CAM ICU Training Slides

7/28/2019 CAM ICU Training Slides

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CAM-ICU Basics

ICU Delirium and Cognitive Impairment Study Group

www.ICUdelirium.org

[email protected]


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What is Delirium?

Delirium is a common clinical syndrome characterized b

Inattention

Acute cognitive

dysfunction

Pathophysiology: Disruption of neurotransmission (drug action,

inflammation, acute stress response)

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

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


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HyperactivePatient may be combative with agitation that may

require sedation (is diagnosed more frequently).

Subtypes of Delirium

HypoactivePatient may be quiet and even peaceful, despite

cognitive impairment. More difficult to assess.

Mixed

Combination of both types


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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 deliriousevery day

Delirium leads to increased mortality, longerhospital stay, poorer recovery, higher costs ofhealthcare, long-term neurocognitive problems.

Ely EW JAMA 2001;286,2703-2710

Ely EW CCM 2001;29,1370-79


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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


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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


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www.ICUdelirium.org

Educational Delirium Website


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A Two Step Approach to Assessing

Consciousness

Step 1

Level of Consciousness (arousal): RASS

Step 2Content of Consciousness (delirium): CAM-ICU


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Step 1: LOC Assessment

Assess for arousal


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Step 1: Arousal Assessment (RASS

+3

+2

+1

0

- 1

- 2

- 3

- 4

- 5

Richmond

Agitation-Sedation

Scale (RASS)


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Step 2: Content Assessment

Assess for Delirium


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Confusion Assessment Method

for the ICU (CAM-ICU)

Feature 1: Acute change orfluctuating course of mental

status

And

Feature 2: Inattention

And

Feature 3: Altered level ofconsciousness

Feature 4: DisorganizedThinking

Or

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


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Feature 1: Alteration/Fluctuation

in Mental Status

Is the pt different than his/herbaseline mentalstatus?

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.


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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 thisillness?


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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 tosqueeze on the letter A (or on a certain number)

Pictures

Similar test with pictures(instructions are in picture packets)


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1. Attempt Letters first.

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

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

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

Inattention Present :If >2 errors


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What if the patient only squeezes once and thenfalls back to sleep? orWhat 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


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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


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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!


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Feature 4: Disorganized Thinking

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

Notes:

If pt is unable to move both arms, for the secondpart 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 patientmisses more than 1 question.



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status

And


And

Feature 3: Altered level ofconsciousness

Feature 4: DisorganizedThinking

Or


Ely, et. al. CCM 2001; 29:1370-1379.4

Ely, et. al. JAMA 2001; 286:2703-2710.5


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Case Studies

C #1 M I


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Case #1: Mr. Icy

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

problemDx: DKA, Intubated

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

Step 1: Arousal AssessmentCurrently: Awake and moving around restless in bed, but

not aggressive.

RASS = +1

What do we do next?

C #1 M I


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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 Neg

Feature

1

Feature2

Feature

3

Feature4

Case #1: Mr. Icy


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C #1 M I


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Step 2: CAM-ICU

- Feature 1:


Fluctuation?

Other RASS Scores: -3 +1

- Feature 2:

Letters = 4 errors

- Feature 3:

RASS = +1- Feature 4

Pos Neg

Feature

1

X

Feature2 X

Feature

3

X

Feature4

Case #1: Mr. Icy

Case #2 Mrs Dapple


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Case #2 Mrs. Dapple

75 y/o female

Dx: Severe pneumonia requiring prolonged mechanicalventilation 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 fo>10 seconds

RASS = -1

What do we do next?

C #2 M D l


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Step 2: CAM-ICU

- Feature 1:

Is she at her MS baseline?

Fluctuation?

- Feature 2:Letters = 1 error

- Feature 3

- Feature 4

Pos Neg

Feature

1

Feature2

Feature

3

Feature4

Case #2 Mrs. Dapple


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Case #2 Mrs Dapple


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Step 2: CAM-ICU

- Feature 1:


Fluctuation?

RASS Variance: 2- Feature 2:

Letters = 1 error

- Feature 3

- Feature 4

Pos Neg

Feature

1

X

Feature2 X

Feature

3

Feature4

Case #2 Mrs. Dapple

Case # 3 Miss Universe


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Case # 3 Miss Universe

Miss Universe was successfully extubated from the

Vent at 0800. All sedation and analgesia had beenstopped earlier in the AM. Yesterday evening andlast night she had periods of agitation with adocumented RASS range of -1 to +3.


Pt alert and calm.

RASS = 0

What do we do next?

Case #3: Miss Universe


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Step 2: CAM-ICU

- Feature 1:


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



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Step 2: CAM-ICU

- Feature 1:


Fluctuation?

RASS Variance = 4

- Feature 2:Letters = 3 errors, but youarent sure.

Pictures = 4 errors

- Feature 3:

RASS = 0

- Feature 4

Pos Neg

Feature

1

X

Feature

2

X

Feature

3

X

Feature

4



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Step 2: CAM-ICU

- Feature 1:Is she at her MS baseline?

Fluctuation?

- Feature 2:


sure.Pictures = 4 errors

- Feature 3:

RASS = 0

- Feature 4:

Answered half the questions wrongUnable to perform 2-step command

3 errors

Pos Neg

Feature

1

X

Feature

2

X

Feature

3

X

Feature

4

X



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What if Miss Universe had

gotten all 4 of her

questions right?



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Step 2: CAM-ICU

- Feature 1:


Fluctuation?

- Feature 2:


sure.

Pictures = 4 errors

- Feature 3:

RASS = 0

- Feature 4:

Answered all 4 questions correct

Unable to perform 2-step command

1 error

Pos Neg

Feature

1

X

Feature

2

X

Feature

3

X

Feature

4

X


Case # 4 Mr. Bubble


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Case # 4 Mr. Bubble

Mr. Bubble works as a traveling salesman, and has been full

independent until admission. He is admitted with acutepancreatitis. His sedatives were turned off 30 minutes agofor a Spontaneous Awakening Trial (SAT).


Eyes closed, moves head to verbal stimulation, no eyecontact

RASS = -3

What do we do next?

Case #4: Mr. Bubble


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Step 2: CAM-ICU

- Feature 1:


Fluctuation?

- Feature 2:

Letters= no squeeze for any letters

- Feature 3:

RASS = -3

- Feature 4:

Pos Neg

Feature

1

Feature

2Feature

3

Feature

4

Case #4: Mr. Bubble


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Case #4: Mr. Bubble


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Step 2: CAM-ICU

- Feature 1:


Fluctuation?

- Feature 2:

Letters= no squeeze for any letters

- Feature 3:

RASS = -3

- Feature 4:

Pos Neg

Feature

1

X

Feature

2

X

Feature

3

X

Feature

4

Case # ubb e



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status

And


And

Feature 3: Altered level of

consciousness

Feature 4: Disorganized

ThinkingOr


Ely, et. al. CCM 2001; 29:1370-1379.4

Ely, et. al. JAMA 2001; 286:2703-2710.5

Stop and THINK


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p

Do any meds need to be stopped

or lowered?

Especially considersedatives

Is patient on minimal amountnecessary?

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

N h l i I t ti


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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


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RASS

(N/D & reason if not done)

CAM-ICU Feature 1

(MS change or fluctuation)

Absent

Present

CAM-ICU Feature 2

(Inattention)

Absent

Present

CAM-ICU Feature 3

(Altered LOC)

Absent

Present

CAM-ICU Feature 4

(Disorganized thinking)

Absent

Present

Overall CAM-ICU1 + 2 + [3 or 4] = CAM-ICU+

Negative

PositiveUTA (RASS -4/-5 only)

Not done:________

Brain Road Map for Rounds


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Brain Road Map for Rounds(Script for Interdisciplinary Communication)

Skipping any of these steps could leave the clini cal team wanting more inf ormatio

Investigate (Ask these questions) Report (only takes 10 seconds)

Where is the patient going? Target sedation score (RASS, SAS, etc)

Where is the patient now?Actual sedation score (RASS, SAS, etc)

Delirium assessment (CAM-ICU, ICDSC, etc

How did they get there? Drug exposures

Case Study - Day 1


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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


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Report:

Action:

What do you do now?

Where is the patient going? Target sedation score: RASS -3

Where is the patient now?Actual sedation score: RASS +1 to +2

Delirium: CAM-ICU positive

How did they get there? Drug exposures: Intermittent fentanyl & midazolam

Case Study Day 3


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y y

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?



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Report:

Action:

What do you do now?

Where is the patient going? Target sedation score: RASS -1

Where is the patient now?Actual sedation score: RASS -3

Delirium: CAM-ICU positive

How did they get there?Drug exposures: Propofol infusion 40 mcg/kg/min &

intermittent fentanyl for pain

Case Study Day 5


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y y

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 positiv

lungs clear, moves all extremities

What next?


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Questions?


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www.ICUdelirium.org

[email protected]

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