delirium: the next proposed “never event.” is this realistic?
TRANSCRIPT
Pratik Pandharipande, MD, MSCIDepartment of Anesthesiology/Critical Care
Vanderbilt University School of Medicine, Nashville, TNVA TN Valley Health Care System
Delirium: The Next Proposed “Never Event.”Is This Realistic?
Disclosure
Research Grant - Hospira Inc
Honorarium - Hospira Inc
FAER Grant
VPSD Award
VA Career Development Award
Delirium: A never event? Maybenot yet……BUT
• Delirium proposed by CMS as a “Never Event”
• “Never Events” are errors in medical care that are clearly identifiable, preventable, and serious in consequences and indicate a problem in the safety of a healthcare facility.
• The proposal has given delirium publicity
• Increased interest and research in this topic
Histogram showing the number of English articles detected when searching for Delirium and ICU as MeSH or Text Words by year from 1990 through 2007.
Articles on Delirium in ICU (MeSH or Text headings in English)
0
10
20
30
40
50
60
70
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
Year
Num
ber o
f Arti
cles
PP--value for trend shift at value for trend shift at year 2000 = 0.002 year 2000 = 0.002
Morandi et al ICM 2008;34:1907-1915
Delirium: A brain organ dysfunction
Morandi et al ICM 2008;34:1907-1915
Prevalence of ICU Delirium
• Occurs in up to 80% MICU/SICU/TICU ventilated patients develop delirium
• 20-50% of lower severity ICU patients develop delirium
• Hypoactive or mixed forms most common
• 65-70% goes undiagnosed if routine monitoring is not implemented
Ely EW. ICM. 2001;27:1892-1900.Ely EW. JAMA. 2001;286,2703-2710.Pandharipande. J Trauma. 2008;65:34-41.Ely EW. CCM. 2001;29:1370-1379.Pandharipande. ICM. 2007;33:1726-1731.Lat I. CCM.2009;37:1898-1905
Roberts B. Aust Crit Care. 2005;18:6,8-9.Thomason J. Crit Care. 2005;9:375-381.
Ely EW. CCM. 2004;32:106-112.Peterson. JAGS. 2006;54:479-484.
Ouimet S. ICM. 2007;33:66-73.Spronk P. Neth J Med.2009;67:296-300
Slooter A. CCM.2009. 37 (6):1881-1885, 2009
Key Points: ICU Delirium
• $15k to $25k higher hospital costs
• Longer hospital stays
• 3 times higher risk of death by 6 months
• Prolonged neuropsychological dysfunction
Milbrandt E, et al. Crit Care Med. 2004;32:955-962.Ely EW, et al. JAMA. 2004;291:1753-1762.
Ouimet S. ICM. 2007;33:66-73.Lin, et al. Crit Care Med. 2004;32:2254-2259.
Girard TD, et al. ATS 2009
0
10
20
30
40
50
60
0 5 10 15 20
Days of ICU Delirium
Cog
nitiv
e F
unct
ion
at 1
2 M
onth
s(P
redi
cted
Mea
n T-
scor
e)
P=.005
Delirium and Long-Term CognitiveOutcomes
Delirium duration and Mortality
Pisani M. Am. J. Respir. Crit.
Care Med. Sept 2009(epub)
Subsyndromal Delirium
Patients who present some symptoms of delirium, but do not fulfill all criteria for delirium.
Subsyndromal Delirium andClinical Outcomes
No Delirium Subsyndromal
ClinicalDelirium P-Value
ICU Mortality 2.4% 10.6% 15.9% <.001
ICU LOS 2.5 (2.1) 5.2 (4.9) 10.8 (11.3) <.001
Mean (SD) when applicable
Ouimet S. Int Care Med. 2007;33:1007-1013.
Pathogenesis of Delirium
•Inflammation•Neurotransmitters•Tryptophan metabolites
Risk Factors for Delirium
• Aging
• Baseline dementia
• Psychiatric disorders
• Underlying illness
– Inflammation
– Coagulation
• Metabolic disturbances
• Hypoxemia
• Genetic predisposition (?)
• Psychoactive medications
• Sleep deprivation
Inouye. JAMA. 1996;275:852-857.Dubois. Intens Care Med. 2001;27:1297-1304.
Inouye. NEJM. 1999;340:669-676.Jacobi. Crit Care Med. 2002;30:119-141.
Milbrandt. Crit Care Med. 2005;33:226-229.Ouimet S. Int Care Med. 2007;33:66-73
Pisani M. Crit Care Med. 2009 Jan;37(1):354-5
50
60
70
80
90
100
No drug
Lorazepam Dose (mg)
Log scale
Original scale
0 -1 1 -2 2 -3 3 -4 4+
0 -2.7 2.7 -7.4 7.4 -20 20 -55 55+
Del
irium
Ris
k
Pandharipande PP, et al. Anesthesiology. 2006;104:21-26.
Lorazepam and Delirium
Surgical Trauma
Users
Non-Users
Midazolam
Daily Midazolam Use (Exc. Coma Days)
% D
ays
Del
iriou
s
0
20
40
60
80
100
P=.014P=.031
Surgical Trauma
UsersNon-Users
Fentanyl
Daily Fentanyl Use (Exc. Coma Days)
% D
ays
Del
iriou
s
0
20
40
60
80
100
P=.007
P=.936
Midazolam and Fentanyl (?) asRisk Factors for Delirium
Pandharipande, et al. J Trauma. 2008;65:34-41.
Benzodiazepines in previous 24 hours (midazolam equivalents)
Od
ds
of
de
liriu
m
0 50 100 150 200
0.0
0.2
0.4
0.6
0.8
1.0
Benzodiazepines
Opiates in previous 24 hours (fentanyl equivalents)
Od
ds
of
de
liriu
m
0 2000 4000 6000 80000.0
0.2
0.4
0.6
0.8
1.0
Opiates
Risk factors of Delirium in Burn ICU patientsRisk factors of Delirium in Burn ICU patients
Pandharipande, Agarwal, Cotton et al. ASA 2009
What should we do to “try andmake delirium a never event?”
• 1. Monitoring
• 2. Non pharmacolgical interventions
• 3. Reduction in deliriogenic medications
• 4. Pharmacological interventions– Dexmedetomidine
– Antipsychotics
1. Target RASS/ (where going?)
(or any valid scale)
2. Actual RASS (where now?)
3. CAM-ICU/ICDSC (content ?)
4. Drugs/toxins/metabolic (how got here?)
BRAIN ROAD MAP on ROUNDS
Confusion Assessment Method(CAM-ICU)
1. Acute onset of mental status changes or a fluctuating course
and
2. Inattention
and
or3. Altered level of consciousness
4. Disorganized thinking
= DeliriumEly 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
Bergeron, et al. ICM. 2001;27:859-864.
Multicomponent preventive protocols
Inouye S.K,1999 NEJM:669-676Marcantonio E.R, 2001 JAGS:516-522Milisen K, 2001 JAGS:523-532
Study design Incidence of delirium Duration of
Delirium
Severity of
Delirium
Inouye Prospective matching
9.9% intervention 15% control
No benefit No benefit
Marcantonio RCT 32% intervention 50% control
No benefit No benefit
Milisen Prospective sequential design
No benefit 1 day intervention 4 days control
Lower CAM score
Lundstrom Clinical Trial No benefit 30.2% intervention 59.7% control
Not evaluated
Vidan Prospective cohort trial
11.7% intervention18.5% control
No benefit No benefit
Lundstrom M, 2005 JAGS:622-628Vidan M.T, 2009 JAGS E Pub
Early Mobilization Protocol in Mechanically Ventilated Patients
Schweickert et al, Lancet 2009;373:1874-82
Daily Wake-Up + Early Mobility
OutcomeIntervention
(n=49)Control(n=50) P
Functionally independent at discharge 29 (59%) 19 (35%) .02
ICU delirium (days) 2.0 (0.0-6.0) 4.0 (2.0-7.0) .03
Time in ICU with delirium (%) 33% (0-58) 57% (33-69) .02
Hospital delirium (days) 2.0 (0.0-6.0) 4.0 (2.0-8.0) .02
Hospital days with delirium (%) 28% (26) 41% (27) .01
Barthel Index score at discharge 75 (7.5-95) 55 (0-85) .05
ICU-acquired paresis at discharge 15 (31%) 27 (49%) .09
Ventilator-free days 23.5 (7.4-25.6) 21.1 (0.0-23.8) .05
Length of stay in ICU (days) 5.9 (4.5-13.2) 7.9 (6.1-12.9) .08
Length of stay in hospital (days) 13.5 (8.0-23.1) 12.9 (8.9-19.8) .93
Hospital mortality 9 (18%) 14 (25%) .53
Schweickert WD, et al. Lancet. 2009;373:1874-1882.
Have a Plan:Sedation Protocols and Targeted Sedation
Trial RCT Outcome(s) Improved by Protocol
Brook et al.1999 Yes Ventilator days, ICU LOS
Kress et al. 2000 Yes Ventilator days, ICU LOS
Brattebo et al. 2002 No Ventilator days
de Lemos et al. 2005 Yes Ventilator days, ICU LOS
De Jonghe et al. 2005 No Ventilator days, time to awaken
Chanques et al. 2006 No Ventilator days, pain/agitation, infection
Quenot et al. 2007 No Ventilator days, extubation success, VAP
Arias-Rivera et al. 2008 No Extubation success
Bucknall et al. 2008 Yes None
Girard et al. 2008 Yes Ventilator days, hospital LOS, survival
Robinson et al. 2008 No Ventilator days, hospital LOS
Tobar et al. 2008 Yes Oversedation rate
Sedation Protocols: The Evidence
Less is More:Daily Interruption of Sedatives and
Wake-Up and Breathe
Study Day
Dai
ly D
ose
of B
enzo
diaz
epin
es
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
0
10
20
30
40
50
60
70Benzodiazepines
Usual Care + SBTSBT + SAT
Study Day
Dai
ly D
ose
of O
piat
es
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
0
2000
4000
6000
Usual Care + SBTSBT + SAT
Opiates
Avoid Benzodiazepines:Alternative Sedatives
MENDS TrialDouble-blind, Randomized, Controlled
Vanderbilt University Medical Center and Washington Hospital Center
MICU/SICU patientsventilated and sedated
Controllorazepam (GABA)
± fentanyl
Interventiondexmedetomidine (α2)
± fentanyl
Pandharipande PP, et al. JAMA. 2007;298:2644-2653.
Risk of Developing Delirium
Pandharipande PP, et al. unpublished data
Delirium/Coma-Free Days
0
2
4
6
8
10
12P=.01
Delirium-Free Days
P=.09 P=.001
Coma-Free Days
Dexmedetomidine
Lorazepam
Brain DysfunctionBrain Dysfunction
Pandharipande PP, et al. JAMA. 2007;298:2644-2653.
Prevalence of Delirium
54% DEX vs 76.6% MDZ, P<.001
Riker et al. JAMA 2009
Risperidone and Delirium
• Double-blind randomized trial (DBRT)
• Single dose (1 mg) of risperidone administered after cardiac surgery
• Reduced the incidence of postoperative delirium
– 11.1% vs.31.7%, P=.009
– RR=0.35, 95% CI=0.16-0.77
Prakanrattana, et al. Anaesth Intensive Care. 2007;35:714-719.
Resolution of Delirium and Coma
Girard TD, et al. Am J Respir Crit Care Med. 2008;177:A817.
1 5 10 15 20
Day
Pat
ient
s W
ithou
t Del
irium
or
Com
a (%
)
0
20
40
60
80
100
Haloperidol (n=35)Ziprasidone (n=32)Placebo (n=36)
Are we making any progress?• Growing awareness about delirium and associated
outcomes
• Better monitoring instruments for health care providers at bedside
• Identification of potential mechanisms and risk factors
• Non pharmacological interventions have shown promise in non-ICU cohorts and in ICU cohorts (early mobilization)
• Reducing benzodiazepine exposure with alternative sedation paradigms, especially dexmedetomidine has shown improvements in delirium rates and duration