(Searching for a) Delerium Algorithm

[firedoor]

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I recall an article in the green journal within the past year or so which contained a very nice pictured algorithm(s) for the workup/tx of delerium.

I've not been able to locate this article by standard searches. Might anyone be able to reference this article or any other good algorithms for delerium?

Thanks!

 

[Manicsleep]

An article in the green journal on post op delirium from 2008 had a host of visual aids. But that was a while ago, not within the last year.

 

[Doc Samson]

Gregory L. Fricchione, Shamim H. Nejad, Justin A. Esses, Thomas J. Cummings, Jr., John Querques, Ned H. Cassem, and George B. Murray
Postoperative Delirium. Am J Psychiatry, Jul 2008; 165: 803 - 812.

 

[Manicsleep]

Should I be surprised the article was by Murray and Samson was the one who cites it?

 

[firedoor]

Gregory L. Fricchione, Shamim H. Nejad, Justin A. Esses, Thomas J. Cummings, Jr., John Querques, Ned H. Cassem, and George B. Murray
Postoperative Delirium. Am J Psychiatry, Jul 2008; 165: 803 - 812.

Thank you. Only slightly embarrased about misspelling delirium!

 

[OldPsychDoc]

Should I be surprised the article was by Murray and Samson was the one who cites it?

More surprised that our Doc S wasn't a co-author. 😀

 

[9point75]

Did you know that Delirium has its latin roots meaning "going off the ploughed track"?

 

[firedoor]

Did you know that Delirium has its latin roots meaning "going off the ploughed track"?

What an interesting tidbit to know!

 

[kugel]

One of the best pieces of advice I ever heard regarding treatment of delirium (not counting "treat the underlying illness!!") was to use small doses of antipsychotic PRN. After 24 hrs, total the doses and provide that total amount (or a little less) into divided BID-TID doses. Still provide some PRN coverage (but even smaller or less frequent doses).

One of the problems I've seen is that a PRN Haldol dose is written on day one - and never changed. The pt gets agitated on one shift and so gets whopping doses. The next shift finds the pt over-sedated, so gives none. The next shift finds the pt agitated......and so on. Once on consult in a hospital where consultants were not permitted to write treatment orders - only recommendations - I consulted daily on a pt whose sepsis cleared days ago, but the pt was still on a Haldol roller coaster. The Haldol/Cogentin was keeping him delirious. Finally, when a very alert nurse wrote down a perfect description of a classic Oculogyric crisis, I went to the Chief of Medicine and complained that the pt was being killed, and here's the proof in the nurses' notes. Haldol got d/c'd and the pt was conscious and conversant within 24 hrs, and home in less than 72.

Of course, when I asked the Nurse Manager where I can get a form to document a commendation for the nurse, I was told there is no such thing. I took a complaint form, crossed out the word "Complaint," and wrote "Commendation" across the top in crayon.

 

[billypilgrim37]

I took a complaint form, crossed out the word "Complaint," and wrote "Commendation" across the top in crayon.

Somehow I think Thoreau would be very proud of this.

 

[Doc Samson]

The Haldol/Cogentin was keeping him delirious. Finally, when a very alert nurse wrote down a perfect description of a classic Oculogyric crisis, I went to the Chief of Medicine and complained that the pt was being killed, and here's the proof in the nurses' notes.

Given the hyperdopaminergic/hypocholinergic hypothesis of delirium, cogentin may well have been contributing to the dleirium, but it's very unlikely (if not neurochemically impossible) that the Haldol was doing so (assuming that it was administered IV, the pt didn't have an allergy, wasn't parkinsonian, etc.). EPS alone shouldn't directly lead to the presentation of delirum.

Otherwise, I agree with your techinque of using the first days total dose and dividing it up for the next day, but I would lead with scheduled and prn doses. Cassem and Murray have long advocated starting with 1 mg (or more) IV, waiting 20-30 minutes (mean time of volume of distribution in healthy subjects is 11 minutes), and then roughly doubling the dose if the desired effect is not seen. Repeat until calm is achieved (i.e., 1, then 2, then 5, then 10, then 20, then 50), then schedule this dose Q4-6 with additional prn doses for the first day. On day 2, calculate the total used and split it over the schedule. Keep an eye on the QTc, K, and Mg, and dump as many other QTc prolongers as you can.

 

[kugel]

Otherwise, I agree with your techinque of using the first days total dose and dividing it up for the next day, but I would lead with scheduled and prn doses. Cassem and Murray have long advocated starting with 1 mg (or more) IV, waiting 20-30 minutes (mean time of volume of distribution in healthy subjects is 11 minutes), and then roughly doubling the dose if the desired effect is not seen. Repeat until calm is achieved (i.e., 1, then 2, then 5, then 10, then 20, then 50), then schedule this dose Q4-6 with additional prn doses for the first day. On day 2, calculate the total used and split it over the schedule. Keep an eye on the QTc, K, and Mg, and dump as many other QTc prolongers as you can.

Thanks!
I'm not at all an expert on this, since I get delirious pts out of the psych ER as fast as possible.

I just want to be clear.
After you give 20mg in this initial strategy, you've given a total of 38mg. Do you give the new scheduled QID dose as 20mg or (rounded up to) 40mg - or are you saying to give a 24-hr total of 20mg divided into 5mg (or 10mg) QID?

Typically, when do you start trying to reduce the dose? Day 3? Day 5? Or do you start trying to drop the Haldol dose as soon as there is headway in getting the underlying illness under control, whether that is on Day 2 or Day 10?

 

[Doc Samson]

Thanks!
I'm not at all an expert on this, since I get delirious pts out of the psych ER as fast as possible.

I just want to be clear.
After you give 20mg in this initial strategy, you've given a total of 38mg. Do you give the new scheduled QID dose as 20mg or (rounded up to) 40mg - or are you saying to give a 24-hr total of 20mg divided into 5mg (or 10mg) QID?

Typically, when do you start trying to reduce the dose? Day 3? Day 5? Or do you start trying to drop the Haldol dose as soon as there is headway in getting the underlying illness under control, whether that is on Day 2 or Day 10?

The repeat doses would be of 20 mg each (though realistically you rarely get to that number - usually the 5 mg dose ends up working nicely). Typically I start to taper the dose when they aren't needing the prns.

 

[Manicsleep]

Samson,

How often do you get past 20mg with that algorithm.

I have a similar style but aggressively start to use gaba, histamine as well as other zeitgeibers after about 20mg total of haldol. That would be the 10mg dose in the scenario you describe unless I have it wrong.

 

[kugel]

I really like the titration strategy, in part because it forces the physician to stick around and make dosing decisions based on pt response. Not just set some orders in place and go away until tomorrow. Or, worse, just making sure you use enough medicine to prevent calls from the nurses.

In my reading induced by this thread, I just found this:
Comparison of delirium assessment tools in a mixed intensive care unit
Critical Care Medicine - Volume 37, Issue 6 (June 2009)
"DISCUSSION: In this comparison study, we found the use of formal delirium detection tools superior to the impression of the ICU physician. The physician missed almost three quarters of all ICU delirium. With delirium assessment by RRs using the DSM-IV criteria as "gold standard," the CAM-ICU had a higher sensitivity than the ICDSC. We found the overall sensitivity for the CAM-ICU and the ICDSC to be 64% and 43%, respectively, and the specificity to be 88% and 95%, respectively."

I'm getting fascinated by the multi-specialty support for the Confusion Assessment Method (CAM), but I can't find a good set of instructions. Who can point me to a good explanation for the CAM along with a set of printed CAM instructions?

I'm also reading about a PDA/Smartphone version of the CAM. Who can point me to one of those?

 

[Doc Samson]

I really like the titration strategy, in part because it forces the physician to stick around and make dosing decisions based on pt response. Not just set some orders in place and go away until tomorrow. Or, worse, just making sure you use enough medicine to prevent calls from the nurses.

In my reading induced by this thread, I just found this:
Comparison of delirium assessment tools in a mixed intensive care unit
Critical Care Medicine - Volume 37, Issue 6 (June 2009)
"DISCUSSION: In this comparison study, we found the use of formal delirium detection tools superior to the impression of the ICU physician. The physician missed almost three quarters of all ICU delirium. With delirium assessment by RRs using the DSM-IV criteria as “gold standard,” the CAM-ICU had a higher sensitivity than the ICDSC. We found the overall sensitivity for the CAM-ICU and the ICDSC to be 64% and 43%, respectively, and the specificity to be 88% and 95%, respectively."

I'm getting fascinated by the multi-specialty support for the Confusion Assessment Method (CAM), but I can't find a good set of instructions. Who can point me to a good explanation for the CAM along with a set of printed CAM instructions?

I'm also reading about a PDA/Smartphone version of the CAM. Who can point me to one of those?

Here you go... PDFs of the tool and instructions AND video tutorials for how to use it. The ICDSC is also thrown in for good measure.

http://www.icudelirium.org/assessment.html

Sorry, can't help with the PDA version.

 

[Doc Samson]

Samson,

How often do you get past 20mg with that algorithm.

I have a similar style but aggressively start to use gaba, histamine as well as other zeitgeibers after about 20mg total of haldol. That would be the 10mg dose in the scenario you describe unless I have it wrong.

Maybe once or twice a year.

I'm very reticent to use anything with any anticholinergic activity, so I try to stick with Haldol monotherapy as far as I can.