ABCDE Bundle Case Scenarios

E. Wes Ely, MD MPH

  1. A 71-year-old woman with coronary artery disease comes is admitted to the ICU with one day of acute, severe, left flank pain, fever, and mild nausea. Three months ago, she was told that she had a urinary tract infection that got better with antibiotics. Gram’s stain of her urine shows Gram negative rods, and you start ciprofloxacin for urosepsis. Despite this, the patient develops progressive hypoxemia and requires mechanical ventilation. She appears anxious but is not trying to remove the endotracheal tube or any other support devices. Temperature is 101.5 F, Pulse is 135 per minute, and blood pressure is 115/62 mm Hg. ECG shows a sinus tachycardia with a QTc of 540 msec.

While the patient is on mechanical ventilation, which of the following choices or approaches to sedation represents the best management strategy for the initiation of sedation?

  1. Deeply sedate her until extubation to minimize memories
  2. Sedate and paralyze her to maximize ventilator tolerance
  3. Keeping her alert by setting a light target titrated via validated sedation/arousal scales
  4. Start antipsychotics to prevent delirium
  5. Use long acting agents such as diazepam to avoid fluctuations in consciousness

Answer: C

Explanation:

This recommendation is in keeping with past guidelines, and will hopefully allow just enough but no excess use of these potent psychoactive medications. Answer C would allow choices such as a sedative drip with propofol or dexmedetomidine, both of which could/should still be accompanied by daily interruption of sedation as shown by Kress et al. and Girard et al and also Strom et al. Answer A is incorrect as it would lead unnecessarily to prolonged and deep sedation. The old notion of trying to “eliminate” memories from the ICU appears to be a risk factor for post-traumatic stress disorder, which occurs in about 15 to 20% of ICU survivors. Answer B is incorrect as paralytics should be avoided unless absolutely necessary or perhaps in refractory ARDS because of problems such as myopathy and prolonged paralysis. Answers D and E represent potentially dangerous decisions for several reasons. Antipsychotics should not be given to patients with prolonged QTc intervals as they (as a class effect) could pose a risk of torsades de pointes, and are not indicated because she is not psychotic or delirious. Diazepam’s long half-life is unnecessary and shorter lasting agents (e.g., propofol, or dexmedetomidine) would aid in reducing duration of mechanical ventilation.

Refs:

  • Jacobi J, Fraser GL, Coursin DB, T et al. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med 2002; 30:119-141.
  • Kress JP, Pohlman AS, O'Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 2000; 342:1471-1477.
  • Girard TD, Kress JP, Fuchs BD, et al., ELY, E.W. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care. LANCET 2008;371:126-134.
  • Strom T, Martinussen, Toft P.. A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial. Lancet 2010;375:475-480.
  1. It is decided by the medical team this same patient should be kept lightly sedated due to her anxiety. The arousal target is set for ”awake and alert” and the team will use a sedation/arousal scale that had been adopted by their institutions ICUs based on its validity and reliability.

Which of the following is a FALSE statement concerning sedation/arousal scales:

  1. It is inappropriate to use sedation/arousal scales to monitor patients’ conscoiuness if sedative drugs have been discontinued.
  2. Two examples of well-validated and reliable scales for use in ICU patients are the RASS and SAS scales.
  3. On rounds, it is best to present the patients’ actual and target sedation/arousal scale levels together while making management decisions.
  4. It takes about 10 to 20 seconds to complete an arousal/sedation scale evaluation.
  5. Implementation of these tools has been shown highly reliable in bedside practice.

Answer: A

Explanation: Option A is untrue and yet I have seen newcomers to sedation scales think that they should stop monitoring their patients when drugs for sedation are D/Ced. Options B through E are all true. The basic principle being illustrated in this question is that sedation/arousal scales are neurological assessment instruments that have been validated as part of the neuro exam. Consciousness is arousal plus content, and these tools help clinicians understand the clinical circumstances of their patients that reflect both instrinsic and iatrogenic components of their cliical status. The newer generation sedation scales are being widely adopted by ICUs all over the world to aid in drug titration and ease of communication amongst the ICU team. They are implementable as shown by many references, one by Vasilevskis below including over 6,000 patient days of data, yet require a culture change that means an interdisciplinary approach must be embraced.

Refs:

  • Riker RR, Picard JT, Fraser GL. Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients. Crit Care Med 1999; 27:1325-1329.
  • Sessler CN, Gosnell MS, Grap MJ, et al. The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med 2002; 166:1338-1344.
  • Ely EW, Truman B, Shintani A, Thomason JW, Wheeler AP, Gordon S et al. Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS). JAMA 2003; 289:2983-2991
  • Vasilevskis E, et al. and Ely EW. Delirium and Sedation Recognition Using Validated Instruments: Reliability of Bedside Intensive Care Unit Nursing Assessments from 2007 to 2010. J Am Geriatr Soc 2011;59:S249–S255.

A 69-year-old woman with a long history of arthritis and peptic ulcer and remote abdominal surgery developed an acute bowel obstruction and underwent laparotomy for release of adhesions. Post-operatively she initially had hypoventilation with a PCO2 of 55, but she was extubated successfully on post-operative day 2 and was in the ICU recovering when 2 days later she developed fluctuations in her mental status and inattention. Her physician thought that she was developing delirium and wrote in her chart, “She is agitated and pulling at her lines, asking to leave the hospital despite being reassured that she needs to stay for recovery.” Her arterial blood gas was normal. Subsequent notes by multiple personnel confirmed, however, that she had no hallucinations or delusions but was having fluctuations in level of consciousness and was unable to pay attention. She had no focal motor or sensory abnormalities.

There are several questions related to this patient’s clinical situation and management that are warranted:

  1. Which of the following statements is TRUE about determining whether she is definitively delirious?
  1. She meets the criteria for delirium because of her well-documented hallucinations and delusions.
  2. The cornerstone of her diagnosis rests on her inability to pay attention.
  3. This agitation that she is displaying is the most worrisome part because hyperactive delirium has a worse prognosis than hypoactive delirium.
  4. Delirium is an all or none phenomenon and the duration of this form of brain dysfunction is not that important.
  1. Before placing a patient on medications for delirium, it is prudent to consider non-pharmacological management considerations that have been shown to reduce either delirium incidence or duration. All of the following would be included in that list of except:
  1. Early mobility and physical therapy
  2. Multi-component delirium protocolized management plans
  3. Sleep aids
  4. Hearing aids and eye glasses
  5. Cognitive rehabilitation
  1. Pharmacological management is chosen by her team. Which of the following would be the best medication choice in managing this patient’s delirium?
  1. Lorazepam
  2. Diphenhydramine
  3. Haloperidol
  4. Propofol

Answers:

The answers to these questions are as follows:

#3 Answer is B

#4 Answer is E

#5 Answer is C

Explanations:

For question 3, the answer is B because inattention is the cornerstone of the diagnosis of delirium, according to the DSM IV, the upcoming DSM V, and recent data on phenomenology of delirium as per Meagher et al. Note that while hallucinations and delusions can be present in delirium, obviously, they are not part of the diagnostic criteria of the DSM IV.

For question 4, the answer is E. While it might seem that the brain can undergo cognitive rehabilitation following ICU care to good effect (as we used physical rehabilitation to improve the body following ICU care), there are limited data at this time and no data to say that this approach would actually shorten or eliminate delirium in the acute ICU setting. The other options are all part of the emerging literature showing that non-pharmacological management issues are very important in the ICU to help reduce the burden of delirium. This includes the option of early mobility and physical/occupational therapy, which cut delirium duration in half in the Schweickert study cited below. On the multi-component protocol front, there is a long way to go, however, as the best study of delirium prevention to date was in non-ICU patients by Inouye and colleagues, in which non-pharmacological means such as those mentioned in options B, C, and D of preventing delirium were successful in reducing the relative risk of delirium by about one-third (from 15% to 9%). Clearly this sort of work should be repeated in the ICU setting since so many issues are drastically different for ICU vs. non-ICU patients.

For question 5, the answer is C because the recommended drugs of choice for delirium are antipsychotics, though no drugs are FDA approved for this indication. Ongoing randomized, placebo controlled trials are investigating different management strategies for ICU delirium. In the study cited by Skrobik et al, the two agents were similar in terms of delirium resolution, and the study did not include a placebo group. Haloperidol does not cause respiratory suppression, which is one reason that it is often used in patients with hypoventilatory respiratory failure like this patient. Another pharmacological option could be to place the patient on atypical antipsychotics, of which there are numerous available. One recent small pilot study (N=17 treated patients with a similar sized control group) showed that quetiapine therapy shortened duration of delirium in ICU patients, but this needs to be evaluated in larger trials. While side effects of antipsychotics are not a component of this question, it is important to realize that all antipsychotics pose a risk of torsades de pointes and extrapyramidal side-effects as well as the more rare neuroleptic malignant syndrome. Answer A is false as lorazepam is actually deliriogenic, and benzodiazepine use in a delirious patient should likely be discontinued other than perhaps in patients experiencing benzodiazepine withdrawal or delirium tremens. Answer B is false because diphenhydramine and other antihistamines are a major risk factor causing delirium, especially in older patients. Answer D is false as there are no data to indicate that propofol has any role in improving delirium resolution.

Refs:

  • Meagher DJ and Trzepacz PT. Phenomenological distinctions needed in DSM-V: delirium, subsyndromal delirium, and dementias. J Neuropsychiatry Clin Neurosci 2007;19:468-470.
  • Meagher DJ, et al and Trzepacz PT. Phenomenology of delirium. Assessment of 100 adult cases using standardised measures. Br.J.Psychiatry 2007;190:135-141.
  • Jacobi J, Fraser GL, Coursin DB, et al. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med 2002; 30:119-141.
  • Schweickert WD, et al, Hall JB, Kress JP. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009;373:1874-1882.
  • Inouye SK, Bogardus ST Jr., Charpentier PA, et al.A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 1999; 340:669-676.
  • Pandharipande PP, Shintani A, Peterson J, Pun BT, Wilkinson GR, Dittus R, Bernard G, Ely EW. Lorazepam is an Independent Risk Factor for Transitioning to Delirium in Intensive Care Unit Patients. Anesthesiology IN PRESS, 2005.
  • Skrobik YK, Bergeron N, Dumont M, Gottfried SB. Olanzapine vs. haloperidol: treating delirium in a critical care setting. Intensive Care Med 2004; 30:444-449.
  • Devlin JW , Roberts RJ, Fong JJ et al. Efficacy and safety of quetiapine in critically ill patients with delirium: a prospective, multicenter, randomized, double-blind, placebo-controlled pilot study. Crit Care Med 2010;38::419-427.