AACN News—September 2008—Practice

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Vol. 25, No. 9, SEPTEMBER 2008



Practice Resource Network

Q What are the causes of delirium and the best methods of management?

A Delirium is a commonly occurring cognitive disorder in seriously ill patients with prevalence ranging from 10%-30% in elderly medical patients, 25%-85% in AIDS patients with advanced disease and 77%-85% of cancer patients. Significant risk factors for the occurrence of delirium that can be identified at the time of admission are: vision impairment, severe illness, dehydration and pre-existing cognitive impairment. Patients admitted to acute care with 3 or 4 of these risk factors present are at high risk for experiencing delirium. Delirium is undiagnosed in 60% of critical care patients.

Delirium is an acute disorder of impaired attention, concentration and cognition. It has been referred to as acute confusion, encephalopathy, organic brain syndrome and ICU psychosis; however, experts advocate for the exclusive use of the term delirium to describe the syndrome. Delirium develops over hours to days and symptoms tend to fluctuate. Patients may present as hypoactive (i.e., lethargic), hyperactive (restless, aggressive) or combative. Patients with delirium are at high risk for pulling out endotracheal tubes, removing central lines, falls removing urinary catheters and pulling out chest tubes.

A reliable tool for assessing delirium, the Confusion Assessment Method for the ICU (CAM-ICU) is designed to be used at the bedside in acute and critical care units. It can be completed in less than 1 minute and has high sensitivity, specificity and reliability. For more information and a copy of the tool go to http://www.icudelirium.org. Other instruments for the assessment of delirium include the Confusion Assessment Method (CAM), the Memorial Delirium Assessment Scale, and the Delirium Rating Scale.

Delirium is thought to occur from an imbalance of the neurotransmitters dopamine, acetylcholine and gamma aminobutyric acid (GABA). Dopamine is excitatory while acetylcholine and GABA are antagonists to dopamine. Causes may be multifactorial. One mnemonic to help identify the etiologies is:

D: Drugs, depression and dehydration
E: Endocrine, environment changes and electrolytes
L: Loss of mobility and liver disease
I: Infection and ischemia (hypoxia)
R: Reduced senses and renal failure
I: Impaction (fecal)
U: Urinary retention
M: MI, malignancies and metabolic disorders

Using restraints and limiting visitors is not effective in the management of delirium. Providing comfort, reassurance and a calm environment are very effective. The presence and reassurance of familiar people, such as family, can help to calm the patient. Restraints, environmental overstimulation and disruption of sleep-wake cycles may exacerbate agitation. First, look for underlying causes such as diminished senses, environmental factors, devices and restraints that may be contributing factors and address these.

When medication management is needed to manage delirium haloperidol has been most researched and is commonly used. It is a neuroleptic butyphenone that blocks dopamine receptors and reduces agitation in hyperactive delirium. It has a wide therapeutic window and a short half-life. It has minimal anticholinergic or cardiovascular side effects. There are three primary side effects related to the dopamine blocking effect:

• Extrapyramidal side effects (akathisa [subjective motor restlessness], drug induced parkinsonism with muscle rigidity and tremors),
• Prolongation of the QT interval
• Neuromalignant syndrome (autonomic instability, profuse diaphoresis, hyperthermia and tremens)
• Incidence of side effects is very low, particularly in short-term use.

Starting doses are 0.5-1.0 mg PO or IM/IV. With moderate to severe onset of symptoms, titration can occur by 2.0-5.0 mg every 30 minutes to 1 hour until symptoms are controlled. This may be used to guide the total daily requirement, which is then administered in 2-3 divided doses per day. Intravenous haloperidol may cause less extrapyramidal symptoms than oral haloperidol. Elderly patients should be started at 1/2 dose (www.eperc.mcw.edu /fastFact/ff_60.htm).

If the delirium is related to withdrawal from alcohol or benzodiazepines then the medication of choice is a benzodiazepine. Choice of benzodiazepine must be guided by duration of action and rapidity of onset. Dosage should be individualized, based on withdrawal severity. Lorazepam is a commonly used benzodiazepine administered 1-2 mg every 6 hours as needed. Benzodiazepines act by inhibiting GABA at the receptor level. Use of a benzodiazepine alone in delirium does not solve the neurotransmitter imbalance and may cause paradoxical worsening of agitation. Clonidine may also be added to control autonomic symptoms.

References

American Association of Critical-Care Nurses (2006). Protocols for Practice: Palliative and End of Life Issues in Critical Care. Boston: Jones & Bartlett. pp 13-14.

Ely W (2005). The Confusion Assessment Method for the ICU (CAM-ICU) Training Manual. Nashville TN; Vanderbilt University Medical Center. http://www.icudelirium.org.

End of Life Physician Resource Center. Fast fact and concept #060:Pharmacologic management of delirium. Accessed at www.eperc.mcw.edu/fastFact/ff_60.htm.

Inouye SK, Van Dyck CH, Alessi CA et al. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann-Internal Med. 1990; 113: 941-948.

Ely EW, Margolin R, Francis J, et al. Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med; 2001;29(7): 1370-9. http://www.icudelirium.org.

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Grap Receives Distinguished Research Lecture Award for 2009



Mary Jo Grap, PhD, RN, FAAN, professor of nursing in the Adult Health and Nursing Systems department at Virginia Commonwealth University in Richmond, Va., has been named the 2009 Distinguished Research Lecturer. As the recipient of this prestigious award, she will present her research at NTI 2009 in New Orleans.

Grap’s research focuses on optimizing pulmonary function in mechanically ventilated, critically ill adults. Her studies have focused on airway management, prevention of ventilator-associated pneumonia (VAP) and, more recently, on evaluating the use of sedation during mechanical ventilation.

Her NIH-, ANF, and AACN-funded work has consistently investigated clinical issues that directly impact nursing care of mechanically ventilated patients, and her contributions in this area of research are deep and broad.

Recently her team has focused on reducing VAP through oral care interventions. They initially examined backrest elevation and oral care practices and frequency in a variety of ICU settings - and found little consistency and few standards in either case. In a study funded by the National Institute of Nursing Research (NINR), the team found that subjects spent most of their time at backrest elevations less than the CDC recommendation (greater than 30 degrees). They found that, although low backrest elevation was not directly related to VAP, the combination of early, low backrest elevation and increased severity of illness raised the incidence of VAP.

In a co-investigation with Dr. Cindy Munro, a 7-day oral care protocol to reduce VAP was tested. Although rates of pneumonia were not reduced with toothbrushing, use of chlorhexidine significantly reduced the incidence of VAP. Grap’s team is presently testing a single peri-intubation oral care intervention to evaluate its effect on VAP.

The team is also evaluating the effects of sedation in mechanically ventilated patients to determine the ability of sedation to meet goals of physiologic stability, ventilator dysynchrony, and comfort. This NINR-funded study will provide important information about sedation effectiveness in critically ill adults. Inappropriate levels of sedation may increase the duration of mechanical ventilation.

Grap also participated in the development and testing of a sedation evaluation tool, the Richmond Agitation Sedation Scale, which has been used across the nation. In addition, her team was among the first to evaluate the use of actigraphy as a means to assess agitation in the critically ill.

Her educational background includes a bachelor’s in nursing from Kent State University, Ohio; a master’s from the University of Colorado, Denver; and a doctorate from Georgia State University, Atlanta.

Grap has published more than 50 articles including AACN’s Practice Alert on Oral Care and the Pulse Oximetry Protocol for Practice. She is associate editor for the American Journal of Critical Care and has presented at numerous international, national and local conferences.

Throughout her career, Grap has been actively involved in preparing the next generation of nurses, and has served as a research consultant and mentor for staff nurses, graduate students, and faculty in a variety of ICU settings to improve critical care nursing practice.

She has been recognized for Excellence in Critical Care Nursing by the Army Surgeon General for officers “who have obtained national prominence in their field.”

Grap’s research team has always been interdisciplinary; it includes respiratory therapists, physicians, biomedical engineers, basic scientists, physical therapists, and critical care equipment developers. Her innovative methods have strengthened the impact and raised the visibility of critical care nursing research.

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Essentials of Critical Care Orientation: The Journey to 2.0

When AACN embarked on its 10-month journey to revise the e-learning course Essentials of Critical Care Orientation (ECCO) the organization sought clinical experts from the critical care community to review and revise the course. After a review panel of clinical educators validated the revised learning objectives and course outline, clinical experts were sought to review the content from the classic version of ECCO and either create new content or update the content to fit the new outline. Each expert reviewed from one to four lessons (out of 42) and provided new content to AACN. After an additional five months of instructional design, creation of graphics and media elements, and development of the technology, ECCO 2.0 was launched in June. The process began with the clinical expertise and knowledge of the following individuals.


Mary Pat Aust, MS, RN, is a Clinical Practice
Specialist at AACN.


Linda Bell, MSN, RN, is a Clinical Practice
Specialist at AACN.


Diane Byrum, RN, MSN, CCRN, CCNS, FCCM, is a Critical Care Nurse Specialist at Presbyterian Hospital in Charlotte, N.C.


Brenda Hardin-Wike, BSN, MSN, is the Nurse Manager CVICU at Palmetto Health Richland Heart Hospital, Columbia, S.C. She has been an ACLS and BLS instructor since 1985.


Barbara “Bobbie” Leeper RN, CNS, CCRN, FAHA, is a Clinical Nurse Specialist in Cardiovascular Services at Baylor University Medical Center. She also is an evaluation consultant and speaker for Edwards
LifeSciences.


Karen Marzlin, BSN, RN,C, CCRN, CMC, is a Clinical Nurse and Educator at Aultman Hospital. She is a partner in Key Choice in Uniontown, Ohio.


Laura McNamara, MSN, RN, CCRN, is a Clinical Practice Specialist at AACN.


Leanna Miller, RN, MN, CCRN, PCCN, CPNP, CEN, is an Education Specialist in Trauma at Vanderbilt University Medical Center in Nashville, Tenn. She started LRM Consulting in 1988, specializing in education, clinical orientation and standards development. Miller has been a member of AACN since 1984 and has served in numerous leadership positions.


Darlene Petersen, RN, MSN, CCRN, CCNS, is the CNS in Cardiac Services at Memorial Hospital in Gulfport, Miss. She has been a speaker at NTI and many other national nursing and multidisciplinary conferences. She has extensive experience as a clinician, consultant, educator, manager and businesswoman.She is founder and president of The Learning Curve.


Patti Radovich, RN, MSN, CNS, FCCM, is the Manager of Nursing Research at Loma Linda University Medical Center in Loma Linda, Calif.


Carol Rauen, RN, MS, CCNS, CCRN, PCCN, is an independent Critical Care Clinical Nurse Specialist in Silver Spring, Md. where she provides critical care education to hospitals and AACN chapters. She has been a speaker at NTI for the past 15 years.


Maureen Seckel, APN, APRN, BC, CCNS, CCRN, is a Clinical Nurse Specialist, Medical Pulmonary Critical Care at the Christiana Care Health System in Newark, Del. She has been an adjunct faculty member at the College of Nursing at the University of Delaware since 1999.
.

Leslie Swadener-Culpepper, RN, MSN, CCRN, CCNS, is a Critical Care Clinical Nurse Specialist at the Medical Center of Central Georgia in Macon, Ga. She has been responsible for clinical nursing practice on four adult critical care units and spoke at the 2007 NTI on incorporating ECCO into a competency-based orientation system.


Cynthia Webner, RN,C, BSN, CCRN, CMC, is a Clinical Nurse and Educator at Aultman Hospital. She is a partner in Key Choice, in Uniontown, Ohio.


Susan Yeager, RN, MSN, CCRN, ACNP, is currently the Neuroscience Nurse Practitioner at Riverside Methodist Hospital in Columbus, Ohio.

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