ABCDE Protocol ICU Delirium and Cognitive Impairment Study Group - PowerPoint Presentation

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 synchronyAvoid 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 stayImpede assessment of neurologic function Increase risk for deliriumNumerous agent-specific adverse eventsKollef MH, et al. Chest. 1998;114:541-548.Pandharipande PP, et al. Anesthesiology. 2006;104:21-26.

Sedation Mechanical Ventilation Delirium Weakness Patient with SepsisCognitive 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 processesBreak 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 ABCD E

A wakening and B reathing CoordinationABC

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 AgitationSelf-removal of tubes/cathetersCare provider assaultMyocardial ischemiaFamily dissatisfactionExcessive sedationProlonged mechanical ventilation, ICU LOSTracheostomyDVT, VAP Additional testingAdded cost Inability to communicate Cannot evaluate for delirium

Structured Approaches to Sedation & Analgesia in the ICU Multidisciplinary development, implementation Establish goals/targets, frequently re-evaluate Measure key components using validated scales Select medications based on characteristics, evidence Incorporate key patient considerationsPrevent oversedation, yet control pain and agitationPromote multidisciplinary acceptance and integration into routine careSessler & 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 balanceTIGHT TITRATION Adjust target depending on current needPer patientDifferent 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 toleranceTitrate therapy for lowest effective doseDaily 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 eyesSqueeze handLift head Stick out tongueRestart 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 2004Kress et al. NEJM. 2000Wake 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 = 0.01Extubated faster Discharged from ICU sooner

“SAT + SBT” Was Superior to Conventional Sedation + SBT Intervention (SAT) group = More unplanned extubation, but not more reintubation P = 0.02P = 0.01Discharged from hospital soonerBetter survival at 1 yr Alive P = 0.01 P = 0.04 Girard et al. Lancet 2008; 371:126-34

A wakening & Breathing CoordinationSynergy of daily awakening – via interruption of sedation – plus spontaneous breathing trial Less medication accumulation, less excessive sedationOpportunity 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 withdrawalNo active agitationNo active paralytic use No myocardial ischemia (24h)Normal intracranial pressureBreathe Safety ScreenNo active agitationOxygen saturation >88%FiO2 < 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 Coordination Eligibility = On the ventilatorSAT Safety Screen - pass/failIf pass safety screen, perform SAT If fail; restart sedatives if necessary (1/2 dose) If pass; continue to SBT safety screen SBT Safety Screen - pass/fail 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 Disturbance of consciousness with reduced ability to focus, sustain or shift attentionA change in cognition or the development of a perceptual disturbance that is not better accounted for by pre-existing, established or evolving dementiaDevelops over a short period of time and tends to fluctuate over the course of the dayThere 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: 1753-1762Lin, SM CCM 2004; 32: 2254-2259Milbrandt 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 AndFeature 3: Altered level of consciousnessFeature 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 factors3. Consider pharmacologic treatmentJacobi 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 planAssess target daily Do sedatives need to be changed? Remember to assess for pain!Toxic SituationsCHF, shock, dehydrationNew organ failure (liver/kidney)Hypoxemia 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 Patients852 patients ≥70 years old on general medicine service, no delirium at time of admissionIntervention : standardized protocol for management of 6 delirium risk factors (n=426)Usual care: standard hospital services (n=426)Primary Outcome: Delirium incidence & prevalenceInouye, et al. NEJM. 1999;340:669-676.

Elder Life Program Targeted Risk Factor Standardized Intervention Cognitive impairment Orientation & therapeutic activity protocol (discuss current events, word games, reorient, etc) Sleep deprivation Sleep enhancement & nonpharm sleep protocol (noise reduction, back massages, schedule adjustment) Immobility Early mobilization protocol (active ROM, reduce restraint use, ambulation, remove catheters) Visual impairment Vision protocol (glasses, adaptive equipment, reinforce use) Hearing impairment Hearing protocol (amplification devices, hearing aids, earwax disimpaction) Dehydration Dehydration protocol (early recognition of dehydration & volume repletion) Inouye, et al. NEJM . 1999;340:669-676.

Results Outcome Intervention Control P-value Incidence of delirium, N (%) 42 (9.9) 64 (15) 0.02 Total days of delirium 105 161 0.02 Episodes of delirium 62 90 0.03 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 COMBATIVE Combative, violent, immediate danger to staff+3 VERY AGITATED Pulls to remove tubes or catheters; aggressive+2 AGITATED Frequent non-purposeful movement, fights ventilator+1 RESTLESS Anxious, apprehensive, movements not aggressive0 ALERT & CALM Spontaneously pays attention to caregiver -1 DROWSY 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

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 hospitalizationUpdate the whiteboards with caregiver namesRequest placement of a clock and calendar in roomDiscuss current events

Nonpharmacologic Interventions Sensory : Determine need for hearing aids and/or eye glassesIf needed, request surrogate provide these for patient when appropriateSleep:Noise reduction strategies (e.g. minimize noise outside the room, offer white noise or earplugs)Normal day-night variation in illuminationUse “time out” strategy to minimize interruptions in sleepMaintain ventilator synchronyPromote 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 Outcome Intervention (n=49) Control (n=50) 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.

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)FIO2 <0.6 PEEP <10 cmH2ONo  dose of any vasopressor infusion for at least 2 hoursNo 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 TherapyIf patient fails, s/he is too critically ill to tolerate exercise/mobility

Active range of motion in bed and sitting position in bed Dangling Transfer to chair (active), includes standing without marching in placeAmbulation (marching in place, walking in room or hall) *All may be done with assistance.Early Exercise & Mobility Levels of Therapy*

E arly E xercise and Mobility Protocol Progression Active ROM (in bed)Sit/ DangleMarch/ Walk Transfer No Exercises, but Passive Range of Motion allowed Progress as tolerated ICU Discharge Exercise screen RASS ≥ -3 RASS -5 / -4

Morandi A et al. Curr Opin Crit Care,2011;17:43-9 Benefits of ABCDE Protocol

Questions? www.ICUdelirium.org delirium@vanderbilt.edu