PostIntensive Care Syndrome and ICU Liberation Shanon Harper
Post-Intensive Care Syndrome and ICU Liberation Shanon Harper, DNP, AG-ACNP, CCRN
Disclosures � There are no conflicts of interest or relevant financial interest that have been disclosed by this presenter. � We will not discuss off-label use and/or investigational use in this presentation.
Objectives � Upon completion of this session, learners should be able to: Understand Post-ICU Syndrome Identify PAD guidelines Describe ICU Liberation Explain considerations for Intensive Care (ICU) Delirium ◦ Discuss how to apply ABCDEF: SAT-SBT, CAMICU, THINK, & Early Mobility ◦ ◦
Post-Intensive Care Syndrome � Video ◦ http: //www. icudelirium. org/testimonials. html
Post-Intensive Care Syndrome � Long-term consequences of critical illness ◦ Physical Impairments ◦ Cognitive Impairments ◦ Mental Health Impairments Needham et al. , 2012
Post-Intensive Care Syndrome Needham et al. , 2012
BRAIN-ICU Study
BRAIN-ICU STUDY � 821 � 3 patients, 74% (606) affected by delirium month follow up cognition scores ◦ 40% worse than moderate TBI ◦ 26% with scores similar to mild Alzheimer’s disease Pandharipande et al. , 2013
BRAIN-ICU STUDY � 12 month follow up cognition scores ◦ 34% moderate TBI ◦ 24% mild Alzheimer’s disease
BRAIN-ICU STUDY v Age was NOT a determining factor of Cognitive Impairment Pandharipande et al. , 2013
BRAIN-ICU STUDY � Longer duration of delirium an independent risk factor for: ◦ Worse RBANS global cognition scores ◦ Worse executive function ◦ Worse function in several individual RBANS domains
Pain, Agitation, & Delirium
ICU Liberation
ICU Delirium and Cognitive Impairment Study Group
Delirium � What is Delirium? ◦ Disturbance of consciousness and cognition that develops over a short period of time and fluctuates over time ◦ Syndrome of brain dysfunction ◦ Hyperactive, hypoactive, and mixed American Psychiatric Association, 2013; Barr et al. , 2013; Mansouri, 2013
Delirium � Rapid onset � Inattention � � � Clouded Consciousness (bewildered) Fluctuating VS Dementia � Gradual Onset � Intellectual � Memory impairment disturbance � Personality/Mood change � No clouding of consciousness
Delirium Risk Factors � Host ◦ Sepsis ◦ HTN ◦ Severity of illness ◦ Surgeries �Especially cardiovascular and orthopedic Barr et al. , 2013; Mansouri, 2013
Delirium Risk Factors � Iatrogenic ◦ Mechanical Ventilation ◦ Restraints ◦ Catheters and Lines ◦ A multitude of medications Barr et al. , 2013; Mansouri, 2013
Delirium Risk Factors � Environmental Factors ◦ Noise ◦ Decrease meaningful sensory stimulation ◦ Sleep deprivation Barr et al. , 2013; Mansouri, 2013
Clinical Problem � Annual ICU admission in the U. S. 5. 7 million ◦ 80% risk of acquiring ICU delirium ◦ Increased morbidity, mortality and length of stay ◦ Prolonged ventilator dependence � Considered a Major Public Health Problem ◦ Annual costs $4 to $6 Billion in the U. S. alone Barr et al. , 2013; Society of Critical Care Medicine, 2012; Ely, 2010
ABCDEF Bundle � Assess, � Both: Prevent, and Manage Pain Spontaneous Awakening Trials & Spontaneous Breathing Trials � Choice of Analgesia & Sedation � Delirium: � Early Assess, Prevent, Manage Mobility and Exercise � Family Engagement and Empowerment Vanderbilt University, 2013
Assess, Prevent, and Manage Pain � Self Reported Gold Standard � Behavioral Pain Scale � Multimodal treatment plan ◦ Opioids ◦ Non-opioids ◦ Nonpharmacological Barr et al, 2013; Morandi, Brummel, & Ely, 2011; Ely 2010
Both: SAT & SBT � SAT and SBT ◦ More successful when paired � Liberation from mechanical ventilation and sedation removes multiple deliriogenic factors Barr et al, 2013; Ely et al. 1996; Girard et al. , 2008
Choice of Analgesia & Sedation � Patient-Oriented, Goal-Directed ◦ Management of pain first. ◦ Avoid over sedation to promote earlier extubation. � Goal for minimal sedation ◦ Validated Tool � Sedation Agitation Scale (SAS) � Richmond Agitation-Sedation Scale (RASS) Barr et al, 2013; Vanderbilt University, 2013
Delirium: Assess, Prevent, Manage � Assessment with a validated tool ◦ The Confusion Assessment method for the ICU (CAM-ICU) ◦ The Intensive Care Delirium Screening Checklist (ICDSC) Barr et al, 2013; Vanderbilt University, 2013
Delirium: Assess, Prevent, Manage � Prevention and Management Strategies ◦ Nonpharmacological ◦ Pharmacologic ◦ THINK Mnemonic Barr et al, 2013; Vanderbilt University, 2013
Delirium: Assess, Prevent, Manage THINK Mnemonic T “TOXIC SITUATIONS” CHF Shock Dehydration Deliriogenic meds (Tight Titration) New organ failure, e. g, liver, kidney H “HYPOXEMIA” I “ 3 I’s” Airway vs Ventilation Infection/Sepsis vs oxygenation (nosocomial) Inflammation Immobilization N K “Nonpharmacologica l interventions” “K or Electrolytes” Hearing aids Glasses Reorientation Sleep protocols Music Noise control Ambulation Potassium Sodium Magnesium Phosphorus Vanderbilt University, 2013
Early Mobility and Exercise � Only intervention shown to decrease duration of delirium � Decreases � ACT-ICU days mechanically ventilated Trial ◦ Decreased days of delirium, readmission, and 1 -year death rates Brummel et al. , 2012; Truong, Fan, Bower, & Needham, 2009; Vanderbilt University, 2013
Family Engagement and Empowerment � Educate ◦ Rounding with family daily � Encourage � Assisting � Prepare journaling in creating a healing environment them for the future Vanderbilt University, 2013
Summary � PICS is a consequence of ICU care � ABCDEF Bundle for ICU Liberation � Goal ◦ Decrease the occurrence of ICU delirium ◦ Improve long term outcomes � QUESTIONS? ?
References � � � American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5 th ed. ). Washington, DC: Author. Retrieved from http: //dsm. psychiatryonline. org/doi/full/10. 1176/appi. books. 9780890425596. dsm 17#CIHDBDFH Barr, J. , Fraser, G. L. , Puntillo, K. , Ely, E. W. , Gelinas, C. , Dasta, J. F. , . . . Jaeschke, R. (2013). Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Critical Care Medicine, 41(1), 263 -306. doi: 10. 1097/CCM. 0 b 013 e 3182783 b 72; 10. 1097/CCM. 0 b 013 e 3182783 b 72 Brummel, N. E. , Jackson, J. C. , Girard, T. D. , Pandharipande, P. P. , Schiro, E. , Work, B. , . . . Ely, E. W. (2012). A combined early cognitive and physical rehabilitation program for people who are critically ill: The activity and cognitive therapy in the intensive care unit (ACT-ICU) trial. Physical Therapy, 92(12), 1580 -1592. doi: 10. 2522/ptj. 20110414 [doi] Ely, E. W. , Baker, A. M. , Dunagan, D. P. , Burke, H. L. , Smith, A. C. , Kelly, P. T. , . . . Haponik, E. F. (1996). Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. The New England Journal of Medicine, 335(25), 1864 -1869. doi: 10. 1056/NEJM 199612193352502 [doi] Girard, T. D. , Kress, J. P. , Fuchs, B. D. , Thomason, J. W. , Schweickert, W. D. , Pun, B. T. , . . . Ely, E. W. (2008). Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (awakening and breathing controlled trial): A randomised controlled trial. Lancet, 371(9607), 126 -134. doi: 10. 1016/S 01406736(08)60105 -1 [doi] ICU Delirium and Cognitive Impairment Study Group. (2013). Vanderbilt University. ABCDEF’s of Prevention and Safety. Retrieved from http: //www. icudelirium. org/index. html Mansouri, P. , Javadpour, S. , Zand, F. , Ghodsbin, F. , Sabetian, G. , Masjedi, M. , & Tabatabaee, H. R. (2013). Implementation of a protocol for integrated management of pain, agitation, and delirium can improve clinical outcomes in the intensive care unit: A randomized clinical trial. Journal of Critical Care, doi: 10. 1016/j. jcrc. 2013. 06. 019; 10. 1016/j. jcrc. 2013. 06. 019 Morandi, A. , Brummel, N. E. , & Ely, E. W. (2011). Sedation, delirium and mechanical ventilation: The 'ABCDE' approach. Current Opinion in Critical Care, 17(1), 43 -49. doi: 10. 1097/MCC. 0 b 013 e 3283427243; 10. 1097/MCC. 0 b 013 e 3283427243 Needham, D. M. , Davidson, J. , Cohen, H. , Hopkins, R. O. , Weinert, C. , Wunsch, H. , … Harvey, M. A. (2012). Improving longterm outcomes after discharge from intensive care unit: Report from a stakeholders' conference. Critical Care Medicine, 40(2), 502 -509. doi: 10. 1097/CCM. 0 b 013 e 318232 da 75 Pandharipande, P. P. , Girard, T. D. , Jackson, J. C. , Morandi, A. , Thompson, J. L. , Pun, B. T. , . . . BRAIN-ICU Study Investigators. (2013). Long-term cognitive impairment after critical illness. The New England Journal of Medicine, 369 (14), 1306 -1316. doi: 10. 1056/NEJMoa 1301372 Truong, A. D. , Fan, E. , Brower, R. G. , & Needham, D. M. (2009, July 13). Bench-to-bedside review: Mobilizing patients in the intensive care unit - from pathophysiology to clinical trials. Critical Care, 13(216). doi: 10. 1186/cc 7885
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