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

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

Subtypes of Delirium
Hypoactive
Patient may be quiet and even peaceful, despite cognitive impairment. More difficult to assess.

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

Mixed
Combination of both types

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

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

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

Educational Delirium Website www.ICUdelirium.org

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

Assess for arousal

Step 1: Arousal Assessment (RASS)

+3

+2
+1

Richmond AgitationSedation Scale (RASS)

0 -1 -2 -3 -4 -5

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

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

Or

Feature 4: Disorganized Thinking

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 Status

Common Questions: What if you do not know the patients 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
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: 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: 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 assessingAttention This patient is inattentive

If you have to explain the directions more than twice, start to be suspicious for inattention

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

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

Yes/No Questions (Use either Set A or Set B) :
Set A 1. Will a stone float on water? 2. Are there fish in the sea? 3. Does one pound weigh more than two pounds? 4. Can you use a hammer to pound a nail? Set B 1. Will a leaf float on water? 2. Are there elephants in the sea? 3. Do two pounds weigh more than one pound? 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 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 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 present if patient
misses more than 1 question.

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

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

Or

Feature 4: Disorganized Thinking

Case Studies

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. 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
Pos Feature 1 Feature 2 Feature 3 Feature 4 Neg

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

Pos Feature 1 Feature 2 Feature 3 Feature 4 X X X

Neg

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. Dapple

Step 2: CAM-ICU
- Feature 1: Is she at her MS baseline? Fluctuation? - Feature 2: Letters = 1 error - Feature 3 - Feature 4 Feature 1 Pos Neg

Feature 2
Feature 3 Feature 4

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 Feature 1 Pos X Neg

Feature 2
Feature 3 Feature 4

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 Universe

Step 2: CAM-ICU
- Feature 1: Is she at her MS baseline? Fluctuation? - Feature 2: Letters = 3 errors, but you arent sure Pictures = 4 errors - Feature 3: RASS = 0 - Feature 4

Pos

Neg

Feature 1
Feature 2 Feature 3 Feature 4

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 arent sure. Pictures = 4 errors - Feature 3: RASS = 0 - Feature 4

Pos

Neg

Feature 1
Feature 2 Feature 3 Feature 4

X
X X

Case #3: Miss Universe

Step 2: CAM-ICU
- Feature 1:

Pos

Neg

Is she at her MS baseline? Fluctuation? - Feature 2: Letters = 3 errors, but you arent sure. Pictures = 4 errors - Feature 3: RASS = 0 - Feature 4: Answered half the questions wrong Unable to perform 2-step command 3 errors

Feature 1
Feature 2 Feature 3 Feature 4

Case #3: Miss Universe

Step 2: CAM-ICU
- Feature 1:

Pos

Neg

Is she at her MS baseline? Fluctuation? - Feature 2: Letters = 3 errors, but you arent sure. Pictures = 4 errors - Feature 3: RASS = 0 - Feature 4: Answered half the questions wrong Unable to perform 2-step command 3 errors

Feature 1
Feature 2 Feature 3 Feature X 4

X
X X

What if Miss Universe had gotten all 4 of her questions right?

Case #3: Miss Universe

Step 2: CAM-ICU
- Feature 1:

Pos

Neg

Is she at her MS baseline? Fluctuation? - Feature 2: Letters = 3 errors, but you arent sure. Pictures = 4 errors - Feature 3: RASS = 0 - Feature 4: Answered all 4 questions correct Unable to perform 2-step command 1 error

Feature 1
Feature 2 Feature 3 Feature 4

X
X X X

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. Bubble

Step 2: CAM-ICU
- Feature 1:

Pos

Neg

Is he at his MS baseline? Fluctuation? - Feature 2: Letters= no squeeze for any letters - Feature 3: RASS = -3 - Feature 4:

Feature 1
Feature 2 Feature 3 Feature 4

Case #4: Mr. Bubble

Step 2: CAM-ICU
- Feature 1:

Pos

Neg

Is he at his MS baseline? Fluctuation? - Feature 2: Letters= no squeeze for any letters - Feature 3: RASS = -3 - Feature 4:

Feature 1
Feature 2 Feature 3 Feature 4

X
X X

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

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

Or

Feature 4: Disorganized Thinking

Stop and THINK

Do any meds need to be stopped or lowered?

Toxic Situations
CHF, shock, dehydration New organ failure (liver/kidney)

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!

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
Environmental changes (e.g. noise reduction) Sensory aids (e.g. hearing aids, glasses) Reorientation and stimulation Sleep preservation & enhancement Exercise and mobility

RASS (N/D & reason if not done)

CAM-ICU Feature 1 (MS change or fluctuation) CAM-ICU Feature 2 (Inattention) CAM-ICU Feature 3 (Altered LOC) CAM-ICU Feature 4 (Disorganized thinking) Overall CAM-ICU
1 + 2 + [3 or 4] = CAM-ICU+

Absent Present Absent Present Absent Present Absent Present Negative Positive UTA (RASS -4/-5 only) Not done:________

Brain Road Map for Rounds

(Script for Interdisciplinary Communication)
Skipping any of these steps could leave the clinical team wanting more information!

Investigate (Ask these questions)

Where is the patient going?

Report (only takes 10 seconds)

Target sedation score (RASS, SAS, etc) Actual sedation score (RASS, SAS, etc) Delirium assessment (CAM-ICU, ICDSC, etc) Drug exposures

Where is the patient now?

How did they get there?

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

Report:
Where is the patient going? Target sedation score: RASS -3 Actual sedation score: RASS +1 to +2 Delirium: CAM-ICU positive

Where is the patient now?

How did they get there?

Drug exposures: Intermittent fentanyl & midazolam

Action: What do you do now?

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 Map

Report:
Where is the patient going? Target sedation score: RASS -1 Actual sedation score: RASS -3 Delirium: CAM-ICU positive Drug exposures: Propofol infusion 40 mcg/kg/min & intermittent fentanyl for pain

Where is the patient now?

How did they get there?

Action: What do you do now?

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 Map

Report:
Where is the patient going? Target sedation score: RASS 0 Actual sedation score: RASS 0 Delirium: CAM-ICU positive Drug exposures: No sedatives/analgesics in the past 24h

Where is the patient now?

How did they get there?

Action: What do you do now?

Questions?

www.ICUdelirium.org delirium@vanderbilt.edu