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What is the RASS Procedure?
- Observe patient:
- Calm? (score 0)
- Restless or agitated behavior? (score +1 to +4)
- If not alert, speak name in a loud clear voice, and direct patient to look at speaker. Repeat once if needed
- If no response to voice, then physically stimulate patient by shaking shoulder, then rubbing sternum
What is the Bispectral Index Monitor (BIS)?
An option to monitor depth of anesthesia
How does a Bispectral index work?
- Uses a nonlinear signal processor to measure brain wave activity in the form of raw electroencephalography and to create a score ranging from 100 (awake) to 0 (no cortical activity)
- Sensor placed on patient’s forehead
When the Bispectral index monitor useful?
- May be useful when patients are deeply comatose or during neuromuscular blockade
- Though, Variable correlation between sedation scores and BIS
There is a ___________ correlation between drug doses and BIS.
There is ______________difference in duration of ventilation or drug doses in RCT comparing BIS to usual care.
What are the general guidelines for Managing ICU Sedation?
- Remove all correctable causes of agitation (endotracheal tube placement, vent settings, pain, etc)
- Concurrently address pain management
- Achieve desired level of sedation with boluses BEFORE initiating the maintenance infusion or bolus dose regimen
- Regain desired level of sedation with boluses BEFORE increasing the maintenance infusion or bolus dose regimen
- Evaluate adequacy of sedation using a sedation scale, and titrate drip to minimum effective dose
Delirium in the ICU
- Organic mental syndrome defined is as:
- acute, potentially reversible impairment of consciousness and cognitive function that fluctuates in severity
- Common in ICU patients
Prevalence of delirium is highest in what patients?
ventilated ICU patients (60-80%)
____________________ is an independent risk factor for prolonged hospitalization and mortality in critically ill patients.
What are the characteristics of Delirium?
Impaired short-term memory, abnormal perception, and intermittent disorientation
What are the Delirium Subtypes?
- Hyperactive delirium
- Agitated psychomotor state and abnormal cognition (Punching/biting)
- Hypoactive delirium (depressed level of consciousness and abnormal cognition (not responding))
- Mixed delirium
What is the most common subtype of Delerium?
Hypoactive delirium/quiet delirium
What is Mixed Delerium?
Fluctuates unpredictably between hypoactive and hyperactive delirium throughout a day or over the course of several days
What are the Delirium Goals of Management?
- Protect the patient from self-inflicted harm
- Protect caregivers from harm
- Identify and correct underlying factors
- Optimize patient comfort, reduce anxiety
What are the non-drug Risk Factors for ICU Delirium?
- CNS disorders
- Etoh or drug withdrawal
- Metabolic disorders
- Electrolyte disorders
What are the drug risk factors for Delirium?
- Anesthetic agents
- H2 blockers
- Cardiac drugs
Delirium Assessment (CAM-ICU) Diagnosis requires what?
two features (altered mental status and inattention) plus one more
Inattention assessment is based upon using the Attention Screening Examination, how is this performed?
- Ask them to Squeeze my hand when I say the letter A
- The say: SAVE A HEART
- Asking four simple yes-or-no questions:
- Does a hammer pound a nail ?
- Does a stone float on water ?
- What is this (show a picture)?
What are the Non-pharmacologic Management methods of Delirium?
- Environment (lights, temperature, noise, window room)
- Remove all invasive lines and catheters as soon as possible
- ABCDE bundle
- What does the ABCDE bundle stand for?
- Awaken the patient daily: sedation cessation
- Breathing: daily interruption of mechanical ventilation
- Coordination: daily awakening and daily breathing
- Delirium monitoring
- Exercise/Early mobility
What is the Pharmacologic Management of Delirium?
- No IV FDA approved agent for ICU delirium
- IV Haloperidol used historically – not great evidence
- Dopamine antagonist, vast clinical experience but no data show superiority over haloperidol
- (Olanzapine, quetiapine, ziprasidone, risperidone)
What is the MOA of Dopamine antagonists (Olanzapine, quetiapine, ziprasidone, risperidone)for the treatment of Delerium in the ICU?
Bind to mixture of histamine and serotonin
What is the dose for Haloperidol (Haldol)?
Dosed 1-5 mg IV q 4-6 hours (1-20 mg)
What are the benefits of Haloperidol (Haldol) in the treatment of delirium?
- Rapid onset, lack of respiratory or hemodyamic effects
- Given routine or as needed – get rid of as soon as can
How should you stop Haloperidol (Haldol)?
Tapered over 5-7 days
What are the Side effects of Haloperidol (Haldol)?
QTc prolongation, reducedseizure threshold, extrapyramidal effects
___________________demonstrated less delirium and Shortened duration of ventilation and ICU length of stay than midazolam in mechanically ventilated patients.
_________________________may reduce overall risk of postoperative delirium in elderly.
_________________nightly vs. placebo in elderly patients for acute care hospitalization may prevent delirium.
Ramelteon 8 mg PO
In critically ill patients, ICU __________use was associated with reduced delirium, especially during sepsis; discontinuation of a previously used _________was associated with increased delirium.
Delirium Treatment Options include:
- Olanzapine (Zyprexa)
- Risperidone (Risperdal)
- Quetiapine (Seroquel)
What is the dose for Olanzapine (Zyprexa)?
2.5 to 5 mg PO/NG/IM daily (5-20 mg)
What is the dose for Risperidone (Risperdal)?
2 to 10 mg PO total daily dose