Guidelines for the Diagnosis and Management of Asthma : Expert

Report
CAM-ICU Basics
ICU Delirium and Cognitive Impairment Study Group
www.ICUdelirium.org
[email protected]
What is Delirium?
Delirium is a common clinical syndrome characterized by:
Inattention
Acute cognitive
dysfunction
Pathophysiology: Disruption of neurotransmission (drug action,
inflammation, acute stress response)
Delirium: Think rapid onset, inattention, clouding of consciousness
(bewildered), fluctuation
Dementia: Think gradual onset, intellectual impairment, memory
disturbance, personality/mood change, no conscious clouding
Subtypes of Delirium
Hypoactive
Patient may be quiet and even peaceful, despite
cognitive impairment. More difficult to assess.
Hyperactive
Patient may be combative with agitation that may
require sedation (is diagnosed more frequently).
Mixed
Combination of both types
Why monitor for Delirium?
• 50-80% of ventilated patients develop delirium
• 20-50% of lower severity ICU patients develop
delirium
• Over 40,000 ventilated patients are delirious
every day
• Delirium leads to increased mortality, longer
hospital stay, poorer recovery, higher costs of
healthcare, long-term neurocognitive problems.
Ely EW JAMA 2001;286,2703-2710
Ely EW CCM 2001;29,1370-79
ICU Delirium:
The Canary in the Coal Mine
Under recognized form of organ
dysfunction
3-fold increase in mortality at 6
months
Each DAY a patients is delirious =
10% INCREASE in risk of death
Delirium in the ICU
Clinical Value of RASS/CAM-ICU Measurement
Stimulates thinking of Rx:
– Delirium recognition is a Burglar Alarm for us
(early sign of danger)
– Forces us to consider treatable causes earlier
– Utilize nonpharmacologic interventions
– Do NOT automatically link delirium monitoring with
a specific drug treatment
Educational Delirium Website
www.ICUdelirium.org
A Two Step Approach to Assessing
Consciousness
Step 1
Level of Consciousness (arousal): RASS
Step 2
Content of Consciousness (delirium): CAM-ICU
Step 1: LOC Assessment
Assess for arousal
Step 1: Arousal Assessment (RASS)
+3
+2
+1
Richmond
AgitationSedation
Scale (RASS)
0
-1
-2
-3
-4
-5
Step 2: Content Assessment
Assess for Delirium
Confusion Assessment Method
for the ICU (CAM-ICU)
Feature 1: Acute change or
fluctuating course of mental
status
And
Feature 2: Inattention
And
Feature 3: Altered level of
consciousness
Inouye, et. al. Ann Intern Med 1990; 113:941-948.1
Ely, et. al. CCM 2001; 29:1370-1379.4
Ely, et. al. JAMA 2001; 286:2703-2710.5
Or
Feature 4: Disorganized
Thinking
Feature 1: Alteration/Fluctuation
in Mental Status
Is the pt different than his/her baseline mental
status?
OR
Has the patient had any fluctuation in mental
status in the past 24 hours (eg fluctuating
RASS, GCS, previous delirium assessments,
etc)
Present: If either question is YES.
Feature 1: Alteration/Fluctuation in
Mental Status
Common Questions:
• What if you do not know the patient’s baseline?
– Assume normal unless you have red flags that make
you suspicious
– Red Flag: patient came from institution
• What about dementia?
– Ask family “What could she/he do prior to this
illness?”
Feature 2: Inattention
Screening for Attention– two options
Letter “A” test
Letters: S A V E A H A A R T (or numbers)
Say 10 letters (or numbers) and instruct the patient to
squeeze on the letter “A” (or on a certain number)
Pictures
Similar test with pictures
(instructions are in picture packets)
Feature 2: Inattention
1. Attempt Letters first.
2. If pt is able to perform the Letter test you are sure of
the results, you are done with Inattention test.
3. If pt is unable to perform the Letter test or you are
unsure of the results, use the Pictures.
If you perform both tests, use the Pictures result to
determine if inattention is present.
Inattention Present : If >2 errors
Feature 2: Inattention
• What if the patient only squeezes once and then
falls back to “sleep”? or What if the patient is too
hyperactive/combative to participate in
squeezing?
– Remember what you are assessing—Attention
– This patient is inattentive
• If you have to explain the directions more than
twice, start to be suspicious for inattention
If either Feature 1 or 2 are absent,
Stop
Overall CAM-ICU is Negative
If Features 1 and 2 are present,
Proceed
to Feature 3
Feature 3: Alt Level of Consciousness
Any LOC other than Alert.
Present: If the Actual RASS score is anything
other than “0” (zero).
You have already done this assessment.
It was the first thing you did when you
walked in the room!
Feature 4: Disorganized Thinking
Yes/No Questions (Use either Set A or Set B) :
Set A
1. Will a stone float on water?
2. Are there fish in the sea?
3. Does one pound weigh more than
two pounds?
4. Can you use a hammer to pound a nail?
Set B
1. Will a leaf float on water?
2. Are there elephants in the sea?
3. Do two pounds weigh
more than one pound?
4. Can you use a hammer to cut wood?
Note: Use whatever form of communication that works (nodding,
hand squeezing, blinking, etc).
Feature 4: Disorganized Thinking
Command
Say to patient: “Hold up this many fingers”
(Examiner holds two fingers in front of patient)
“Now do the same thing with the other hand”
(Not repeating the number of fingers).
• Patient gets credit only if able to successfully
complete the entire command
Feature 4: Disorganized Thinking
Present: If there is >1 error for the combined
questions + command.
• Notes:
– If pt is unable to move both arms, for the second
part of the command ask patient “Add one more
finger”.
– If patient is unable to move arms at all
(quadriplegic), then feature 4 is present if patient
misses more than 1 question.
Confusion Assessment Method
for the ICU (CAM-ICU)
Feature 1: Acute change or
fluctuating course of mental
status
And
Feature 2: Inattention
And
Feature 3: Altered level of
consciousness
Inouye, et. al. Ann Intern Med 1990; 113:941-948.1
Ely, et. al. CCM 2001; 29:1370-1379.4
Ely, et. al. JAMA 2001; 286:2703-2710.5
Or
Feature 4: Disorganized
Thinking
Case Studies
Case #1: Mr. Icy
45 y/o man, lawyer with no previous memory or attention
problem
Dx: DKA, Intubated
In the past 24hrs the RASS scores have been -3 to +1.
Step 1: Arousal Assessment
Currently: Awake and moving around restless in bed, but
not aggressive.
RASS = +1
What do we do next?
Case #1: Mr. Icy
Step 2: CAM-ICU
- Feature 1:
Is he at his MS baseline?
Fluctuation?
- Feature 2:
Letters = 4 errors
- Feature 3:
RASS = +1
- Feature 4
Pos
Feature
1
Feature
2
Feature
3
Feature
4
Neg
Case #1: Mr. Icy
Step 2: CAM-ICU
- Feature 1:
Is he at his MS baseline?
Fluctuation?
Other RASS Scores: -3 +1
- Feature 2:
Letters = 4 errors
- Feature 3:
RASS = +1
- Feature 4
Pos
Feature
1
X
Feature
2
X
Feature
3
X
Feature
4
Neg
Case #2 Mrs. Dapple
75 y/o female
Dx: Severe pneumonia requiring prolonged mechanical
ventilation and difficulty weaning
In past 24 hours: RASS scores -3 to -1
Step 1: Arousal Assessment
Eyes closed, but awakens to voice; maintains eye contact for
>10 seconds
RASS = -1
What do we do next?
Case #2 Mrs. Dapple
Pos
Step 2: CAM-ICU
- Feature 1:
Is she at her MS baseline?
Fluctuation?
- Feature 2:
Letters = 1 error
- Feature 3
- Feature 4
Feature
1
Feature
2
Feature
3
Feature
4
Neg
Case #2 Mrs. Dapple
Pos
Step 2: CAM-ICU
- Feature 1:
Is he at his MS baseline?
Fluctuation?
RASS Variance: 2
- Feature 2:
Letters = 1 error
- Feature 3
- Feature 4
Feature
1
Feature
2
Feature
3
Feature
4
Neg
X
X
Case # 3 Miss Universe
Miss Universe was successfully extubated from the
Vent at 0800. All sedation and analgesia had been
stopped earlier in the AM. Yesterday evening and
last night she had periods of agitation with a
documented RASS range of -1 to +3.
Step 1: Arousal Assessment
Pt alert and calm.
RASS = 0
What do we do next?
Case #3: Miss Universe
Pos
Step 2: CAM-ICU
- Feature 1:
Is she at her MS baseline?
Fluctuation?
- Feature 2:
Letters = 3 errors, but you aren’t
sure
Pictures = 4 errors
- Feature 3:
RASS = 0
- Feature 4
Feature
1
Feature
2
Feature
3
Feature
4
Neg
Case #3: Miss Universe
Pos
Step 2: CAM-ICU
- Feature 1:
Is she at her MS baseline?
Fluctuation?
RASS Variance = 4
- Feature 2:
Letters = 3 errors, but you
aren’t sure.
Pictures = 4 errors
- Feature 3:
RASS = 0
- Feature 4
Feature
1
X
Feature
2
X
Feature
3
Feature
4
Neg
X
Case #3: Miss Universe
Pos
Step 2: CAM-ICU
- Feature 1:
Is she at her MS baseline?
Fluctuation?
- Feature 2:
Letters = 3 errors, but you aren’t
sure.
Pictures = 4 errors
- Feature 3:
RASS = 0
- Feature 4:
Answered half the questions wrong
Unable to perform 2-step command
3 errors
Feature
1
Feature
2
Feature
3
Feature
4
Neg
Case #3: Miss Universe
Step 2: CAM-ICU
Pos
Neg
- Feature 1:
Is she at her MS baseline?
Fluctuation?
- Feature 2:
Letters = 3 errors, but you aren’t
sure.
Pictures = 4 errors
- Feature 3:
RASS = 0
- Feature 4:
Answered half the questions wrong
Unable to perform 2-step command
3 errors
Feature
1
X
Feature
2
X
Feature
3
Feature X
4
X
What if Miss Universe had
gotten all 4 of her
questions right?
Case #3: Miss Universe
Pos
Step 2: CAM-ICU
- Feature 1:
Is she at her MS baseline?
Fluctuation?
- Feature 2:
Letters = 3 errors, but you aren’t
sure.
Pictures = 4 errors
- Feature 3:
RASS = 0
- Feature 4:
Answered all 4 questions correct
Unable to perform 2-step command
1 error
Feature
1
X
Feature
2
X
Neg
Feature
3
X
Feature
4
X
Case # 4 Mr. Bubble
Mr. Bubble works as a traveling salesman, and has been fully
independent until admission. He is admitted with acute
pancreatitis. His sedatives were turned off 30 minutes ago
for a Spontaneous Awakening Trial (SAT).
Step 1: Arousal Assessment
Eyes closed, moves head to verbal stimulation, no eye
contact
RASS = -3
What do we do next?
Case #4: Mr. Bubble
Pos
Step 2: CAM-ICU
- Feature 1:
Is he at his MS baseline?
Fluctuation?
- Feature 2:
Letters= no squeeze for any letters
- Feature 3:
RASS = -3
- Feature 4:
Feature
1
Feature
2
Feature
3
Feature
4
Neg
Case #4: Mr. Bubble
Pos
Step 2: CAM-ICU
- Feature 1:
Is he at his MS baseline?
Fluctuation?
- Feature 2:
Letters= no squeeze for any letters
- Feature 3:
RASS = -3
- Feature 4:
Feature
1
X
Feature
2
X
Feature
3
X
Feature
4
Neg
Confusion Assessment Method
for the ICU (CAM-ICU)
Feature 1: Acute change or
fluctuating course of mental
status
And
Feature 2: Inattention
And
Feature 3: Altered level of
consciousness
Inouye, et. al. Ann Intern Med 1990; 113:941-948.1
Ely, et. al. CCM 2001; 29:1370-1379.4
Ely, et. al. JAMA 2001; 286:2703-2710.5
Or
Feature 4: Disorganized
Thinking
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
– Assess target daily
• Do sedatives need to be changed?
• Remember to assess for pain!
Toxic Situations
• CHF, shock, dehydration
• New organ failure (liver/kidney)
Hypoxemia
Infection/sepsis (nosocomial),
Immobilization
Nonpharmacologic interventions
• Hearing aids, glasses, reorient,
sleep protocols, music, noise control,
ambulation
K+ or electrolyte problems
Consider antipsychotics after evaluating etiology & risk factors
Nonpharmacologic Interventions
• Environmental changes (e.g. noise
reduction)
• Sensory aids (e.g. hearing aids, glasses)
• Reorientation and stimulation
• Sleep preservation & enhancement
• Exercise and mobility
RASS
(N/D & reason if not done)
CAM-ICU Feature 1
(MS change or fluctuation)
Absent
Present
CAM-ICU Feature 2
(Inattention)
Absent
Present
CAM-ICU Feature 3
(Altered LOC)
Absent
Present
CAM-ICU Feature 4
(Disorganized thinking)
Absent
Present
Overall CAM-ICU
1 + 2 + [3 or 4] = CAM-ICU+
Negative
Positive
UTA (RASS -4/-5 only)
Not done:________
Brain Road Map for Rounds
(Script for Interdisciplinary Communication)
Skipping any of these steps could leave the clinical team wanting more information!
Investigate (Ask these questions)
Report (only takes 10 seconds)
Where is the patient going?
Target sedation score (RASS, SAS, etc)
Where is the patient now?
Actual sedation score (RASS, SAS, etc)
Delirium assessment (CAM-ICU, ICDSC, etc)
How did they get there?
Drug exposures
Case Study - Day 1
Female, age 61
Hx: hypertension
CC: altered mental status, pneumonia
Dx: Septic shock, ARDS, acute renal failure
Vent settings: A/C rate 16, TV 400, PEEP 14, FiO2 70%
Infusions: Levophed 8 mcg/min, vasopressin 0.4 units/min, insulin gtt, IVF
Assessment: Target RASS -3, actual RASS +1 to +2, displaying vent
asynchrony, CAM-ICU positive, bilateral rhonchi, pulses present
Drugs: Receiving intermittent boluses of fentanyl and midazolam
What next?
Review your Road Map
Report:
Where is the patient going?
Target sedation score: RASS -3
Where is the patient now?
Actual sedation score: RASS +1 to +2
Delirium: CAM-ICU positive
How did they get there?
Drug exposures: Intermittent fentanyl & midazolam
Action:
What do you do now?
Case Study – Day 3
Vent settings: AC rate 16, TV 400, PEEP 6, FiO2 40%
Infusions: propofol 40 mcg/kg/hr, Levophed 4 mcg/min,
vasopressin 0.4 units/min, insulin gtt, IVF
Drugs: Intermittent fentanyl for analgesia
Assessment: Target RASS -1, actual RASS -3, CAM-ICU
positive, not breathing over vent set rate, bilateral rhonchi,
pulses present, moving extremities spontaneously
What next?
Review your Road Map
Report:
Where is the patient going?
Target sedation score: RASS -1
Where is the patient now?
Actual sedation score: RASS -3
Delirium: CAM-ICU positive
How did they get there?
Drug exposures: Propofol infusion 40 mcg/kg/min &
intermittent fentanyl for pain
Action:
What do you do now?
Case Study – Day 5
Vent settings: Pressure support 5, PEEP 5, 40% and tolerating
spontaneous breathing trial
Infusions: Levophed/vasopressin off, insulin gtt, IVF, propofol
off
Septic shock resolved, passed SAT/SBT
Assessment: Target RASS 0, actual RASS 0, CAM-ICU positive,
lungs clear, moves all extremities
What next?
Review your Road Map
Report:
Where is the patient going?
Target sedation score: RASS 0
Where is the patient now?
Actual sedation score: RASS 0
Delirium: CAM-ICU positive
How did they get there?
Drug exposures: No sedatives/analgesics in the past 24h
Action:
What do you do now?
Questions?
www.ICUdelirium.org
[email protected]

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