Hi, I'm Brenda Pun, and in this micro-learning session, we're going to focus on approaching delirium in patients with COVID-19. Let's start with what we know about delirium in the ICU pre-COVID. It's incredibly prevalent among our ICU population and especially among the sicker patients with up to 80 percent of our mechanical ventilated patients experiencing it. It's associated with some really negative patient outcomes, increased time on the vent, increased length of stay, increased mortality both in the hospital and for ICU survivors post-hospitalization, and it's associated with increased long-term cognitive impairment, which also leads to post-intensive care syndrome. There are recommendations for care, routine monitoring with a validated tool, the CAM-ICU or the ICD-SC, and suggestion to use bundled interventions like the ABCDF bundle. Then the recommendations suggest against using antipsychotics and to only consider them when it's absolutely necessary for behavioral control. A good mantra is to start low and go slow and discontinue them when they're no longer needed. The Atlantic produced a documentary featuring coronavirus survivors describing their experience with delirium while in the intensive care unit. It's a great video to watch and I would encourage all of you to check it out. It outlines why COVID-19 is a delirium factory for these patients. The scenario in this virus has created multiple risk factors for our patients in developing delirium. Here's some of the risk factors that place our COVID-19 patients at greater risk for developing delirium in the ICU. The first three and especially the first two are largely non-modifiable. They're the effects of this virus on the body. The direct central nervous system invasion, the induction of central nervous system inflammatory mediators. Then the third one is the effect of the other organ failures as that starts to unfold in these patients. Of course, there are things that we can do to support patients during this time and to support and try to reverse that organ failure. But what I want us to focus on for the rest of this presentation is really the bottom half of these risk factors. What are the things that we can do that are more modifiable in our care? Prolonged mechanical ventilation time, effective deep sedation strategies, immobilization among these patients, and social isolation and quarantine without family. All four of these place our patients at great risk for developing delirium. I believe there's some things that we can do to adapt and modify recommendations that we long held prior to COVID season and try to adapt them for use during this time as well for these patients. I think it's really important for us to remember the recommendations for caring for these patients, all ICU patients. To do routine screening for delirium, to use the think mnemonic or another mnemonic to help your team to think through what the etiology of the delirium might be for the patients. Is it some electrolyte abnormality? Is it associated with some new hypoxemia or some other problem, a toxic situation? Applying and adapting the ABCDF bundle is really needed in these patients. And then recommending the use of antipsychotics as needed for behavior, but to really consider discontinuing them as soon as they are no longer needed. As we wrap up this microlearning experience, I want to point to a couple of resources that I think have some really great things for all of us that are at the bedside trying to figure out how to adapt things to our bedside practice in this time period. The Hospital Elder Life Program has a really neat delirium prevention toolkit that's full of a lot of great ideas for adapting our usual care to our situation now where we don't have sitters, we don't have family members to help us, the patients are experiencing a lot of hyperactive delirium. This is a really great toolkit and it's free. I'd suggest you to go check it out, download it, see what applies to your unit. At Vanderbilt, we've also updated our icudelirium.org website to have a COVID-19 resource page. On that page, you can find a whole group of patient stories about their experiences, ICU survivors, and some family members of non-ICU survivors sharing what it was like for them during their time in the ICU. Additionally, there's a whole section on research that we're a part of to help better understand this horrible virus and its effect on our patients and how we might better care for them. If you have any questions, feel free to reach out to us either through the website or you can contact me directly at brenda.punn at vumc.org. Thanks so much.

delirium

ICU patients

COVID-19

risk factors

routine screening