Transcript
Speaker: Welcome to Critical Matters, a sound critical care podcast covering a broad range of topics related to the practice of intensive care medicine.
Speaker: And now, your host, Dr. Sergio Zanotti.
Speaker: In previous episodes of Critical Matters, we have discussed the A to F bundle and the most recent guidelines for the prevention and management of pain, agitation, delirium, immobility and sleep disruption in patients in the ICU, also known as the PATIS guideline.
Speaker: Today, we will take a deeper dive into delirium.
Speaker: Marcus Aurelius, the Roman emperor and stoic philosopher, said that the quality of our thoughts determines the quality of our life.
Speaker: If our mind plays such a critical role in our well-being during health, it is reasonable to believe that our minds are also critical in our recovery from critical illness.
Speaker: Understanding the effects of critical illness on our minds has been a focal point of our guest academic career.
Speaker: Dr. E. Wesley Illy is a professor of medicine at Vanderbilt University School of Medicine with subspecialty training in pulmonary and critical care medicine.
Speaker: Dr. Ily's research has focused on improving the care and outcomes of critically ill patients with ICU-acquired brain disease, manifested acutely as delirium and chronically as acquired dementia.
Speaker: He is the co-director of the Center for Critical Illness, Brain Dysfunction, and Survivorship, CIBS Center, which has enrolled thousands of patients into clinical trials answering vital questions about ICU-acquired brain disease and other components of ICU survivorship.
Speaker: His team developed the CAM ICU, the primary tool used to measure delirium in ICU-based trials and clinically at the bedside.
Speaker: The CAM ICU has been translated into over 30 languages and is utilized in ICUs all over the world.
Speaker: Dr. Ely has published extensively with over 400 peer-reviewed publications and over 50 published book chapters and editorials.
Speaker: It is a real honor to welcome him to the podcast to discuss a topic he is passionate about and has been instrumental in advancing our understanding for our field.
Speaker: Wes, welcome to Critical Matters.
Speaker: Thank you, Sergio.
Speaker: It's my pleasure to be here.
Speaker: So I think a good place to start would be with defining what delirium really is.
Speaker: And I think that people use sometimes definitions very loosely.
Speaker: But from your perspective, if you were to find somebody who's outside of medicine, what is delirium?
Speaker: Right.
Speaker: That is a good place to start.
Speaker: And by the way, I love that you gave the intro, including Marcus Aurelius.
Speaker: who is a great thinker and somebody that we can all emulate and try and be like to some degree.
Speaker: If Marcus Aurelius was sick and in the hospital back in the day and somebody went up to him and tried to figure out if he was delirious, what the most important thing for them to do would be to see how long he can pay attention.
Speaker: So delirium is really an inability to pay attention or in attention.
Speaker: Aurelius would not have to be hallucinating or delusional.
Speaker: He could just not have the ability to pay attention to a 10 to 15 second command.
Speaker: And that would be a very sensitive barometer of the brain not working.
Speaker: So when we're in the ICU and we're testing with the CAM ICU, we try to find out if somebody can, for example, squeeze my hand on a certain letter, the letter A, for example, and we can spell out the word Casablanca or save a heart.
Speaker: or a bad, bad day, or even abracadabra.
Speaker: And all of these 10 letter phrases actually have a mixture of consonants and vowels.
Speaker: Whenever the patient squeezes on the A, they're following the command.
Speaker: When they don't squeeze on the A, they're following the command.
Speaker: And if they do either of the opposite, it's kind of a sin of omission or commission.
Speaker: And if they cannot, if they can get eight out of 10 correct, they're paying attention.
Speaker: If they can't get eight out of 10 correct, they're unable to pay attention and then therefore might be delirious.
Speaker: Let's start with that.
Speaker: And I think to follow up, I think there's two very important points that come up to mind immediately.
Speaker: On one hand, is that this is a very broad syndrome.
Speaker: And I think that a lot of things that people call otherwise would fall in that category.
Speaker: So is this just kind of a very vast umbrella of brain dysfunction?
Speaker: Or is it a distinct entity that might have a different pathophysiology of something like we would call acute metabolic encephalopathy?
Speaker: Yeah.
Speaker: Right.
Speaker: Well, the definition I gave you a second ago isn't the complete definition.
Speaker: It's part of it.
Speaker: A delirious patient is also unable to organize their thinking.
Speaker: They have fluctuations in the level of consciousness, and those wouldn't be attributable to, for example, sleep.
Speaker: Somebody might not be able to pay attention if they were having a stroke, for example, if they were having a bleed inside their head.
Speaker: So you have to make sure that they're not having an organized neuronal catastrophe at a macro level, like a stroke or a bleed or a
Speaker: head trauma.
Speaker: In the absence of those things, a pneumonia patient or a sepsis patient, for example, might have microclots in their body and get a downstream difficulty neurologically, and then it would manifest as delirium, disorganized thinking and attention, et cetera.
Speaker: So encephalopathy is another great word, more of a neurologist's term for delirium.
Speaker: Most patients who are encephalopathic are delirious, and they could be
Speaker: encephalopathic from hepatic dysfunction, from Tylenol overdose, from acid in their blood, from an overdose, etc.
Speaker: And those patients would be CAM positive and also delirious.
Speaker: What we have done is use the literature that we collected, the data to drive our understanding of whether or not this problem, this broad syndrome is important.
Speaker: And what we know, and I'll stop after I say this, is that the days that you spend delirious, inattentive,
Speaker: not organizing your thinking, et cetera, the days you spend like that as a patient contribute or are predictive of, independently predictive of four major outcomes.
Speaker: And those are higher likelihood of dying, longer likelihood of staying in the hospital, more cost of care, and an accelerated form of dementia, acquired dementia, which doesn't necessarily get better in the upcoming weeks and months.
Speaker: And I think that that is obviously a great point in terms that people talk about delirium.
Speaker: We've been talking about it for several years now and recognizing more and more regarding the impact it has on patients.
Speaker: But that's the answer of why we should care, because the days that you spend delirious in the ICU have a tremendous impact on the short term in terms of outcomes, but also on the long term.
Speaker: Can you explain?
Speaker: expand a little bit on the long-term effects of being delirious?
Speaker: Because I think that as ICU providers, we're very focused on getting people out of the ICU, but we haven't done a very good job as a group in understanding what happens to an ICU patient maybe six months later after they've survived their septic shock.
Speaker: Yes, that's a great question.
Speaker: And, you know, imagine if you were sick in the ICU and you
Speaker: you couldn't think well and you were delirious.
Speaker: So it might be confusing to you, might be scary to you.
Speaker: It's a form of suffering for sure.
Speaker: But in the old days, we would say, you know what, daddy's confused, but he will get better.
Speaker: But now we say, you know, this confusion he has, this delirium is a predictor of this long term problem of not being able to think clearly when you get out of the hospital.
Speaker: And I was just sitting yesterday with a 27 year old woman who got out of the ICU after ARDS
Speaker: and rhabdomyolysis and kidney failure.
Speaker: And she said, you know, my brain just doesn't work the way it used to.
Speaker: And I can't I can't remember people's names.
Speaker: I can't do my job.
Speaker: I used to work in Excel spreadsheets and that sort of thing.
Speaker: And I can't do that anymore very well.
Speaker: What is going on?
Speaker: And I said, you know, maybe maybe you feel like your brain is swimming in molasses or you have cobwebs in your brain.
Speaker: And that's exactly she started nodding her head.
Speaker: Yes.
Speaker: That is a form of neuropsychological dysfunction, which is clinically a manifestation of problems with memory, executive function, and visuospatial function, all these things that we know can go awry after critical illness.
Speaker: And we've now studied, Sergio, thousands of patients and found that delirium duration is a predictor of that problem.
Speaker: We don't want to claim cause and effect yet because we're still studying all that.
Speaker: But actually we're about to start an investigation to couple with the previous New England Journal paper we published here from the Sibs Center at Vanderbilt University, which showed that dementia occurred after the ICU stay.
Speaker: And what we're going to do next is we're going to redo the whole cohort.
Speaker: And it's going to be called BRAIN2, the previous study BRAIN1.
Speaker: This BRAIN-ICU2 study is actually going to collect the brains of our patients once they die
Speaker: whether it be months or years later, and try and determine exactly what kind of dementia is this and what can we do to help prevent and mitigate the deficit.
Speaker: And I think that
Speaker: recognizing the short-term impacts on outcome obviously is extremely important.
Speaker: I think that was what we identified first, and there's still a lot of room for trying to improve that.
Speaker: But also, I think as we understand more and more of what happens downstream in those survivors, it seems, Wes, that we're almost like finding parallel findings to what we have in a traumatic brain injury that we would see in our trauma units.
Speaker: I mean, I've had
Speaker: family members and patients who've had, I mean, even not as severe traumatic brain injuries, but they will describe that for months afterwards, they have, I mean, those cow webs and difficulty getting back to where they were before.
Speaker: And really, it seems like critical illness is just another form of traumatic brain injury almost.
Speaker: It very much is.
Speaker: In fact, we are doing a study, an NIH-sponsored study right now called Insight ICU, which
Speaker: where we're studying delirium and these long term cognitive outcomes in trauma patients.
Speaker: So the overlap between what a neurologically injured patient like a trauma or a stroke patient experiences and what a medical ICU or surgical ICU patient experiences is much greater than we once thought.
Speaker: We used to think these were totally different worlds, but now we know through the advent of our epidemiological studies and even interventional trials that they're what
Speaker: Patients have in common across ICUs is this form of an acquired brain injury, even though you might have come in with a problem in your lung or your gallbladder or something neck down.
Speaker: And I think that it's fascinating just, I mean, to see over the span of my career from residency to where we are right now, how we have really evolved in understanding this and what it seems that we really identified in the late 90s and early 2000s is the tip of the iceberg.
Speaker: And that there really is a lot of consequences that perhaps we didn't appreciate as well before, but are becoming more and more apparent with all the work that your group and other colleagues are doing.
Speaker: Let me ask you.
Speaker: Go ahead.
Speaker: Sorry.
Speaker: No, go ahead.
Speaker: Let me go with your next question.
Speaker: So I think that one of the things that I see commonly in critical care when I talk with providers is we have a lot of syndromes and that we always argue about definitions.
Speaker: But one of the things that I often have heard clinicians say is that, well, I can recognize it if I see it.
Speaker: And I think that when it applies to delirium, that is not necessarily true, right?
Speaker: Because we seem to see it all the time and not recognize it.
Speaker: Can you dive a little bit more into the development of the CAM-ICU, how to really implement it, and how you would actually recommend somebody who's never done anything formally in their ICU to identify patients with delirium, how you would guide them in that direction?
Speaker: Sure.
Speaker: Let's talk about that.
Speaker: So first off, delirium, most of it will be invisible to you as a clinician because the vast majority of delirium is hypoactive delirium.
Speaker: Think of an old lady sitting in the bed with pneumonia who can tell you not a yes or no if you ask her yes or no questions, but she may have no idea what you're asking.
Speaker: And so you have to do something a little bit more objective to figure out if she's actually following your conversation.
Speaker: And there's a lot of times where I'm sitting there looking at somebody, they're nodding, and then I test them with the cam and they're very delirious.
Speaker: And I think, wow, what a dummy I am to not have tested with the cam first because the cam saves you a ton of time.
Speaker: Imagine having like some five-minute conversation with somebody and they're totally delirious.
Speaker: They're never gonna remember it anyway.
Speaker: The answers you got don't mean anything.
Speaker: And it was just a total waste of everybody's time.
Speaker: So start with the cam in the ICU.
Speaker: And that means just walk up to the bedside,
Speaker: hold the patient's hands.
Speaker: And this is a beautiful thing is that delirium monitoring actually gets you to the bedside in a beautiful way to hold hands.
Speaker: So they have them squeeze on a certain letter that I showed you.
Speaker: We have videos on our website.
Speaker: Our website is ICU delirium.org.
Speaker: And those videos will show you how to measure delirium.
Speaker: And it takes about 30 to 40 seconds on average.
Speaker: We actually used a computer to test it.
Speaker: It was 37 seconds on average.
Speaker: And
Speaker: That's hundreds of patients, 37 seconds.
Speaker: That's a small price to pay for the amount of information you get from that exam.
Speaker: But still, when you start this, you will find that patients, excuse me, that healthcare professionals don't want to do it at first because it's something that they're not used to doing.
Speaker: So we have to make it appealing to them, make them realize that it's easy.
Speaker: And the way to do that is just to have good nurses in your hospital
Speaker: demonstrate to the other nurses, have a train the trainer session in your in your ICU.
Speaker: And the second big thing to do is that you have to make sure you're talking about this on rounds so that on rounds, there is absolutely a conversation taking place where the nurse presents the delirium data and the team entertains what to do with that with those data.
Speaker: If you don't have that conversation, I guarantee you, you will never get delirium monitoring implemented in a meaningful way.
Speaker: And I think that one of the things that I find very often, and it applies to the CAM ICU, it applies to RAS scores, but also might apply to the A to F bundles, is that you might ask an ICU, and it's overdoing that.
Speaker: And then when you start really digging a little bit deeper or watch them in rounds, it might be that they're documenting somewhere in the chart, but it's not really integrated into the care of that patient itself.
Speaker: in a consolidated way.
Speaker: Can you talk a little bit about how you would push teams that, okay, you don't do anything, you're not measuring the CAMICU, learn how to do it well, what's the next step?
Speaker: The next step is that you're right, just because you're doing it on paper doesn't mean you're using the information.
Speaker: Just like if you put a SWAN in and you sat there and looked at the SWAN all day long but didn't look up at the monitor to see what the wedge was, then what's the point, what the mean arterial pressure was?
Speaker: So if you're doing, if you're collecting, if the nurse is collecting this information and enters it into the chart, but on rounds, nobody uses the information to affect the patient's care, then what was the point of all of that?
Speaker: So the way to make it useful and productive and helpful is to, on rounds, at the beginning of every patient's presentation is for the nurse out loud to say to the rest of the team, the patient's
Speaker: you know, they don't have to say A, B, C, D. They don't have to say the letters like that.
Speaker: You could, you could say A is assessment treatment management of pain and the CPOT today is.
Speaker: But our nurses don't even say the letters.
Speaker: They just say the pain scale rating today for CPOT is a four.
Speaker: The patient got an SAT, which is a spontaneous awakening trial.
Speaker: And we stopped all the medications and she woke up to verbal command.
Speaker: And then we moved on to the SBT and the SBT was failed.
Speaker: So we couldn't take her off the ventilator because she failed the SVT.
Speaker: We started thinking about the choice of drugs and she was still on benzodiazepines.
Speaker: So we stopped the benzodiazepines.
Speaker: We tested her with the cam and the RAS.
Speaker: Her target RAS was a zero, but her actual RAS was a minus two.
Speaker: So we judged that she was deeper than she should have been and her cam was positive.
Speaker: So we went ahead, as we said earlier, and stopped the benzos.
Speaker: And then in terms of E for early mobility,
Speaker: We we've decided since she's delirious and she was a little overstated, we let her wake up a little bit more and she now has off the drugs.
Speaker: And now we're going to get her out of the bed and do range of motion exercises.
Speaker: And we're actually going to walk her around her room.
Speaker: We got the physical therapist coming or you could say the physical therapist isn't here, but we're going to do it as nurses.
Speaker: And then F the family is at the bedside this morning and they're they're going to actually help us get this patient moving around because engaging with the family obviously is a delirium reducer.
Speaker: We know that from literature.
Speaker: So that was maybe a one minute, 30 second, one minute presentation.
Speaker: Think of how much information I just gave you about this patient.
Speaker: And that is the way that the bundle has to take place is it actually has to generate a conversation.
Speaker: And then once I say that stuff, I stop talking and then rest of the team members chime in, disagree, agree, modify what I said and so on.
Speaker: And that conversation is good patient management.
Speaker: It's just that we organized what used to be chaos
Speaker: into a structured, evidence-based way of taking care of people.
Speaker: And I think that that's really the difficult part, right?
Speaker: I mean, everybody can do it on paper, but to really integrate it into your care in a way that's meaningful is the harder part.
Speaker: And like I think I've heard you say at your presentation last year at SCCM, even ICUs that are doing a great job have room for improvement.
Speaker: So I think that we should always be trying to improve what we're doing because this is truly something that can make a difference for our patients and their lives.
Speaker: in a way that maybe 20 years ago we didn't even understand.
Speaker: Yeah.
Speaker: Well, in fact, we just published a paper in October of Critical Care Medicine, came out in the paper form in January of 2019, that have data on 15,000 people demonstrating that at the end of the day, after implementing the ABCDEF bundle at 70 hospitals in the United States, that we have shown very nice dose response
Speaker: curves for reductions in mortality, length of stay, bounce backs to the ICU, more transfers to home rather than nursing homes, and of course, reductions in delirium and coma.
Speaker: So those are some pretty great outcomes that all of us would agree are target items for patients for us in medicine.
Speaker: Absolutely.
Speaker: So I want to ask you a couple more questions around the CAMICU, Wes.
Speaker: And specifically, do you have any tips that you can share with our audience in terms of
Speaker: getting it rolling or I think that one of the complaints that I always hear is that physicians or providers might say, oh, they just don't know how to do it, but we don't teach them.
Speaker: On the other hand, when they're doing it, sometimes we don't actually bring it up in rounds and specifically ask them, what is it?
Speaker: I might see you would have a discussion about that.
Speaker: But any other tips you can give us or your insight and how to really make it a fabric of our rounds?
Speaker: Yeah, I think I would use what's called the brain roadmap.
Speaker: And we use this term brain roadmap.
Speaker: We made it up to be a shorthand for four things that we want every nurse to say on every patient at the bedside with their attending physician.
Speaker: And those four things are the target RAS, the actual RAS, the CAM, and the drugs that the patient is on.
Speaker: So if I tell you the target is minus one and the actual is minus three,
Speaker: and the cam is positive, and the patient is on a fentanyl versus a drip, you automatically hear in five seconds, that I want the patient basically alert to mildly calm, that I've got the patient way over sedated, I know which drugs they're on, and they're delirious.
Speaker: And that little brain roadmap, if you just say that it takes five to 10 seconds max, it just provides so much useful information and fodder for patient management decisions.
Speaker: And
Speaker: When the doctors don't know how to do the CAM, I actually don't really care that much that they don't know how to use it.
Speaker: As long as they know that a CAM positive means a predictor of brain dysfunction that leads, that is a predictor of death, length of stay, cost of care and dementia.
Speaker: Well, that's enough for them to know.
Speaker: And they say, well, if they're CAM positive, I need to do something about it.
Speaker: What do I do?
Speaker: Well, I got to, I got to stop sedation.
Speaker: I got to get them out of the bed.
Speaker: I got to incorporate their family.
Speaker: Cause those are the three biggest things right there.
Speaker: Uh, incorporation of family, getting them out of the bed and, and stopping sedation.
Speaker: Uh, they have to do other good things like, is there a new sepsis here?
Speaker: Does the patient need a chest X-ray or white count?
Speaker: Um, is the patient gotten sicker for some reason?
Speaker: Is there CHF?
Speaker: The two most important medical maladies would be blood flow problems like CHF, too much volume, you know, whatever, or, um, or any type of infection.
Speaker: So the good intensivists will have a short list on the differential diagnosis of what to do when they hear that the patient is CAM positive.
Speaker: Sergio, have you ever heard of the Dr. Dre?
Speaker: I have not.
Speaker: Well, I mean, I actually have.
Speaker: I mean, I've heard of one Dr. Dre, but he's a rapper.
Speaker: I don't know if that's the one.
Speaker: Yeah, yeah, that's who I'm talking about.
Speaker: The Dr. Dre is a rapper, and he has the earbuds, you know, the big earbuds.
Speaker: Yep, yep, yep.
Speaker: Well, we made up a mnemonic called the Dr. Dre and we use it every day at every bedside.
Speaker: So it stands for diseases, drug removal and environment to D DRE.
Speaker: Doctor could be disease remediation if you want for a D R disease remediation.
Speaker: And then the Dre is DRE drug removal environment.
Speaker: So when the patient is delirious, we just say to the nurse, run the doctor, Dr. Dre.
Speaker: And she says, OK, let's think of what diseases we need to solve disease remediation.
Speaker: CHF infection in the main two ones, COPD, hypoxemia, think of all that.
Speaker: And then drugs to be removed.
Speaker: So we run the list of medicines.
Speaker: And then environment.
Speaker: So eyeglasses, hearing aids, sleep, ambulation, family, all that stuff.
Speaker: And if you run the Dr. Dre, you will get at the vast majority of things that could be creating the delirium.
Speaker: And I think that this is probably worth, I mean, reemphasizing because I think this is just gold here, Wes, in terms that a lot of the...
Speaker: the complaints I might hear from some of our clinicians is that, well, there's nothing really I can do about it, which is not true, right?
Speaker: We'll get to treatment.
Speaker: I just gave you a whole list.
Speaker: A little later, but this, Dr. Dre, is exactly what I think people need to understand.
Speaker: So if you have a patient who was CAM negative and now is CAM positive,
Speaker: or they're still CAM positive, you should think about these three things.
Speaker: And I think that in terms of emphasizing just a couple of questions.
Speaker: So I've seen, for example, disease removal recovery.
Speaker: I've seen historically that patients who severe ARDS or septic shock, when we used to blast them with fluids, that a lot of times, I mean, they were very, I mean, unresponsive or very
Speaker: And with diuresis over time, their mental status improves.
Speaker: I mean, is that something that you have encountered?
Speaker: Yeah, absolutely.
Speaker: Any comments on that?
Speaker: It totally does.
Speaker: I just said a minute ago that the two most common medical maladies that lead to delirium are infections of any type and fluid problems, flow problems.
Speaker: CHF is the best example.
Speaker: And what you just said supports that.
Speaker: I absolutely think that's the case.
Speaker: And also when you diurese somebody, they're more able to be mobile.
Speaker: They can get out of the bed better.
Speaker: They can move better.
Speaker: There's just lots of things that we need to think about medically and then physically for our loved ones, for our patients and their families to get them on the right road.
Speaker: It's just brain health, you know?
Speaker: Absolutely.
Speaker: And I think with drug removal, I think that
Speaker: Even though this has been well published and discussed, I still find people not recognizing the perils of benzodiazepines, especially in elderly people.
Speaker: That seems to be, from what I read the literature, the single most dangerous risk factor from a drug perspective.
Speaker: Any comments on that, Wes?
Speaker: Yeah, listen to this.
Speaker: There are about 30 randomized controlled trials of benzos up against some other
Speaker: medicine, about 30 in critical care.
Speaker: And if you look at all of them, whether the benzo is compared to propofol, dexamidatomidine, a narcotic, whatever it is, I don't know of a single one that the benzo one out.
Speaker: It loses every time.
Speaker: It's either neutral or loses every time to the comparator.
Speaker: So the benzo is evidence-based wise the worst choice for lots of different outcomes, whether it be length of stay,
Speaker: delirium, time on vent, you name it, it loses over and over again.
Speaker: So the other day, we had a nurse who needed to give a benzo because it's part of a study protocol, a rescue protocol.
Speaker: And she looked scared.
Speaker: I said, what's the matter?
Speaker: She says, I've never given a benzo.
Speaker: She's been up in our ICU for four years, had never given a benzo.
Speaker: So we rarely use them anymore.
Speaker: And I think that that is something that in ICUs throughout the country, I still see, unfortunately, benzodrips and there's better options and definitely something that we can push for.
Speaker: The third component of the Dr. Dre is the environment.
Speaker: And I used to joke when I was a fellow, but we would used to say that if you want the patient to look better, put their glasses on and they immediately look 10 times better.
Speaker: So when the attending comes, put the glasses on, they'll look much better.
Speaker: But they also look
Speaker: look better probably because it helps them in many other ways that now are linked to delirium.
Speaker: So any comments, I mean, on the importance of us asking glasses, hearing aids?
Speaker: I had a guy in the hospital recently that came in for an in-stemmy, and then he got aspiration, but he got so much better.
Speaker: He's all the way better.
Speaker: He was on the downhill of his critical illness.
Speaker: And then out of nowhere, he got profoundly delirious.
Speaker: And long story short, because we're short on time here, it was his glasses.
Speaker: He needed his glasses.
Speaker: He needed to read.
Speaker: He hadn't read in days.
Speaker: He was used to reading a lot every day.
Speaker: And so I gave him the glasses out of my out of my lab coat.
Speaker: And the next day I walked in, he was totally fine.
Speaker: He was sitting there reading like crazy one of his biographies.
Speaker: And it was a beautiful thing.
Speaker: And it was such a I just kicking myself.
Speaker: I was like, why didn't I think of that two days earlier?
Speaker: But we have to realize that people need to do sensory deprivation is a huge delirogenic situation.
Speaker: And it's not benign.
Speaker: And I think that, again, this mnemonic, I mean, Dr. Dre, the single thing that I, one thing you're going to learn from this podcast is just apply that every time you have a count positive and will probably make a big, big impact on our patients.
Speaker: Now, I have another question, and this is something that has been bothering me for some time, and I just want to know what your experience is and how you have looked at this.
Speaker: So I feel that we're very focused on the patients in the ICU, right?
Speaker: And we do the A to F bundle.
Speaker: But I think there's a huge voltage drop when people leave our ICUs.
Speaker: And we're not doing a good job for our patients.
Speaker: And maybe sharing information that might be helpful elsewhere.
Speaker: So, for example, I have never seen somebody be transferred from an ICU to a step down a floor or a LTAC.
Speaker: And in the report, somebody include the CAM status.
Speaker: Because it seems that a lot of people might leave with some delirium or might get them when they leave the ICU.
Speaker: Is that something that you have looked at or any comments on that, Wes?
Speaker: That's really – it was around 2005 that we here at Vanderbilt, we started teaching delirium to every single nurse who got – who came on at faculty – say on staff at Vanderbilt.
Speaker: And the reason we did that was on purpose to take care of the problem you just outlined.
Speaker: We wanted the floor nurses and the ICU nurses all to know about delirium so that when the ICU nurse checked out a patient to go to the floor, she said the patient's scanned positive.
Speaker: And then the floor nurse would say, oh, I know what that means.
Speaker: I learned about that when I was initiated here at Vanderbilt.
Speaker: And so, yes, we make that part of our regular warm handoff of information.
Speaker: And I think it's something that for our group, which is a large group, I mean, that deals with a lot of impatience.
Speaker: That's something probably that we should work on because I think that's very inconsistent, I mean, from program to program, from hospital to hospital.
Speaker: Absolutely.
Speaker: So let's talk a little bit about –
Speaker: treatment in terms of prevention and actual treatment.
Speaker: And I know that when people think of prevention, you talked about some of the things that can help, obviously, but there's non-pharmacological and pharmacological things that people have looked at in terms of prevention.
Speaker: Can you kind of summarize the way you think of, okay, this is a high-risk patient for delirium.
Speaker: What are the things I can do before their CAM ICU becomes positive to try to avoid it becoming positive?
Speaker: I think about the elements of the ABCDF bundle.
Speaker: Let me let me take you through it.
Speaker: If somebody's in pain, it's delirogenic.
Speaker: I need to take care of that.
Speaker: That's A. B is both SATs and SBTs.
Speaker: So I want to make sure that every day the patient has the opportunity to be taken off whatever sedatives they're on.
Speaker: That's a spontaneous awakening trial, stopping the drugs and then to be taken off the ventilator, which is very sensory depriving because it locks them down with a tube down their throat.
Speaker: So we need an SBT as soon as they wake up to verbal stimulation.
Speaker: C is choice of drugs, which gets you to avoid benzos and other delirogenic agents.
Speaker: D is measuring the delirium just to know that it's there or not.
Speaker: E is the early mobility and it's getting somebody out of the bed.
Speaker: We know that the Schweikert study and Lancet cut delirium in half.
Speaker: And F, family involvement in the great Brazil study by Rose, we found that the patient's delirium was also cut in half by expanding
Speaker: family visitation.
Speaker: So these are really a great list of things that help you prevent delirium.
Speaker: It's not rocket science.
Speaker: It's basic stuff.
Speaker: But you need a checklist kind of like when you're reading an EKG, you don't jump all around.
Speaker: You go rate, rhythm, axis, and you go down a certain order.
Speaker: When you're reading an X-ray, you go patient position, rotation, inspiration, lines, bones, soft tissues, lungs.
Speaker: Same order every day.
Speaker: Same thing.
Speaker: And that way you don't skip any steps.
Speaker: What about any other interventions?
Speaker: I mean, we talked about making sure patients have their glasses, their hearing aids.
Speaker: Any comments on, and this isn't the PADIS guideline, but from your experience on sleep protocols, other things that we can do to improve the environment?
Speaker: Yes, I think that, for one thing, as soon as the sun comes up,
Speaker: We begin to open windows, turning lights on, getting the patient out of the bed.
Speaker: It's daytime.
Speaker: Let's let's act like it's daytime.
Speaker: When the night comes, we can try and have them tired enough that they will fall asleep.
Speaker: Not not chemically, but naturally.
Speaker: And to do that, we want to get the patient walking, get them tired.
Speaker: So rather than chemically get them to go to sleep, we'll try and get them physically to fall asleep.
Speaker: These things, plus the environment of reduction of noise at night so they can sleep.
Speaker: And then, of course,
Speaker: hearing aids and eyeglasses during the day.
Speaker: So all of these things we think improve the environment quite a bit.
Speaker: And in terms of pharmacological prevention, one thing I think that you've covered very clearly is that one way of pharmacologically preventing delirium is avoiding benzos.
Speaker: But what about, there's been some small studies recently in the Blue Journal about low-dose dexmetomidine in elderly patients for sleep.
Speaker: Any comments on where we stand there right now and what would be the current recommendations, Wes?
Speaker: Sure.
Speaker: And I would disclose that I have received honoraria for giving talks that were sponsored by the companies that make Dix Metatomini like Orion and Pfizer.
Speaker: I don't have any stock in those companies, and I will tell you right now what I'm about to say is evidence-based.
Speaker: So evidence-based-wise, there's no sedative agent that has even remotely the amount of data behind it
Speaker: that alpha 2 agonists specifically dex has in terms of delirium reduction whether it be the men's study m-e-n-d-s in jama sedcom prodex mydex the uh the studies by yaya shahabi in australia which are the spice studies um the low dose dexamontomany study by joanna scrobic and john devlin all of these investigations have pushed us in the same direction was it which is that
Speaker: Alpha-2 agonists are a safer, kinder, gentler way to provide sedation in the ICU, which is associated with less delirium, less brain dysfunction, shorter time on the ventilator, et cetera.
Speaker: This is a much evidence-based evolution of data over the past five to 10 years.
Speaker: And I think that any clinician can stand firm on those data.
Speaker: Any other, there's been some comments in the PADIS guidelines about melatonin and other drugs that might be utilizing the ICU.
Speaker: Any comments on your part?
Speaker: I think all of those other agents are potential, you know, good ways to go, but the evidence is way, way thinner.
Speaker: So I'm interested in melatonin, but does melatonin work because it helps or because it gets out of your hand a more dangerous agent that you might have given like Ambien or Benzo?
Speaker: I don't know the answer to that question.
Speaker: And if melatonin works, is it because of sleep?
Speaker: We don't have good data showing that the sleep works.
Speaker: Like the data we have from the RCTs doesn't actually show a benefit to sleep.
Speaker: So what's the mechanism in that sort of thing?
Speaker: Excellent.
Speaker: So let's dive a little bit now into treatment of patients who are actually delirious.
Speaker: And I think that it was made electronically available in October, but I think published in the last...
Speaker: edition of December of the New England Journal of Medicine, the Haloperidol and Ciprasidone for Treatment of Delirium and Critical Illness, or the MIND USA study, which you're a senior author on.
Speaker: The first thing that I noticed that actually struck me, which is always interesting, is what you already said at the beginning, that 89% of the patients in this study had hypoactive delirium.
Speaker: So we're not seeing it unless we look for it.
Speaker: And the other thing that struck me, which I think just illustrates the enormous complexity and difficulties in pulling through these studies, was the percent of people who were approached for the study and the family said, do not want to participate.
Speaker: That was really a little bit of a downer for me.
Speaker: But I think it just illustrates the amount of work that your team had to do to get this study off the ground and working.
Speaker: Why don't you walk us through the study and tell us how you interpret it, Wes?
Speaker: Sure.
Speaker: Well, for 40 years, four decades, people have been giving antipsychotics for delirium.
Speaker: It all started with Ned Kasim at MGH back in 78.
Speaker: And for the last four decades, we've been doing this as usual care.
Speaker: And our question was, hey, you know, is this helping or hurting or is it neutral or what's going on?
Speaker: And so we went to the NIH and we did get a large multimillion dollar grant.
Speaker: We set up a multicenter trial and
Speaker: We wanted all comers who were delirious.
Speaker: That's hypo and hyperactive delirium or mixed delirium because all of those patients get antipsychotics.
Speaker: Now, you might say, Sergio, in my unit, I only give antipsychotics for hyperactive delirium.
Speaker: That may be true, but in plenty of units, people give them for hypoactive delirium.
Speaker: We have good, solid epidemiological data that say that patients who are delirious in the ICU, whether hyper or hypoactive, get antipsychotics all over the world.
Speaker: for delirium.
Speaker: So the scientific question was, is that right or is it wrong?
Speaker: And while 89% had hypoactive delirium at the beginning, a higher percentage of them eventually had mixed or hyper over time.
Speaker: But still the majority were hypoactive.
Speaker: And it really didn't matter whether you were hyperactive or hypoactive, the receipt of a set of a intravenous form of Haldol or the praesadone
Speaker: didn't do anything to the duration of delirium.
Speaker: So the amount of hours you spent delirious was the same whether you got those antipsychotics or placebo, which I think is a really important thing for us to know moving forward.
Speaker: It doesn't mean it's not practice to give an antipsychotic, but you should give it for a reason that you think you're going to accomplish, like perhaps sedation in a hyper agitated patient.
Speaker: not giving it in order to say we are treating the delirium.
Speaker: And I think that's an important point because, like you said, a lot of ICUs, if they had a CAM positive patient, whether they're agitated or not, might start these medications on a kind of around-the-clock basis.
Speaker: And that seems to be answered with this study as something that... And after those are started, about a third of them
Speaker: sometimes 20 to 30 percent of them will leave the hospital still on that drug that was started in the ICU.
Speaker: So what you think is just going to be a day or two of it can end up being months and months of antipsychotics.
Speaker: Yeah, I think a very important lesson.
Speaker: So let me ask you, Wes, in 2019, when do you use haloperidol in the ICU?
Speaker: I use haloperidol or another antipsychotic in the ICU mainly for things like this.
Speaker: My patient is having respiratory failure.
Speaker: and they need to tolerate BiPAP, but their anxiety level is too great and they won't tolerate BiPAP.
Speaker: So CHF, asthma, COPD, I might give them dexmedetomidine, but if I don't want to give the person an intravenous drip, I might just give them bolus doses of an antipsychotic because it doesn't suppress the respiratory drive and allows them to tolerate the claustrophobia circumstance of a BiPAP mask.
Speaker: Another circumstance will be a patient in DTs, which is hyperactive delirium.
Speaker: and they're withdrawing from a benzo or a narcotic or something, either again, either dex or an antipsychotic is an excellent choice because all you're really trying to do is calm the patient's safety situation down to the point that they're not dangerous to the self or others and do it in a way that doesn't make them stop breathing so that they land on a ventilator.
Speaker: And Haldol or dex or even clonidine are great choices in that circumstance.
Speaker: And those are times I think
Speaker: that I still use these agents.
Speaker: And I think it's important because, like you said, it's not malpractice if you use it for a specific reason, but we shouldn't be using it routinely for treating delirium where it's hyperactive or hypoactive unless we have those compelling reasons like you explained.
Speaker: And again, I think that over and over again, we find that dogma or what we do on a regular basis when evaluated more critically is
Speaker: It might not be helping our patients, and I think that we have to have that flexibility to practice at the best available evidence, understanding that as we learn more, things might change.
Speaker: Fantastic.
Speaker: Thank you for that summary.
Speaker: What are you most excited about looking forward to the next year, two years in the field of delirium?
Speaker: I am very excited about the results of our just recently completed MENDS-2 study, MENDS-2.
Speaker: because there is a there's a ton of propofol use in the world.
Speaker: And we are trying to find out if the pilot if the pilot data from our MENS-1 MENDS-1 study published in JAMA and later intensive care medicine and critical care, some sub studies were were real, where we saw a potential survival advantage to getting an alpha two agonist over a GABAergic drug like propofol.
Speaker: And that's going to be very interesting for us.
Speaker: So we've just completed randomization of propofol versus dexmedetomidine.
Speaker: And we are very interested to see if there's any advantage to one drug or the other.
Speaker: That'll be coming out hopefully by the end of 2019, early 2020.
Speaker: And I'm also then the second thing will be I'm very excited for our brain two study where we're going to be getting these brains out and trying to determine what kind of dementia the patients are experiencing.
Speaker: And let me ask you a question related to the men's two.
Speaker: In patients who need heavy sedation, let's say they're paralyzed, ARDS, prone, what would you do, I mean, if dexmatomidine was not enough?
Speaker: Well, first of all, I would never use dex by itself with a paralytic agent.
Speaker: No way.
Speaker: It's not a deep enough sedative.
Speaker: If you're going to be paralyzed, you've got to be deep enough.
Speaker: So propofol or even a benzo has got to happen for those patients.
Speaker: You cannot risk.
Speaker: Somebody feeling like they're buried alive, paralyzed, and not able to communicate.
Speaker: So DEX is a total no-go there.
Speaker: And that was a contraindication in our study, an exclusion.
Speaker: If you're on paralytics, you could not be on the study drug.
Speaker: So you have to have a deeper sedative agent, and propofol will be a very appropriate one of the choices.
Speaker: Excellent.
Speaker: So I think that it's been a wonderful conversation, Wes.
Speaker: I want to be very respectful of your time.
Speaker: But one of the things that we like to do at Critical Matters is also tap into the wisdom of our guest and talk about some couple topics that might not be related directly to delirium.
Speaker: Sure.
Speaker: Would that be okay?
Speaker: Sure.
Speaker: Sure.
Speaker: Whatever.
Speaker: So my first question is, what book or books have influenced you the most or what books have you gifted most often to others?
Speaker: Yeah.
Speaker: That's a great question.
Speaker: It's a broad question.
Speaker: It's a good one.
Speaker: I'm looking on my bookshelf right here in my office here.
Speaker: I usually keep a few extra books in my office.
Speaker: And when I meet with people, students especially, once I see what kind of person they are, what they're interested in, I might gift them a different book.
Speaker: One of them sitting on the shelf here is Boys in the Boat, which is a great story of life and work and success from the famous 1936 Olympic
Speaker: rowing team.
Speaker: Another one sitting here staring at me is the is a biography of Alexander Solzhenitsyn, which was a beautiful book by Joseph Pierce called a soul in exile.
Speaker: Solzhenitsyn represents a soul who obviously was in exile for many years in the Russian gulag.
Speaker: He wrote the gulag archipelago.
Speaker: And that's a great story of his life.
Speaker: We can learn a lot from from him.
Speaker: Another bog another book that that is one of my favorite books of all time
Speaker: is by Viktor Frankl, Man's Search for Meaning.
Speaker: He was a physician in Auschwitz who survived and wrote about those struggles.
Speaker: And I'll give you one last one.
Speaker: I'll give you two last ones.
Speaker: Atul Gawande's Being Mortal is a great book about end of life and growing old in the United States.
Speaker: And one I recently read last year, which is just a beautiful book, it's called Just Mercy by Bryan Stevenson.
Speaker: about, basically about prejudice and the problems within the American justice system.
Speaker: So those are a few titles that I give out a lot and that have helped me in my struggle to become a better person.
Speaker: And I think that a lot of them obviously are books that are wonderful that I have read.
Speaker: I have not read Soul in Exile, so I definitely would have to look that up.
Speaker: And we'll put links to all these books in the show notes.
Speaker: But I think that Boys in the Boat, I would imagine Soul in Exile, and especially Viktor Frankl's book, I think really talk a lot about finding purpose, right?
Speaker: Finding purpose as a guidance.
Speaker: for succeeding.
Speaker: In fact, the Solzhenitsyn book is very important because Joseph Pierce is the only person who has ever written a biography of Solzhenitsyn that actually Solzhenitsyn asked him to come to his house in Russia and gave him in-person interviews.
Speaker: Wow.
Speaker: So that's the only biography we have of Solzhenitsyn where the biographer had contact with him in person at his own house over a long period of time.
Speaker: So we'll definitely have to look into that and that we will put all these in the show notes alongside the address to the website for delirium and some of the studies that we've mentioned.
Speaker: So the second question, Wes, is what do you believe to be true in medicine or in life that most other people don't believe?
Speaker: I don't know if it's that most people don't believe it, but especially a lot of people in medicine now believe that
Speaker: that of all of the bioethical principles that autonomy is the kingpin and that nothing else can compete with autonomy.
Speaker: But I just recently watched one doctor do the exact opposite with regard to patient autonomy.
Speaker: The patient wanted to be one patient of this doctor wanted end of life and specifically physician assisted suicide.
Speaker: And the patient was in California.
Speaker: So I was told the story by this doctor.
Speaker: that they provided physician assisted dying.
Speaker: And then that same doctor told me that they had a patient who wanted everything done in the ICU, but they judged that it was inappropriate.
Speaker: So they went against the patient's autonomous wishes.
Speaker: The answer to your question is that I think that all life is totally priceless and that I don't have the right to take it.
Speaker: So I will do everything I can
Speaker: at the end of life in the ICU to relieve human suffering and and to provide the best palliative care I can.
Speaker: But in no way, shape or form would I ever feel comfortable to deliberately intentionally shorten the life of a patient.
Speaker: I remove life support all of the time.
Speaker: And that is in keeping with whenever something has been judged disproportionate or extraordinary care.
Speaker: And that's a that allows the patient's life to take its natural course.
Speaker: But I wrote a piece in CNN last year.
Speaker: You could put a link to that on from CNN.org about approach I took to a patient's life when they asked me to end it.
Speaker: And that's just a patient story that kind of represents what I think is my calling as a physician.
Speaker: Excellent.
Speaker: And we'll definitely put that link in there as well.
Speaker: And finally, the last question is, what would you want every provider intensivist who's listening to us in this podcast to know?
Speaker: It could be a quote, a fact, or just a reflection.
Speaker: I would want every intensivist to know this and to remind me of it too, so that I can do a better job with this, that when the patient is in that ICU room, look in their eyes.
Speaker: and realize that that is a deep well of of of a complicated individual human being that is not just about our decision of what antibiotic to use what mean or to a pressure to use whatever and we have to ask the patients about themselves.
Speaker: I want to know the name of their dog.
Speaker: I want to know how long they've been married.
Speaker: I want to know how they met their wife or husband or you know what their problems have been in life and the things
Speaker: And then when I say to that person, not here is what's the matter with you, I want to say what matters to you.
Speaker: Flip that around, not what's the matter with you, but what matters to you.
Speaker: And in so doing that, that is the way that I can serve that patient to the best of my ability.
Speaker: And I think this is a perfect place to stop, Wes.
Speaker: Again, I want to thank you for your generosity with your time, with your knowledge.
Speaker: Always a pleasure to hear what's new in the world of delirium, to talk with you.
Speaker: And look forward to having you on the podcast soon again as a guest.
Speaker: Thank you, Sergio.
Speaker: I greatly appreciate it.
Speaker: Bye-bye now.
Speaker: Thanks again for listening to Critical Matters.
Speaker: Make sure to subscribe to this podcast on iTunes or Google Play.
