Acute Mental Status Changes in the Intensive Care Unit

Acute Mental Status Changes in the Intensive Care Unit
By:Danagra Georgia Ikossi, MD
Stanford General Surgery Resident


* Brief review of Delirium, Seizures and Stroke
* “ICU Psychosis”
o How do you know if they’re confused? (J. Am. Ger. Soc. 2005)
o Why do they become delirious? (Critical Care 2001)
o Does delirium portend a poor outcome? (JAMA 2004)
o Geriatrics: Delirium plus dementia, what to do? (J. Am. Ger. Soc. 2005)


Disorders of Mentation
* Abnormalities of mental function
* Levels of Conciousness

Etiology of depressed level of consciousness
In non head injured patients
o SMASHED
o Substrate deficiencies (glucose, thiamine)
o Meningoencephalitis or Mental illness (malingering, psychogenic coma)
o Alcohol or Accident (CVA)
o Seizures
o Hyper-capnia, -glycemia, -thyroid, -thermia OR Hypo-xia, -tension, -thyroid, -thermia
o Electrolyte abnormalities (hyperNa, hypoNa, hyperCa) and Encephalopathies
o Drugs

Eye Opening
Spontaneous
To Speech
To Pain
Verbal Oriented
Inappropriate
Incomprehensible
Abnormal Extension
Abnormal Flexion
Withdraws
Localizes
Obeys Commands
Motor
Glascow Coma Scale: GCS
“T” denotes intubation
Predictive value of GCS
* Septic Encephalopahthy
Delirium
DSM-IV Diagnosis of Delirium
A. Reduced ability to maintain and shift attention to external stimuli
B. Disorganized thinking, as indicated by rambling, irrelevant, or incoherent speech
C. At least two of the following:

1. Reduced level of consciousness
2. Perceptual disturbances: misinterpretations, illusions, or hallucinations
3. Disturbance of sleep–wake cycle with insomnia or daytime sleepiness
4. Increased or decreased psychomotor activity
5. Disorientation to time, place, or person
6. Memory impairment

D. Abrupt onset of symptoms (hours to days), with daily fluctuation

E. Either one of the following:
1. Evidence from history, physical examination, or laboratory tests of specific organic etiologic factor(s)
2. Exclusion of non-organic mental disorders when no etiologic organic factor can be identified

Delirium
* Hypoactive delirium:
* Dementia and Delerium:
* Management
THIS IS MUCH MORE THAN WE USE
Important to differentiate Delirium from DTs
* Delirium Tremens
Cocaine Related Delirium
Who becomes delirious?

Delirium, Dementia or Both?
* Delirium is a risk factor for increased ICU and Hospital length of stay
* In the geriatric population, becomes difficult to differentiate between underlying dementia and delirium
* Group at Brown did a prospective study of 118 patients in ICU
* Baseline dementia diagnosis given by family on Blessed Dementia Scale
* Delirium diagnosed by CAM and CAM-ICU scales
CAM ICU SCORE
Overall CAM ICU Score:
Delirium and mortality
Perspective on ICU Psychosis
AACM and SCCM Guidelines
Seizures
* Second most common neurologic complication in ICU
* Movements
* Generalized Seizures
* Partial Seizures
* Status Epilepticus
New Onset Seizures
* Drug intoxication
(amphetamies, cocaine, phenocyclidine, cipro, imipenam, lidocaine, PCN, theophylline, TCA)
* Drug withdrawal (EtOH, BZO, Barbiturates, Opiates)
* Infection (Meningoencephalitis, abscess)
* Ischemia (focal or diffuse)
* Space occupying lesion (tumors or bleeds)
* Metabolic derrangement
(hepatic encephalopathy, uremia, hypo-glycemia, -natremia, -calcemia)

* Evaluation:
o Examination looking for lateralizing signs
o Review of medications
o Imaging (CT)
o Procedural diagnostics (LP, labs, blood cultures)
* Management:
o BZO
o Valium 0.2mg/kg IV stops 80% of seizures within 5 min, effect lasts 30 min
o Ativan 0.1mg/kg is as effective and lasts 12-24hrs
o Dilantin 20mg/kg following valium, aim for 20mg/l therapeutic serum level

Stroke
* Acute neurologic disorder
* Nontraumatic brain injury, vascular origin
* Focal findings (not global)
* Persists for more than 24 hours
* 80% ischemic, 20% of which are embolic
o Most thrombi are mural, LA, LV, DVT with PFO
* TIA: transient ischemic attack, focal deficits resolve in less than 24 hours (ischemia rather than infarction)
* Minor Stroke = RIND (reversible ischemic neurologic deficit) resolves within 3 weeks of event
* Major Stroke = deficits persist for more than 3 weeks
* Evaluation: common things you’ll see at the bedside
o Full neuro exam, looking for focal deficits
o Seixures in 10% of cases, focal and within first 24 hours
o Fever in 50% of strokes (not with TIA) – look for other sources
o Coma and LOC are not common – more likely hemorrhage, massive infarct with edema, brainstem infarction, seizure (absence) or postictal state
o Aphasia – Left MCA distribution
o Weakness in contralateral limbs (can also have other metabolic causes)

Diagnostic Studies
* Time is brain
* Coags, Chemistries: hypoglycemia, hyponatremia, ARF
* ECG: Afib?
* CT head: 70% sensitivity for infarct, 90% for hemorrhage - critical to distinguish btwn these
* Better if after 24 hours for infarct
* MRI: more sensitive esp for brainstem and cerebellar strokes
Diagnostics and Treatment
* ICP: monitoring not recommended routinely
o Elevate HOB 30 degrees
o Do not use measures that will decrease CBF
o minimize suctioning (HTN)
o Do not hyperventilate (reduces CBF)
o Steroids not recommended
o Hyperosmolar therapy can be used if edema is severe (Mannitol, HTS)

Acute Mental Status Changes in the Intensive Care Unit.ppt

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PEGylation

Mr. Sanju Patel a visitor of this blog asked me to post detail information on pegylation.

According to medical dictionary -
Oeginterferon alfa-2a,
a covalent conjugate of recombinant interferon alfa-2a and polyethylene glycol, used in the treatment of chronic infection by hepatitis C virus. It is administered subcutaneously. - Mosby's Medical Dictionary, 8th edition.

Pegasys
Pharmacologic class: Interferon
Therapeutic class: Biological response modifier
Pregnancy risk category C
FDA Boxed Warning

• Drug may cause or aggravate fatal or life-threatening neuropsychiatric, autoimmune, ischemic, and infectious disorders. Monitor patient closely with periodic clinical and laboratory evaluations. Withdraw drug in patients who have persistently severe or worsening signs or symptoms of these conditions. In most cases, these disorders resolve once therapy ends.
• Concurrent use with ribavirin may cause birth defects or fetal death. Use extreme care to avoid pregnancy in female patients and female partners of male patients.
Action

Unclear. Thought to bind to specific cell-surface receptors, suppressing cell proliferation and viral replication. Also increases effector protein levels and reduces white blood cell (WBC) and platelet counts.
Availability

Injection: 180-mcg/ml vial

⊘Indications and dosages

➣ Chronic hepatitis C virus infection

Adults: 180 mcg subcutaneously q week for 48 weeks. If poorly tolerated, reduce to 135 mcg weekly; some patients may need reduction to 90 mcg.
Dosage adjustment

• Neutrophil count less than 750 cells/mm3 or platelet count less than 50,000 cells/mm3
• Hepatic disease
• End-stage renal disease requiring dialysis
• Serious adverse reactions
Off-label uses

• Renal cell carcinoma
Contraindications

• Hypersensitivity to drug
• Autoimmune hepatitis
• Decompensated hepatic disease
• Infants and neonates (due to benzyl alcohol content)
Precautions

Use cautiously in:
• thyroid disorders; bone marrow depression; hepatic, renal, or cardiac disease; pancreatitis; autoimmune disorders; pulmonary disorders; colitis; ophthalmic disorders; depression
• elderly patients
• pregnant or breastfeeding patients
• children younger than age 18.
Administration

• Keep refrigerated. Before giving, roll vial between palms for 1 minute to warm; don't shake. Protect solution from light.
• Don't use if solution is cloudy or contains visible particles.
• Administer undiluted in abdomen or thigh by subcutaneous injection.
• Know that drug may be used alone or with ribavirin.

Adverse reactions

CNS: dizziness, vertigo, insomnia, fatigue, rigors, poor memory and concentration, asthenia, depression, irritability, anxiety, peripheral neuropathy, mood changes, suicidal ideation

CV: hypertension, chest pain, supraventricular arrhythmias, myocardial infarction

EENT: vision loss, blurred vision, retinal artery or vein thrombosis, retinal hemorrhage, optic neuritis, retinopathy, papilledema

GI: nausea, vomiting, diarrhea, abdominal pain, dry mouth, anorexia, GI tract bleeding, ulcerative and hemorrhagic colitis, pancreatitis

Hematologic: anemia, leukopenia, thrombocytopenia, neutropenia

Metabolic: diabetes mellitus, aggravated hypothyroidism or hyperthyroidism

Musculoskeletal: myalgia, back pain, joint pain

Respiratory: pneumonia, interstitial pneumonitis, bronchoconstriction, respiratory failure

Skin: alopecia, pruritus, diaphoresis, rash, dermatitis, dry skin, eczema

Other: weight loss, flulike symptoms, injection-site reaction, pain, autoimmune phenomena, severe and possibly fatal bacterial infections, severe hypersensitivity reactions including angioedema and anaphylaxis
Interactions

Drug-drug. Theophylline: increased theophylline blood level

Drug-diagnostic tests. Absolute neutrophil count, hematocrit, hemoglobin, platelets, WBCs: decreased values

Alanine aminotransferase: transient increase

Glucose, thyroid function tests: decreased or increased levels

Triglycerides: increased levels
Patient monitoring

Assess cardiac and pulmonary status closely. Watch for evidence of infections and hypersensitivity reactions, including anaphylaxis.
• Before therapy begins, assess CBC (including platelet count), blood glucose level, and thyroid, kidney, and liver function tests. Continue to monitor at 1, 2, 4, 6, and 8 weeks and then every 4 weeks during therapy (more often if abnormalities occur). Monitor thyroid function tests every 12 weeks.
Monitor for development of diabetes mellitus, hypothyroidism, and hyperthyroidism.
If serious adverse reaction occurs, discontinue drug or adjust dosage until reaction abates, as prescribed. If reaction persists or recurs despite adequate dosage adjustment, discontinue drug.
Patient teaching

• Teach patient or caregiver how to administer injection subcutaneously in thigh or abdomen and how to dispose of equipment properly, if appropriate.
Advise patient to promptly report rash, bleeding, bloody stools, infection symptoms (such as fever), decreased vision, chest pain, severe stomach or lower back pain, shortness of breath, depression, or suicidal thoughts.
• Instruct patient to administer drug exactly as prescribed. If he misses a dose but remembers it within 2 days, tell him to take missed dose as soon as possible; if more than 2 days have elapsed, tell him to contact prescriber.
• Caution patient not to switch brands without prescriber's approval.
• Instruct patient to have periodic eye exams.
• Advise female patient of childbearing age to avoid pregnancy and use two birth control methods before, during, and up to 6 months after therapy. Instruct male patient to use condoms.
• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs and tests mentioned above.

Nursing Spectrum Drug Handbook 2009. © 2009 by The McGraw-Hill Companies, Inc.

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Current and Future Treatment of Chronic Hepatitis C

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Genetic Hearing Loss

Genetic Hearing Loss
By: Jing Shen M.D.
Ronald Deskin M.D.
UTMB Dept of Otolaryngology

Epidemiology
Methods
Syndromic deafness
Alport syndrome
Branchio-oto-renal syndrome
Jervell and Lange-Nielsen syndrome
Norrie syndrome
Pendred Syndrome
Treacher-collins syndrome
Usher syndrome
Waardenburg syndrome
Non-syndromic deafness
Ion homeostasis
GJB2 (Gap Junction Beta 2)
Transcription factors
Cytoskeleton proteins
Extracellular matrix components
Unknown function genes
Mitochondrial disorders
Evaluation
Genetic screening
Genetic counseling
Cochlear gene therapy
Resources for hereditary hearing loss

* Hereditary hearing loss home page http://www.uia.ac.be/dnalab/hhh
* Online Mendelian Inheritance in Man www.ncbi.nlm.nih.gov/Omim

Genetic Hearing Loss.ppt

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