 2007;35(9):2031-2036.
Pharmacist Enforced Adherence to an ICU Sedation Guideline: Boston Medical Center MICU
25 20 15 10 RPh intervention n = 78 Control n = 78 P = 0.0004
8.9
5.3
P = 0.002
10.6
7 P = 0.001
19.8
11.8
Significant patient characteristics/metrics/outcomes RPh Control
Alcohol/drug overdose † 15 (19.2) 6 (7.7) Lorazepam equivalents/vent day, mg* 65.2 ± 114.1
74.8 76.1
± Fentanyl equivalents/vent day, mcg* 102.5 328 ± 400 1026 *Data presented in mean ; † Data presented as n (%) ±
P value
0.03
0.54
0.02
5 0 Duration of MV ICU LOS Hospital LOS
Single center trial of 156 adult MICU patients requiring mechanical ventilation before (n = 78) and after (n = 78) implementation of RPh enforced guideline sedation management at Boston Medical Center. Guideline addressed use of agent selection, goal oriented therapy, and dose limitation strategies.
Marshall J, et al.
Crit Care Med
. 2008;36(2):427-433.
Quality Improvement Project: Implementing ABCDE
• Multidisciplinary team focused on reducing heavy sedation, using SAT-SBT protocol and increasing MICU staffing to include full-time physical and occupational therapists with new consultation guidelines • Results: – Delirium decreased – Sedation use decreased – Physical mobility improvement – Decrease hospital length of stay – Increased MICU admissions Needham DM, et al.
Arch Phys Med Rehabil
. 2010;91(4):536-542.
Needham DM, et al.
Top Stroke Rehabil.
2010;17(4):271-281.
QI Program for Changing the ICU Culture
Summarize the Evidence Identify Local Barriers to Implementation Measure Performance Ensure All Patients Receive the Interventions Needham DM, et al.
Top Stroke Rehabil
. 2010;17(4):271-281.
Barriers to Changing the ICU Culture
Needham DM, et al.
Top Stroke Rehabil
. 2010;17(4):271-281.
Barriers to Changing the ICU Culture (cont)
Needham DM, et al.
Top Stroke Rehabil
. 2010;17(4):271-281.
Results of ICU Quality Initiative
Needham DM, et al.
Top Stroke Rehabil
. 2010;17(4):271-281.
Results of ICU Quality Initiative (cont)
Needham DM, et al.
Top Stroke Rehabil
. 2010;17(4):271-281.
Developing and Implementing ICU Sedation Protocols and Guidelines
Phase III: Phase II: Phase I: Implementation Continuous Quality Improvement (CQI) Development 1.
Creation of the “physical champion(s)” 2. Multidisciplinary Committee 3. Data synthesis 4. Protocol drafting 1. Pilot Analysis • Efficacy, Safety, Adherence 2. Endorsement of protocol from institutional credible bodies 3. Education to all ICU clinicians 4. Integration with electronic documentation and clinical monitoring systems 1. Periodic Metric Assessment 2. Guideline update with current literature 3. Publication of efficacy, safety, and compliance data • Benchmarking against other institutions • Assistance in guideline development
Key Steps for Effective Change
• Linking effective care processes with hospital and long-term patient outcomes • Creating a strategy to improve teamwork and collaboration • Creating a process for early mobilization • Recognizing that current practice patterns may interfere with mobility • Agreeing on a need to change • Identification of a local champion Wheelan SA, et al.
Am J Crit Care.
2003;12:527-534.
Durbin CG.
Crit Care Med.
2006;34(3 Suppl):S12-S17.
Conclusions
• Oversedation in the ICU is common; associated with negative sequelae • Analgosedation has been shown to improve outcomes; consider sedation only if necessary • Use the ABCDE protocol • Titrate all sedative medications using a validated assessment tool to keep patients comfortable and arousable if possible • Use of benzodiazepines should be minimized
Conclusions
• Consider nonpharmacological management of delirium and reduce exposure to risk factors • Typical and atypical antipsychotic medications may be used to treat delirium if nonpharmacological interventions are not adequate • Early mobility in ICU patients decreases delirium and improves functional outcomes at discharge