ABCDE Protocol and MIND-USA: Enhancing Critical Care Practices
ABCDE Protocol
ICU Delirium and Cognitive Impairment Study Group
www.icudelirium.org
delirium@vanderbilt.edu
Why the ABCDE Protocol?
Need for Sedation and Analgesia
•
Prevent pain and anxiety
•
Decrease oxygen consumption
•
Decrease the stress response
•
Patient-ventilator synchrony
•
Avoid adverse neurocognitive sequelae
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.
-
Depression, PTSD
Potential Drawbacks of Sedative
and Analgesic Therapy
•
Oversedation:
•
Failure to initiate spontaneous breathing trials (SBT) leads to increased
duration of mechanical ventilation (MV)
•
Longer duration of ICU stay
•
Impede assessment of neurologic function
•
Increase risk for delirium
•
Numerous agent-specific adverse events
Kollef MH, et al.
Chest
. 1998;114:541-548.
Pandharipande PP, et al.
Anesthesiology
. 2006;104:21-26.
Sedation
Mechanical
Ventilation
Delirium
Weakness
Patient with
Sepsis
Cognitive and Functional Impairment, Institutionalization, M
ortality
Vasilevskis et al Chest 2010; 138;1224-1233
We Need Coordinated Care
•
Many tasks and demands on critical care staff
•
Great need to align and supporting the people,
processes, and technology already existing in ICUs
•
ABCDE protocol is multiple components,
interdependent, and designed to:
•
Improve collaboration among clinical team members
•
Standardize care processes
•
Break the cycle of oversedation and prolonged ventilation
Vasilevskis et al Chest 2010; 138;1224-1233
What is the MIND-USA
ABCDE Protocol?
Awakening and Breathing
Coordination
Delirium Identification and
Management
Early Exercise and Mobility
ABC
D
E
A
wakening and
B
reathing
C
oordination
Over sedation
Patient Comfort and
Ventilatory Optimization
ICU Sedation: It’s a Balancing
Act
Consequences of Suboptimal
Sedation
Inadequate
sedation/analgesia
•
Anxiety
•
Pain
•
Patient-ventilator
dyssynchrony
•
Agitation
–
Self-removal of
tubes/catheters
•
Care provider assault
•
Myocardial ischemia
•
Family dissatisfaction
Excessive sedation
•
Prolonged mechanical
ventilation, ICU LOS
–
Tracheostomy
–
DVT, VAP
•
Additional testing
•
Added cost
•
Inability to
communicate
•
Cannot evaluate for
delirium
Structured Approaches to
Sedation & Analgesia in the ICU
1.
Multidisciplinary development, implementation
2.
Establish goals/targets, frequently re-evaluate
3.
Measure key components using validated scales
4.
Select medications based on characteristics, evidence
5.
Incorporate key patient considerations
6.
Prevent oversedation, yet control pain and agitation
7.
Promote multidisciplinary acceptance and integration
into routine care
Sessler & Pedram. Crit Care Clinics 2009; 25:489-513
Validated ICU Sedation Scales
•
Richmond agitation-sedation scale (RASS)
•
Sedation agitation scale (SAS)
•
Ramsay sedation scale
•
Motor activity assessment scale (MAAS)
•
Vancouver interactive and calmness scale
(VICS)
•
Adaptation to intensive care environment
(ATICE)
•
Minnesota sedation assessment tool
(MSAT)
Setting Targets
Provide for agitation/anxiety free,
amnesia, comfort
•
Trying to achieve a balance
•
TIGHT TITRATION
Adjust target depending on current need
•
Per patient
•
Different over the course of
Illness/Treatment
Use Protocols to Achieve Goals,
Minimize Drug Accumulation,
Maximize Alertness
•
Patient-focused drug selection
•
Preference for analgesia > sedation
•
Intermittent therapy via boluses
•
Frequent evaluation of sedation, pain,
ICU therapy tolerance
–
Titrate therapy for
lowest effective dose
•
Daily interruption of sedation
•
RCT: 2x2 factorial design
–
Midazolam vs propofol
–
Daily interruption of sedation vs routine
•
Discontinue all sedative and analgesic medications
•
Monitor patient closely until awake or agitated,
i.e., can perform at least 3 of 4 on command:
–
Open eyes
–
Squeeze hand
–
Lift head
–
Stick out tongue
•
Restart medications at half dosage (if necessary)
Kress et al. N Engl J Med 2000; 342:1471-7
•
Shorter duration
of mechanical
ventilation
•
Shorter ICU LOS
•
Fewer tests for
altered mental
status
Kress et al. N Engl J Med 2000; 342:1471-7
Daily Awakening
Trial Results
Why Is Interruption of Sedation
Effective?
•
Less accumulation of sedative drug and
metabolites
–
Significantly less midazolam and morphine with DIS
in midazolam subgroup
–
But… no difference in amount of propofol and
morphine with DIS in propofol subgroup
•
Opportunity for more effective weaning from
mechanical ventilation?
Sessler CN. Crit Care Med 2004
Kress et al.
NEJM.
2000
Wake Up and Breathe
Multicenter RCT:
•
168 patients with “spontaneous
awakening trial” (SAT)
–
i.e., daily interruption of sedation (SAT)
+ spontaneous breathing trial (SBT)
•
168 patients with standard sedation + SBT
“SAT + SBT” Was Superior to
Conventional Sedation + SBT
Intervention (SAT) group = Less benzodiazepine
Girard et al. Lancet 2008; 371:126-34
P = 0.02
P = 0.01
Extubated faster
Discharged from ICU sooner
“SAT + SBT” Was Superior to
Conventional Sedation + SBT
Intervention (SAT) group =
More unplanned
extubation, but not more reintubation
P = 0.02
P = 0.01
Discharged from hospital sooner
Better survival at 1 yr
Alive
P = 0.01
P = 0.04
Girard et al. Lancet 2008; 371:126-34
A
wakening
&
B
reathing
C
oordination
•
Synergy of daily awakening – via
interruption of sedation – plus
spontaneous breathing trial
–
Less medication accumulation, less
excessive sedation
–
Opportunity for more effective
independent breathing (SBT)
•
Perform safety screens for SAT and for
SBT
ABC
Safety Screens
Wake Up Safety Screen
•
No active seizures
•
No active alcohol
withdrawal
•
No active agitation
•
No active paralytic
use
•
No myocardial
ischemia (24h)
•
Normal intracranial
pressure
Breathe Safety Screen
•
No active agitation
•
Oxygen saturation
>
88%
•
FiO
2
<
50%
•
PEEP
<
7.5 cm H
2
O
•
No active myocardial
ischemia (24h)
•
No significant
vasopressor use
Girard et al. Lancet 2008; 371:126-34.
Kress et al. Crit Care Med 2004; 32(6):1272-6
Ely et al. NEJM 1996; 335:184-9
ABC
A
wakening &
B
reathing
C
oordination
Eligibility = On the ventilator
1.
SAT Safety Screen - pass/fail
2.
If pass safety screen, perform SAT
If fail
; restart sedatives if necessary
(1/2 dose)
If pass
; continue to SBT safety screen
3.
SBT Safety Screen - pass/fail
4.
If pass safety screen, perform SBT
If fail
; return to previous ventilatory support
If pass
; consider extubation
D
D
elirium Monitoring and
Management
Delirium: Key Features
1.
Disturbance of
consciousness
with reduced ability to
focus, sustain or shift
attention
2.
A change in
cognition
or the development of a
perceptual
disturbance that is not better accounted
for by pre-existing, established or evolving dementia
3.
Develops over a
short period
of time and tends to
fluctuate over the course of the day
4.
There is
evidence
from the H&P and/or labs that the
disturbance is caused by a
medical condition,
substance intoxication or medication side effect
Delirium Subtypes
Alert & Calm
Combative
Agitated
Restless
Lethargic
Sedated
Stupor
Hyperactive Delirium
Hypoactive Delirium
Mixed
Delirium
ICU Delirium
•
Increased ICU length of stay (8 vs 5 days)
•
Increased hospital length of stay (21 vs 11
days)
•
Increased time on ventilator (9 vs 4 days)
•
Higher ICU costs ($22,000 vs $13,000)
•
Higher ICU mortality (19.7% vs 10.3%)
•
Higher hospital mortality (26.7% vs 21.4%)
•
3-fold increased risk of death at 6 months
Ely, et al. ICM2001; 27, 1892-1900
Ely, et al, JAMA 2004; 291: 1753-1762
Lin, SM CCM 2004; 32: 2254-2259
Milbrandt E, et al, Crit Care Med 2004; 32:955-962.
Ouimet, et al, ICM 2007: 33: 66-73.
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
Feature 4:
Disorganized
thinking
Or
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
Delirium Management
1. Identify etiology
2. Identify risk factors
3. Consider pharmacologic
treatment
Jacobi J, et al.
Crit Care Med
2002;30:119-141
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!
T
oxic Situations
•
CHF, shock, dehydration
•
New organ failure (liver/kidney)
H
ypoxemia
I
nfection/sepsis (nosocomial),
I
mmobilization
N
onpharmacologic interventions
•
Hearing aids, glasses, reorient,
sleep protocols, music, noise
control, ambulation
K
+ or electrolyte problems
Consider antipsychotics after evaluating etiology & risk factors
A Multicomponent Intervention
to Prevent Delirium in
Hospitalized Older 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 &
prevalence
Inouye, et al.
NEJM
. 1999;340:669-676.
Elder Life Program
Inouye, et al.
NEJM
. 1999;340:669-676.
Results
•
Improved (p=0.04) orientation score with
targeted intervention
•
Reduced rate of sedative use for sleep
(p=0.001)
•
87% overall adherence to protocol
Inouye, et al.
NEJM
. 1999;340:669-676.
Eligibility = RASS ≥ -3
D
elirium
Nonpharmacologic Interventions
+
4
C
O
M
B
A
T
I
V
E
C
o
m
b
a
t
i
v
e
,
v
i
o
l
e
n
t
,
i
m
m
e
d
i
a
t
e
d
a
n
g
e
r
t
o
s
t
a
f
f
+
3
V
E
R
Y
A
G
I
T
A
T
E
D
P
u
l
l
s
t
o
r
e
m
o
v
e
t
u
b
e
s
o
r
c
a
t
h
e
t
e
r
s
;
a
g
g
r
e
s
s
i
v
e
+
2
A
G
I
T
A
T
E
D
F
r
e
q
u
e
n
t
n
o
n
-
p
u
r
p
o
s
e
f
u
l
m
o
v
e
m
e
n
t
,
f
i
g
h
t
s
v
e
n
t
i
l
a
t
o
r
+
1
R
E
S
T
L
E
S
S
A
n
x
i
o
u
s
,
a
p
p
r
e
h
e
n
s
i
v
e
,
m
o
v
e
m
e
n
t
s
n
o
t
a
g
g
r
e
s
s
i
v
e
0
A
L
E
R
T
&
C
A
L
M
S
p
o
n
t
a
n
e
o
u
s
l
y
p
a
y
s
a
t
t
e
n
t
i
o
n
t
o
c
a
r
e
g
i
v
e
r
-
1
D
R
O
W
S
Y
N
o
t
f
u
l
l
y
a
l
e
r
t
,
b
u
t
h
a
s
s
u
s
t
a
i
n
e
d
a
w
a
k
e
n
i
n
g
t
o
v
o
i
c
e
(
e
y
e
o
p
e
n
i
n
g
&
c
o
n
t
a
c
t
>
1
0
s
e
c
)
-
2
L
I
G
H
T
S
E
D
A
T
I
O
N
B
r
i
e
f
l
y
a
w
a
k
e
n
s
t
o
v
o
i
c
e
(
e
y
e
s
o
p
e
n
&
c
o
n
t
a
c
t
<
1
0
s
e
c
)
-
3
M
O
D
E
R
A
T
E
S
E
D
A
T
I
O
N
M
o
v
e
m
e
n
t
o
r
e
y
e
o
p
e
n
i
n
g
t
o
v
o
i
c
e
(
n
o
e
y
e
c
o
n
t
a
c
t
)
-
4
D
E
E
P
S
E
D
A
T
I
O
N
N
o
r
e
s
p
o
n
s
e
t
o
v
o
i
c
e
,
b
u
t
m
o
v
e
m
e
n
t
o
r
e
y
e
o
p
e
n
i
n
g
t
o
p
h
y
s
i
c
a
l
s
t
i
m
u
l
a
t
i
o
n
-
5
U
N
A
R
O
U
S
E
A
B
L
E
N
o
r
e
s
p
o
n
s
e
t
o
v
o
i
c
e
o
r
p
h
y
s
i
c
a
l
s
t
i
m
u
l
a
t
i
o
n
D
elirium
Nonpharmacologic Interventions
Pain:
•
Monitor and manage pain using an objective
scale (e.g., FACES, BPS, VAS, CPOT, etc.)
Orientation:
•
Convey the day, date, place, and reason for
hospitalization
•
Update the whiteboards with caregiver names
•
Request placement of a clock and calendar in
room
•
Discuss current events
Nonpharmacologic Interventions
Sensory:
•
Determine need for hearing aids and/or eye glasses
•
If needed, request surrogate provide these for patient
when appropriate
Sleep:
•
Noise reduction strategies (e.g. minimize noise outside the
room, offer white noise or earplugs)
•
Normal day-night variation in illumination
•
Use “time out” strategy to minimize interruptions in sleep
•
Maintain ventilator synchrony
•
Promote comfort and relaxation (e.g., back care, oral
care, washing face/hands, and daytime bath, massage)
E
arly
E
xercise and Mobility
E
Early Exercise in the ICU
•
Early exercise = progressive mobility
•
Study design: paired SAT/SBT protocol
with PT/OT from earliest days of
mechanical ventilation
Schweickert WD, et al.
Lancet.
2009;373:1874-1882.
Wake Up, Breathe, and Move
Early Exercise Study Results
Schweickert WD, et al.
Lancet.
2009;373:1874-1882.
E
arly
E
xercise and Mobility
Eligibility = All patients are
eligible for Early Exercise and
Mobility
Perform Safety Screen First
Safety Screen
•
Patient responds to verbal stimulation (i.e., 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 (24hrs)
If patient
passes
Exercise/Mobility Safety Screen, move on to
Exercise and Mobility Therapy
If patient
fails
, s/he is too critically ill to tolerate exercise/mobility
1.
Active range of motion in bed and sitting
position in bed
2.
Dangling
3.
Transfer to chair (active), includes standing
without marching in place
4.
Ambulation (marching in place, walking in
room or hall)
*All may be done with assistance.
E
arly
E
xercise & Mobility
Levels of Therapy*
E
arly
E
xercise and Mobility Protocol
Progression
Morandi A et al. Curr Opin Crit Care,2011;17:43-9
Benefits of ABCDE Protocol
Questions?
www.ICUdelirium.org
delirium@vanderbilt.edu
Explore the importance of the ABCDE Protocol in managing ICU patients, focusing on sedation, analgesia, and the prevention of delirium. Learn about the potential drawbacks of sedative therapies and the need for coordinated care in critical care settings. Discover the MIND-USA ABCDE Protocol, emphasizing awakening, breathing coordination, delirium identification, and early exercise and mobility.
Download Presentation
Please find below an Image/Link to download the presentation.
The content on the website is provided AS IS for your information and personal use only. It may not be sold, licensed, or shared on other websites without obtaining consent from the author. Download presentation by click this link. If you encounter any issues during the download, it is possible that the publisher has removed the file from their server.
E N D
Presentation Transcript
ABCDE Protocol ICU Delirium and Cognitive Impairment Study Group www.icudelirium.org delirium@vanderbilt.edu
Need for Sedation and Analgesia Prevent pain and anxiety Decrease oxygen consumption Decrease the stress response Patient-ventilator synchrony Avoid adverse neurocognitive sequelae - Depression, PTSD 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.
Potential Drawbacks of Sedative and Analgesic Therapy Oversedation: Failure to initiate spontaneous breathing trials (SBT) leads to increased duration of mechanical ventilation (MV) Longer duration of ICU stay Impede assessment of neurologic function Increase risk for delirium Numerous agent-specific adverse events Kollef MH, et al. Chest. 1998;114:541-548. Pandharipande PP, et al. Anesthesiology. 2006;104:21-26.
Patient with Sepsis Mechanical Ventilation Sedation Weakness Delirium Cognitive and Functional Impairment, Institutionalization, Mortality Vasilevskis et al Chest 2010; 138;1224-1233
We Need Coordinated Care Many tasks and demands on critical care staff Great need to align and supporting the people, processes, and technology already existing in ICUs ABCDE protocol is multiple components, interdependent, and designed to: Improve collaboration among clinical team members Standardize care processes Break the cycle of oversedation and prolonged ventilation Vasilevskis et al Chest 2010; 138;1224-1233
What is the MIND-USA ABCDE Protocol? Awakening and Breathing Coordination Delirium Identification and Management ABC D Early Exercise and Mobility E
ABC Awakening and Breathing Coordination
Consequences of Suboptimal Sedation Inadequate sedation/analgesia Anxiety Pain Patient-ventilator dyssynchrony Agitation Self-removal of tubes/catheters Care provider assault Myocardial ischemia Family dissatisfaction Excessive sedation Prolonged mechanical ventilation, ICU LOS Tracheostomy DVT, VAP Additional testing Added cost Inability to communicate Cannot evaluate for delirium
Structured Approaches to Sedation & Analgesia in the ICU 1. Multidisciplinary development, implementation 2. Establish goals/targets, frequently re-evaluate 3. Measure key components using validated scales 4. Select medications based on characteristics, evidence 5. Incorporate key patient considerations 6. Prevent oversedation, yet control pain and agitation 7. Promote multidisciplinary acceptance and integration into routine care Sessler & Pedram. Crit Care Clinics 2009; 25:489-513
Validated ICU Sedation Scales Richmond agitation-sedation scale (RASS) Sedation agitation scale (SAS) Ramsay sedation scale Motor activity assessment scale (MAAS) Vancouver interactive and calmness scale (VICS) Adaptation to intensive care environment (ATICE) Minnesota sedation assessment tool (MSAT)
Setting Targets Provide for agitation/anxiety free, amnesia, comfort Trying to achieve a balance TIGHT TITRATION Adjust target depending on current need Per patient Different over the course of Illness/Treatment
Use Protocols to Achieve Goals, Minimize Drug Accumulation, Maximize Alertness Patient-focused drug selection Preference for analgesia > sedation Intermittent therapy via boluses Frequent evaluation of sedation, pain, ICU therapy tolerance Titrate therapy for lowest effective dose Daily interruption of sedation
RCT: 2x2 factorial design Midazolam vs propofol Daily interruption of sedation vs routine Discontinue all sedative and analgesic medications Monitor patient closely until awake or agitated, i.e., can perform at least 3 of 4 on command: Open eyes Squeeze hand Lift head Stick out tongue Restart medications at half dosage (if necessary) Kress et al. N Engl J Med 2000; 342:1471-7
Daily Awakening Trial Results Shorter duration of mechanical ventilation Shorter ICU LOS Fewer tests for altered mental status Kress et al. N Engl J Med 2000; 342:1471-7
Why Is Interruption of Sedation Effective? Less accumulation of sedative drug and metabolites Significantly less midazolam and morphine with DIS in midazolam subgroup But no difference in amount of propofol and morphine with DIS in propofol subgroup Opportunity for more effective weaning from mechanical ventilation? Wake Up and Breathe Sessler CN. Crit Care Med 2004 Kress et al. NEJM. 2000
Multicenter RCT: 168 patients with spontaneous awakening trial (SAT) i.e., daily interruption of sedation (SAT) + spontaneous breathing trial (SBT) 168 patients with standard sedation + SBT
SAT + SBT Was Superior to Conventional Sedation + SBT Intervention (SAT) group = Less benzodiazepine Extubated faster Discharged from ICU sooner P = 0.01 P = 0.02 Girard et al. Lancet 2008; 371:126-34
SAT + SBT Was Superior to Conventional Sedation + SBT Discharged from hospital sooner Better survival at 1 yr P = 0.04 P = 0.01 Alive P = 0.01 P = 0.02 Intervention (SAT) group = More unplanned extubation, but not more reintubation Girard et al. Lancet 2008; 371:126-34
Awakening & Breathing Coordination Synergy of daily awakening via interruption of sedation plus spontaneous breathing trial Less medication accumulation, less excessive sedation Opportunity for more effective independent breathing (SBT) Perform safety screens for SAT and for SBT
ABC Safety Screens Wake Up Safety Screen No active seizures No active alcohol withdrawal No active agitation No active paralytic use No myocardial ischemia (24h) Normal intracranial pressure Breathe Safety Screen No active agitation Oxygen saturation >88% FiO2 < 50% PEEP < 7.5 cm H2O No active myocardial ischemia (24h) No significant vasopressor use Girard et al. Lancet 2008; 371:126-34. Kress et al. Crit Care Med 2004; 32(6):1272-6 Ely et al. NEJM 1996; 335:184-9
ABC Awakening & Breathing Coordination Eligibility = On the ventilator 1. SAT Safety Screen - pass/fail 2. If pass safety screen, perform SAT If fail; restart sedatives if necessary (1/2 dose) If pass; continue to SBT safety screen 3. SBT Safety Screen - pass/fail 4. If pass safety screen, perform SBT If fail; return to previous ventilatory support If pass; consider extubation
D Delirium Monitoring and Management
Delirium: Key Features 1. Disturbance of consciousness with reduced ability to focus, sustain or shift attention 2. A change in cognition or the development of a perceptual disturbance that is not better accounted for by pre-existing, established or evolving dementia 3. Develops over a short period of time and tends to fluctuate over the course of the day 4. There is evidence from the H&P and/or labs that the disturbance is caused by a medical condition, substance intoxication or medication side effect
Delirium Subtypes Hyperactive Delirium Combative Agitated Restless Mixed Delirium Alert & Calm Lethargic Sedated Stupor Hypoactive Delirium
ICU Delirium Increased ICU length of stay (8 vs 5 days) Increased hospital length of stay (21 vs 11 days) Increased time on ventilator (9 vs 4 days) Higher ICU costs ($22,000 vs $13,000) Higher ICU mortality (19.7% vs 10.3%) Higher hospital mortality (26.7% vs 21.4%) 3-fold increased risk of death at 6 months Ely, et al. ICM2001; 27, 1892-1900 Ely, et al, JAMA 2004; 291: 1753-1762 Lin, SM CCM 2004; 32: 2254-2259 Milbrandt E, et al, Crit Care Med 2004; 32:955-962. Ouimet, et al, ICM 2007: 33: 66-73.
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 Feature 4: Disorganized thinking Or 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
Delirium Management 1. Identify etiology 2. Identify risk factors 3. Consider pharmacologic treatment Jacobi J, et al. Crit Care Med 2002;30:119-141
Stop and THINK Do any meds need to be stopped or lowered? 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 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! Consider antipsychotics after evaluating etiology & risk factors
Delirium Nonpharmacologic Interventions Eligibility = RASS -3 +4 +3 +2 +1 0 -1 COMBATIVE VERY AGITATED AGITATED RESTLESS ALERT & CALM DROWSY Combative, violent, immediate danger to staff Pulls to remove tubes or catheters; aggressive Frequent non-purposeful movement, fights ventilator Anxious, apprehensive, movements not aggressive Spontaneously pays attention to caregiver Not fully alert, but has sustained awakening to voice (eye opening & contact >10 sec) -2 LIGHT SEDATION Briefly awakens to voice (eyes open & contact <10 sec) -3 MODERATE SEDATION Movement or eye opening to voice (no eye contact) -4 DEEP SEDATION No response to voice, but movement or eye opening to physical stimulation -5 UNAROUSEABLE No response to voice or physical stimulation
Delirium Nonpharmacologic Interventions Pain: Monitor and manage pain using an objective scale (e.g., FACES, BPS, VAS, CPOT, etc.) Orientation: Convey the day, date, place, and reason for hospitalization Update the whiteboards with caregiver names Request placement of a clock and calendar in room Discuss current events
Nonpharmacologic Interventions Sensory: Determine need for hearing aids and/or eye glasses If needed, request surrogate provide these for patient when appropriate Sleep: Noise reduction strategies (e.g. minimize noise outside the room, offer white noise or earplugs) Normal day-night variation in illumination Use time out strategy to minimize interruptions in sleep Maintain ventilator synchrony Promote comfort and relaxation (e.g., back care, oral care, washing face/hands, and daytime bath, massage)
E Early Exercise and Mobility
Early Exercise in the ICU Early exercise = progressive mobility Study design: paired SAT/SBT protocol with PT/OT from earliest days of mechanical ventilation Wake Up, Breathe, and Move Schweickert WD, et al. Lancet. 2009;373:1874-1882.
Early Exercise Study Results Intervention (n=49) Control (n=50) Outcome P Functionally independent at discharge 29 (59%) 19 (35%) 0.02 ICU delirium (days) 2.0 (0.0-6.0) 4.0 (2.0-7.0) 0.03 Time in ICU with delirium (%) 33 (0-58) 57 (33-69) 0.02 Hospital delirium (days) 2.0 (0.0-6.0) 4.0 (2.0-8.0) 0.02 Hospital days with delirium (%) 28 (26) 41 (27) 0.01 Barthel index score at discharge 75 (7.5-95) 55 (0-85) 0.05 ICU-acquired paresis at discharge 15 (31%) 27 (49%) 0.09 Ventilator-free days 23.5 (7.4-25.6) 21.1 (0.0-23.8) 0.05 Length of stay in ICU (days) 5.9 (4.5-13.2) 7.9 (6.1-12.9) 0.08 Length of stay in hospital (days) 13.5 (8.0-23.1) 12.9 (8.9-19.8) 0.93 Hospital mortality 9 (18%) 14 (25%) 0.53 Schweickert WD, et al. Lancet. 2009;373:1874-1882.
Early Exercise and Mobility Eligibility = All patients are eligible for Early Exercise and Mobility
Perform Safety Screen First Safety Screen Patient responds to verbal stimulation (i.e., RASS > -3) FIO2 <0.6 PEEP <10 cmH2O 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 (24hrs) If patient passes Exercise/Mobility Safety Screen, move on to Exercise and Mobility Therapy If patient fails, s/he is too critically ill to tolerate exercise/mobility
Early Exercise & Mobility Levels of Therapy* 1. Active range of motion in bed and sitting position in bed 2. Dangling 3. Transfer to chair (active), includes standing without marching in place 4. Ambulation (marching in place, walking in room or hall) *All may be done with assistance.
Early Exercise and Mobility Protocol Progression RASS -5 / -4 RASS -3 Active ROM (in bed) No Exercises, but Passive Range of Motion allowed Progress as tolerated Exercise screen ICU Discharge Sit/ Dangle Transfer March/ Walk
Benefits of ABCDE Protocol Morandi A et al. Curr Opin Crit Care,2011;17:43-9
Questions? www.ICUdelirium.org delirium@vanderbilt.edu
![[PDF⚡READ❤ONLINE] Zen Mind, Beginner's Mind: 50th Anniversary Edition](/thumb/20459/pdf-read-online-zen-mind-beginner-s-mind-50th-anniversary-edition.jpg)
