Page 20

ezMag_277323_SmithBucklin_NCS_March_Currents_3

Treatment of Delirium in the Neuro ICU patient By Jeffrey Fong, PharmD, BCPS Delirium in critically ill patients is independently associated with increased morbidity, cost, greater mortality and, in survivors, decreased functional status and increased likelihood for developing a dementia like cognitive state. In Neuro ICU patients, this data is not as robust given most clinical trials have excluded patients with neurological impairments or diagnoses. However, recent investigations by Ely and Naidech in patients admitted with ischemic stroke and ICH have revealed outcomes very similar to other populations of critically ill patients. (CCM 2012 and AJRCCM 2013). Detection and diagnosis of delirium in the neuro ICU patient is complicated given the interaction between the patient’s preadmission cognitive state, acute neurological injury, development of complications (i.e.; vasospasm in aneurysmal subarachnoid hemorrhage) or the progression of an evolving disease state such as cerebral edema and the exposure to delirigenic risk factors such as use of benzodiazepines, anticholinergics, physical restraints and prolonged mechanical ventilation. Despite such challenges, clinicians can utilize objective assessment tools to diagnose delirium in this setting. Clinical tools such as the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and Intensive Care Delirium Screening Checklist (ICDSC) have been studied and validated in the neuro ICU population. Both scales were associated with high degree of interrater reliability similar to its validation in other critically ill populations. Clinical trials investigating the treatment of ICU delirium have excluded patients with acute neurological injury thus limiting evidence based recommendations to expert opinions. Table 1 summarizes the three main clinical trials used to formulate the treatment recommendations of the 2013 Society of Critical Care Medicine Pain, Agitation and Delirium Management Guidelines. It is important to note these clinical trials have been conducted in medical and surgical ICU patients. Non-pharmacological interventions are considered first line given the need to preserve a neurological exam. Efforts should be made to exclude other etiologies, such as disease progression or development of a new complication like vasospasm, for a fluctuating neurological exam. Considerations should be made on a case by case basis for the possibility of co-existence of delirium and a progressing neurological condition. Table 1: Summary of key clinical trials for delirium treatment in the critically ill patient. Trial Design Intervention Control Key Results Skrobik 2004 RCT O:5mg qday titrate to clinical response H 2.5-5mg ENT q8hrs • No difference in delirium severity scores between groups, p=0.64. • However delirium severity decreased over time in both groups. Devlin 2010 PC, DB, MC, RCT Q: 50mg ENT q12hrs titrate to 200mg ENT q12hrs after additional PRN haloperidol dose H 1-10 IV q2hrs prn delirium symptoms Matching placebo • Q reduced Delirium duration: 36 vs 120 hrs, p=0.006 • Quicker resolution of delirium symptoms: 1 vs 4.5 days, p=0.001 • No difference in mortality: Q: 11% vs 17%, p=1.0 MIND 2010 PC, DB, MC, RCT Z 40mg ENT q6hrs H: 5mg ENT q6hrs Matching placebo • No difference in median delirium or coma free days: H: 14 vs Z: 15 vs P: 12.5 days, p=0.66 • No differences in ventilator free days (p=0.25) or mortality (p=0.81) ENT: enteral, H: haloperidol, Hrs: hours, MC: multicentered, O: olanzapine, MIND: Modifying the Incidence of Delirium trial, PC: placebo controlled, PRN: as needed, Q: quetiapine, qday: once daily, RCT: randomized controlled trial, Z: zisprasidone 20


ezMag_277323_SmithBucklin_NCS_March_Currents_3
To see the actual publication please follow the link above