DIAGNOSIS AND TREATMENT OF AGITATION AND DELIRIUM IN

DIAGNOSIS AND TREATMENT OF AGITATION AND DELIRIUM IN THE ICU PATIENT ד"ר אסתר דהאן

DELIRIUM – ACUTE CONFUSIONAL STATE n n n DEFINITION: A REVERSIBLE ORGANIC MENTAL DISORDER WHOSE HALLMARKS ARE AN ACUTE ONSET OF CONFUSION AND AN ALTERED LEVEL OF CONSCIOUSNESS. ABNORMAL CONSCOUSNESS DISTINGUISHES DELIRIUM FROM DEMENTIA.

ETIOLOGY: Ø Ø PRIMARY INTRACRANIAL DISEASES SYSTEMIC DISEASES THAT SECONDARILY AFFECT THE BRAIN Ø EXOGENIC TOXIC AGENTS Ø DRUG WITHDRAWAL

PRIMARY INTRACRANIAL DISEASES n INFECTION – HIV ENCEPHALOPATHY, MENINGITIS, ENCEPHALITIS, NEUROSYPHILIS n n n NEOPLASM SEIZURES VASCULAR-HYPERTENSIVE ENCEPHALOPATHY, STROKE, VASCULITIS, INTRACRANIAL HAEMORRHAGE Ø NPH

SYSTEMIC DISEASES n n n CARDIOPULMONARY ENDOCRINE/METABOLICFLUID/ELECTROLYTES, ACIDBASE, HEPATIC, RENAL, PORPHYRIA, CAL CIUM, GLUCOSE. INFECTION-SEPSIS, SBE. PARANEOPLASTIC SYNDROME NUTRITIONAL DEFICIENCYTHIAMINE, FOLIC ACID, B 12, NIACIN.

EXOGENOUS TOXIC AGENTS n DRUGS OF ABUSE ALCOHOL AMPHETAMINES COCAINE LSD PCP q NONMEDICAL SUBSTANCE CO HEAVY METALS q MEDICATIONS

DRUG WITHDRAWAL ALCOHOL n PROPANEDIOLS – CHLORAL HYDRATE MEPROBAMATE q SEDATIVE-HYPNOTIC AGENTSBARBITURATES BENZODIAZEPINES q NARCOTICS n

COMMON DELIRIUM-INUCED DRUGS USED IN THE ICU: n n n n antiarrhythmics: lidocaine, mexilletine, procaineamide, quinidine. Antibiotics: penicillin, rifampine. Anticholinegics: atropine, scopolamine. Antihistamines: atarax, phenergan, cimetidine, ranitidine. Beta-blockers: propranolol Corticosteroids Narcotics: meperidine, morphine, pentazocine.

TREATMENT n n n CORRECTION OF METABOLIC AND SYSTEMIC ABNORMALITIES ELIMINATION OF DRUG TOXICITY TREATMENT OF DRUG WITHDRAWAL USE OF MECHANICAL RESTRAINT PHARMACOLOGIC TREATMENT

CORRECTION OF METABOLIC AND SYSTEMIC ABNORMALITIES n n n REVIEW THE PATIENT CHART! CONTROL THE TEMPRETURE MAINTENE NORMAL PERFUSION PRSSURE AVOID HYPOXEMIA CORRECT FLUID AND ELECTROLYTES IMBALANCE

ELIMINATION OF DRUG TOXICITIY ELIMINATION OR REDUCTION OF THE OFFENDING AGENT n USE AN ANTIDOTE: NALOXONE PHYSOSTIGMINE FLUMAZENIL VERAPAMIL(PCP) THE ROLE OF MEPERIDINE n

TREATMENT OF DRUG WITHDRAWAL n v v THE DIAGNOSIS REQUIRES A HIGH INDEX OF SUSPICION: EMERGENT ICU ADMISSION-A SUDDEN DISCONTINUATION OF THE ABUSED DRUG UNEFFECTIVE COMMUNICATION NON-SPECIFIC PHYSICAL SIGNS NO LABORATORY TEST IS DIAGNOSTIC OF DRUG WITHDRAWAL

PHARMACOLOGIC TREATMENT OF DELIRIUM AND AGITATION X X X X HALOPERIDOL ALONE(PO OR IV) A COMBINATION OF IV HALOPERIDOL AND A BDZ OTHER NEUROLEPTIC A BDZ ALONE A NARCOTIC PROPOFOL GENERAL ANESTHESIA WITH INTUBATION

HALOPERIDOL n n A HIGH PTENCY BUTYROPHENONE NEUROLEPTIC EXTENSIVE RECORD OF SAFETY AND EFFICACY IN CRITICALLY ILL PATIENTS n ORAL STARTING DOSE: 0. 5 MG TID(PREVIOUS CNS DYSFUNCTION, UNSTABLE HEMODYNAMICS) 2 -5 MG QID(STABLE INDIVIDUALS) q SUDDEN DISCONTINUATION IS GENERALLY UNEVENTFULL.

PARENTERAL HALOPERIDOL ! INDICATED WHEN RAPID ONSET OF EFFECT IS DESIRD. ! IV STARTING DOSE=HALF THE ORAL DOSE. ! IF A CALMING EFFECT DOSE NOT EVENTUATE WITHIN 15 MIN, DOUBLE THE PREVIOUS DOSE! ! IF THE PATIENT BECOMES CALM, THE LAST DOSE SHOULD BE REPEATED AT THE NEXT DOSING. ! THE DOSING INTERVAL IS DETERMINED BY THE DURATION OF CALM. ! INTENSE AGITATION MAY REQUIRE HOURLY DOSING. ! AN INDIVIDUAL BOLUS OF 150 MG, AND AS MUCH AS 1200 MG DAILY, HAS BEEN REQUIRED TO CONTROL SEVERE AGITATION!

CONTINOUS INFUSION OF HALOPERIDOL n n HAS BEEN USED SAFELY AND EFFECTIVELY TO CONTROL INTENSE AGITATION PROVED TO BE SUPERIOR TO THE BOLUS METHOD OF ADMINISTRATION THE HOURLY DOSES REQUIRED WERE LESS. NO EXTRAPYRAMIDAL EFFECTS WERE REPORTED.

SIDE EFFECTS-HALOPERIDOL n n USUALLY MILD AND UNCONSEQUENTAL LESS SEDATION, LESS HYPOTENSION, FEWER ANTICHOLINERGIC EFFECTS, COMPERED TO OTHER NEUROLEPTICS. HIGHER RATE OF EXTRAPYRAMIDAL EFFECTS. IV ADMINISTRATION IN ICU’IS ASSOCIATED WITH LESS EXTRAPYRAMIDAL EFFECTS THEN THE IM OR PO ROUTE.

OTHER NEUROLEPTICS n n n DROPERIDOL-A MORE SEDATIVE BUTYROPHENONE. CHLOROPROMAZINE -A DANGEROUS AGENT IN CRITICALLY ILL PATIENTS ATYPICAL ANTIPSYCHOTIC OLANZEPINE

BENZODIAZEPINES n n EFFECTIVE IN MANIC, PANIC AND PHOBIC AGITATION. CLONAZEPAM – THE ORAL DRUG OF CHOICE. MIDAZOLAM – A WIDE MARGINS OF SAFETY USE CAREFULLY IN ELDERLY AND DEBILITATED PATIENTS, COPD, HEPATIC DYSFUNCTION, CONCURRENT ADMINISTRATION OF OPIATS.

PROPOFOL n ALKYLPHENOL, SHORT ACTING SEDATIVE HYPNOTIC WITH MODERATE ANXIOLYTIC AND AMNESTIC EFFECT, AND NO INTRINSIC ANALGESIC EFFECT. n A POTENT RESPIRATORY DEPRESSANT n A POTENT VASODILATOR AND CARDIODEPRESSANT n PROLONGED ADMINISTRATION IN ICU PATIENT – A WITHDRAWAL SYNDROME WHEN CASSETION IS ABRUPT! IT MANIFESTS WITH TACHYCARDIA, HYPERTENSION AND AGITATION.