cam icu basics n.
Download
Skip this Video
Download Presentation
CAM-ICU Basics

Loading in 2 Seconds...

play fullscreen
1 / 58

CAM-ICU Basics - PowerPoint PPT Presentation


  • 173 Views
  • Uploaded on

CAM-ICU Basics. ICU Delirium and Cognitive Impairment Study Group www.ICUdelirium.org delirium@vanderbilt.edu. What is Delirium?. Delirium is a common clinical syndrome characterized by: Inattention Acute cognitive dysfunction

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'CAM-ICU Basics' - alana-carlson


Download Now An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
cam icu basics

CAM-ICU Basics

ICU Delirium and Cognitive Impairment Study Group

www.ICUdelirium.org

delirium@vanderbilt.edu

what is delirium
What is Delirium?

Delirium is a common clinical syndrome characterized by:

Inattention

Acute cognitive

dysfunction

Pathophysiology: Disruption of neurotransmission (drug action, inflammation, acute stress response)

Delirium: Think rapid onset, inattention, clouding of consciousness (bewildered), fluctuation

Dementia: Think gradual onset, intellectual impairment, memory disturbance, personality/mood change, no conscious clouding

slide3
Hyperactive

Patient may be combative with agitation that may require sedation (is diagnosed more frequently).

Subtypes of Delirium

Hypoactive

  • Patient may be quiet and even peaceful, despite cognitive impairment. More difficult to assess.

Mixed

  • Combination of both types
why monitor for delirium
Why monitor for Delirium?
  • 50-80% of ventilated patients develop delirium
  • 20-50% of lower severity ICU patients develop delirium
  • Over 40,000 ventilated patients are delirious every day
  • Delirium leads to increased mortality, longer hospital stay, poorer recovery, higher costs of healthcare, long-term neurocognitive problems.

Ely EW JAMA 2001;286,2703-2710

Ely EW CCM 2001;29,1370-79

icu delirium the canary in the coal mine
ICU Delirium: The Canary in the Coal Mine

Under recognized form of organ dysfunction

3-fold increase in mortality at 6 months

Each DAY a patients is delirious = 10% INCREASE in risk of death

delirium in the icu clinical value of rass cam icu measurement
Delirium in the ICUClinical Value of RASS/CAM-ICU Measurement

Stimulates thinking of Rx:

  • Delirium recognition is a Burglar Alarm for us (early sign of danger)
  • Forces us to consider treatable causes earlier
  • Utilize nonpharmacologic interventions
  • Do NOT automatically link delirium monitoring with a specific drug treatment
slide8

A Two Step Approach to Assessing Consciousness

Step 1

Level of Consciousness (arousal): RASS

Step 2

Content of Consciousness (delirium): CAM-ICU

step 1 loc assessment
Step 1: LOC Assessment

Assess for arousal

step 1 arousal assessment rass
Step 1: Arousal Assessment (RASS)

+3

+2

+1

0

- 1

- 2

- 3

- 4

- 5

Richmond Agitation-Sedation Scale (RASS)

step 2 content assessment
Step 2: Content Assessment

Assess for Delirium

confusion assessment method for the icu cam icu

Feature 1: Acute change or fluctuating course of mental status

And

Feature 2: Inattention

And

Feature 3: Altered level of consciousness

Feature 4: Disorganized Thinking

Or

Confusion Assessment Method for the ICU (CAM-ICU)

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

feature 1 alteration fluctuation in mental status
Feature 1: Alteration/Fluctuation in Mental Status

Is the pt different than his/her baseline mental status?

OR

Has the patient had any fluctuation in mental status in the past 24 hours (eg fluctuating RASS, GCS, previous delirium assessments, etc)

Present: If either question is YES.

feature 1 alteration fluctuation in mental status1
Feature 1: Alteration/Fluctuation in Mental Status

Common Questions:

  • What if you do not know the patient’s baseline?
    • Assume normal unless you have red flags that make you suspicious
    • Red Flag: patient came from institution
  • What about dementia?
    • Ask family “What could she/he do prior to this illness?”
feature 2 inattention
Feature 2: Inattention

Screening for Attention– two options

Letter “A” test

Letters: S A V E A H A A R T (or numbers)

Say 10 letters (or numbers) and instruct the patient to squeeze on the letter “A” (or on a certain number)

Pictures

Similar test with pictures

(instructions are in picture packets)

feature 2 inattention1
Feature 2: Inattention

1. Attempt Letters first.

2. If pt is able to perform the Letter test you are sure of the results, you are done with Inattention test.

3. If pt is unable to perform the Letter test or you are unsure of the results, use the Pictures.

If you perform both tests, use the Pictures result to determine if inattention is present.

Inattention Present :If >2 errors

feature 2 inattention2
Feature 2: Inattention
  • What if the patient only squeezes once and then falls back to “sleep”? or What if the patient is too hyperactive/combative to participate in squeezing?
    • Remember what you are assessing—Attention
    • This patient is inattentive
  • If you have to explain the directions more than twice, start to be suspicious for inattention
slide20

If either Feature 1 or 2 are absent,

Stop

Overall CAM-ICU is Negative

If Features 1 and 2 are present,

Proceed

to Feature 3

feature 3 alt level of consciousness
Feature 3: Alt Level of Consciousness

Any LOC other than Alert.

Present:If the Actual RASS score is anything other than “0” (zero).

You have already done this assessment.

It was the first thing you did when you walked in the room!

feature 4 disorganized thinking
Feature 4: Disorganized Thinking

Yes/No Questions(Use either Set A or Set B) :

Set A Set B

1. Will a stone float on water? 1. Will a leaf float on water?

2. Are there fish in the sea? 2. Are there elephants in the sea?

3. Does one pound weigh more than 3. Do two pounds weigh

two pounds? more than one pound?

4. Can you use a hammer to pound a nail? 4. Can you use a hammer to cut wood?

Note: Use whatever form of communication that works (nodding, hand squeezing, blinking, etc).

feature 4 disorganized thinking1
Feature 4: Disorganized Thinking

Command

Say to patient: “Hold up this many fingers” (Examiner holds two fingers in front of patient) “Now do the same thing with the other hand” (Not repeating the number of fingers).

  • Patient gets credit only if able to successfully complete the entire command
feature 4 disorganized thinking2
Feature 4: Disorganized Thinking

Present: If there is >1 error for the combined questions + command.

  • Notes:
    • If pt is unable to move both arms, for the second part of the command ask patient “Add one more finger”.
    • If patient is unable to move arms at all (quadriplegic), then feature 4 is presentif patient misses more than 1 question.
confusion assessment method for the icu cam icu1

Feature 1: Acute change or fluctuating course of mental status

And

Feature 2: Inattention

And

Feature 3: Altered level of consciousness

Feature 4: Disorganized Thinking

Or

Confusion Assessment Method for the ICU (CAM-ICU)

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

case 1 mr icy
Case #1: Mr. Icy

45 y/o man, lawyer with no previous memory or attention problem

Dx: DKA, Intubated

In the past 24hrs the RASS scores have been -3 to +1.

Step 1: Arousal Assessment

Currently: Awake and moving around restless in bed, but not aggressive.

RASS = +1

What do we do next?

case 1 mr icy1
Case #1: Mr. Icy

Step 2: CAM-ICU

- Feature 1:

Is he at his MS baseline?

Fluctuation?

- Feature 2:

Letters = 4 errors

- Feature 3:

RASS = +1

- Feature 4

case 1 mr icy2
Case #1: Mr. Icy

Step 2: CAM-ICU

- Feature 1:

Is he at his MS baseline?

Fluctuation?

Other RASS Scores: -3 +1

- Feature 2:

Letters = 4 errors

- Feature 3:

RASS = +1

- Feature 4

Is this patient delirious??

case 2 mrs dapple
Case #2 Mrs. Dapple

75 y/o female

Dx: Severe pneumonia requiring prolonged mechanical ventilation and difficulty weaning

In past 24 hours: RASS scores -3 to -1

Step 1: Arousal Assessment

Eyes closed, but awakens to voice; maintains eye contact for >10 seconds

RASS = -1

What do we do next?

case 2 mrs dapple1
Case #2 Mrs. Dapple

Step 2: CAM-ICU

- Feature 1:

Is she at her MS baseline?

Fluctuation?

- Feature 2:

Letters = 1 error

- Feature 3

- Feature 4

slide34

Case #2 Mrs. Dapple

Step 2: CAM-ICU

- Feature 1:

Is he at his MS baseline?

Fluctuation?

RASS Variance: 2

- Feature 2:

Letters = 1 error

- Feature 3

- Feature 4

Is this patient delirious??

case 3 miss universe
Case # 3 Miss Universe

Miss Universe was successfully extubated from the Vent at 0800. All sedation and analgesia had been stopped earlier in the AM. Yesterday evening and last night she had periods of agitation with a documented RASS range of -1 to +3.

Step 1: Arousal Assessment

Pt alert and calm.

RASS = 0

What do we do next?

case 3 miss universe1
Case #3: Miss Universe

Step 2: CAM-ICU

- Feature 1:

Is she at her MS baseline?

Fluctuation?

- Feature 2:

Letters = 3 errors, but you aren’t sure

Pictures = 4 errors

- Feature 3:

RASS = 0

- Feature 4

case 3 miss universe2
Case #3: Miss Universe

Step 2: CAM-ICU

- Feature 1:

Is she at her MS baseline?

Fluctuation?

RASS Variance = 4

- Feature 2:

Letters = 3 errors, but you aren’t sure.

Pictures = 4 errors

- Feature 3:

RASS = 0

- Feature 4

Do you need to do Feature 4??

case 3 miss universe3
Case #3: Miss Universe

Step 2: CAM-ICU

- Feature 1:

Is she at her MS baseline?

Fluctuation?

- Feature 2:

Letters = 3 errors, but you aren’t sure.

Pictures = 4 errors

- Feature 3:

RASS = 0

- Feature 4:

Answered half the questions wrong

Unable to perform 2-step command

3 errors

case 3 miss universe4
Case #3: Miss Universe

Step 2: CAM-ICU

- Feature 1:

Is she at her MS baseline?

Fluctuation?

- Feature 2:

Letters = 3 errors, but you aren’t sure.

Pictures = 4 errors

- Feature 3:

RASS = 0

- Feature 4:

Answered half the questions wrong

Unable to perform 2-step command

3 errors

Is this patient delirious??

case 3 miss universe5
Case #3: Miss Universe

Step 2: CAM-ICU

- Feature 1:

Is she at her MS baseline?

Fluctuation?

- Feature 2:

Letters = 3 errors, but you aren’t sure.

Pictures = 4 errors

- Feature 3:

RASS = 0

- Feature 4:

Answered all 4 questions correct

Unable to perform 2-step command

1 error

Is this patient delirious??

case 4 mr bubble
Case # 4 Mr. Bubble

Mr. Bubble works as a traveling salesman, and has been fully independent until admission. He is admitted with acute pancreatitis. His sedatives were turned off 30 minutes ago for a Spontaneous Awakening Trial (SAT).

Step 1: Arousal Assessment

Eyes closed, moves head to verbal stimulation, no eye contact

RASS = -3

What do we do next?

case 4 mr bubble1
Case #4: Mr. Bubble

Step 2: CAM-ICU

- Feature 1:

Is he at his MS baseline?

Fluctuation?

- Feature 2:

Letters= no squeeze for any letters

- Feature 3:

RASS = -3

- Feature 4:

case 4 mr bubble2
Case #4: Mr. Bubble

Step 2: CAM-ICU

- Feature 1:

Is he at his MS baseline?

Fluctuation?

- Feature 2:

Letters= no squeeze for any letters

- Feature 3:

RASS = -3

- Feature 4:

Is this patient delirious??

confusion assessment method for the icu cam icu2

Feature 1: Acute change or fluctuating course of mental status

And

Feature 2: Inattention

And

Feature 3: Altered level of consciousness

Feature 4: Disorganized Thinking

Or

Confusion Assessment Method for the ICU (CAM-ICU)

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

stop and think
Stop and THINK

Do any meds need to be stoppedor lowered?

Especially consider sedatives

Is patient on minimal amount necessary?

Daily sedation cessation

Targeted sedation plan

Assess target daily

Do sedatives need to be changed?

Remember to assess for pain!

  • Toxic Situations
    • CHF, shock, dehydration
    • New organ failure (liver/kidney)
  • Hypoxemia
  • Infection/sepsis (nosocomial), Immobilization
  • Nonpharmacologic interventions
    • Hearing aids, glasses, reorient, sleep protocols, music, noise control, ambulation
  • K+ or electrolyte problems

Consider antipsychotics after evaluating etiology & risk factors

nonpharmacologic interventions
Nonpharmacologic Interventions
  • Environmental changes (e.g. noise reduction)
  • Sensory aids (e.g. hearing aids, glasses)
  • Reorientation and stimulation
  • Sleep preservation & enhancement
  • Exercise and mobility
brain road map for rounds script for interdisciplinary communication
Brain Road Map for Rounds(Script for Interdisciplinary Communication)

Skipping any of these steps could leave the clinical team wanting more information!

case study day 1
Case Study - Day 1

Female, age 61

Hx: hypertension

CC: altered mental status, pneumonia

Dx: Septic shock, ARDS, acute renal failure

Vent settings: A/C rate 16, TV 400, PEEP 14, FiO2 70%

Infusions: Levophed 8 mcg/min, vasopressin 0.4 units/min, insulin gtt, IVF

Assessment: Target RASS -3, actual RASS +1 to +2, displaying vent asynchrony, CAM-ICU positive, bilateral rhonchi, pulses present

Drugs: Receiving intermittent boluses of fentanyl and midazolam

What next?

review your road map
Review your Road Map

Report:

Action:

What do you do now?

case study day 3
Case Study – Day 3

Vent settings: AC rate 16, TV 400, PEEP 6, FiO2 40%

Infusions: propofol 40 mcg/kg/hr, Levophed 4 mcg/min, vasopressin 0.4 units/min, insulin gtt, IVF

Drugs: Intermittent fentanyl for analgesia

Assessment: Target RASS -1, actual RASS -3, CAM-ICU positive, not breathing over vent set rate, bilateral rhonchi, pulses present, moving extremities spontaneously

What next?

review your road map1
Review your Road Map

Report:

Action:

What do you do now?

case study day 5
Case Study – Day 5

Vent settings: Pressure support 5, PEEP 5, 40% and tolerating spontaneous breathing trial

Infusions: Levophed/vasopressin off, insulin gtt, IVF, propofol off

Septic shock resolved, passed SAT/SBT

Assessment: Target RASS 0, actual RASS 0, CAM-ICU positive, lungs clear, moves all extremities

What next?

review your road map2
Review your Road Map

Report:

Action:

What do you do now?

questions
Questions?

www.ICUdelirium.org

delirium@vanderbilt.edu

ad