Listen to Dr. Wes Ely on the show Talk Radio Europe as he talks about the devastating consequences of severe disease that results in admission to critical care units, specifically in the context of the Covid-19 Pandemic.
The title of the presentation is “Understanding the Long Shadow of COVID and ICU Care.”
I know I’d been saying that I probably wouldn’t have time to
attend Wes Ely’s Grand Rounds presentation yesterday, “A New Frontier in
Critical Care: Saving the Injured Brain.” But against all odds, I
actually got to go, along with some medical students and a Family Medicine resident.
As I expected, Dr. Ely brought the house down. His talk was similar to the one he gave at Emory University in Atlanta, Georgia, but not identical. He described the results of the study “Haloperidol and Ziprasidone for treatment of Delirium in Critical Illness,” published last October in the New England Journal of Medicine. There’s a YouTube video of that in my March 28, 2019 post announcing his visit to Iowa City.
He also discussed in detail the ABCDEF bundle for protecting the brains of patients in the ICU.
When he outlined the history of intravenous haloperidol for the treatment of delirium in critical care units, I had to cringe because I remembered the continuous IV haloperidol infusion protocol (running at 5-10 mg an hour) developed by Riker and colleagues. I mention it for historical reasons only. I don’t recommend using it.
Riker, R. R., G. L. Fraser and P. M. Cox (1994). “Continuous infusion of haloperidol controls agitation in critically ill patients.” Critical care medicine 22(3): 433-440.
After his presentation, Dr. Ely asked for questions. I asked him what he thought the role of the psychiatrist is regarding ICU delirium. He actually recognized me; we met very briefly at a meeting of the American Delirium Society in Indianapolis several years ago.
Even better, he knew enough to mention the catatonic variant of delirium and the irony of using a benzodiazepine to treat it, which you would avoid like the plague in delirium (except for alcohol withdrawal, for example). However, benzodiazepines can reverse catatonia. See my post from April 10, 2019 (“Delirium and Catatonia: Medical Emergencies”). He thought psychiatrists would know more about that and would be important collaborators in managing catatonia.
It’s difficult not to be excited by the advances in medicine
and psychiatry when an inspirational scientist, humanist, and visionary leader
like Wes comes to town. It makes me wonder how I’m going to get a buzz like
that out of anything I do in retirement.
On the other hand, I get a kick out of making silly videos.
Wes Ely, MD will be giving the Internal Medicine Grand Rounds today at noon at University of Iowa Hospitals and Clinics. The title of his presentation is “A New Frontier in Critical Care: Saving the Injured Brain.”
I’m on duty today in the general hospital as a psychiatric consultant. I’m pretty sure I won’t be able to attend Dr. Ely’s talk, ironically because I’ll be helping colleagues care for delirious patients.
But I found a YouTube video of the talk he gave with the same title. He delivered it in 2017 at a Critical Care Summit meeting at Emory University in Atlanta, Georgia.
I gave a talk to the medical students yesterday about delirium and dementia, which you can view in yesterday’s post. I urged them to try to attend Dr. Ely’s talk today because it would be a stellar, eye-opening, inspirational presentation. I talked about many of the same topics relevant to delirium that he does–but he’s a rock star. He’s a scientist and a humanist. I met him briefly at a meeting of the American Delirium Society several years ago and he’s brilliant.
I was listening to his talk via this YouTube video as I quickly tapped out this post. He’s an intensivist and focuses on delirium in critical care. While the focus of his talk is called “ICU delirium,” I think it’s important to realize that delirium is delirium–anywhere in the hospital or in nursing homes, skilled care facilities, and hospital emergency rooms.
The first-person video that Dr. Ely shows of a patient who developed what is essentially a dementia from prolonged delirium in the ICU is compelling. It’s a stunning revelation from someone who has not recovered from the neurocognitive injury that we call delirium. Some patients have even committed suicide because of the long-term brain injury resulting from delirium.
Dr. Ely makes the point that changing the culture of hospital medicine regarding the approach to assessing and managing delirium is a baby step process. It takes time.
Change happens, especially if we approach it as a team.
Retirement takes a back seat today for this announcement: Dr. Wes Ely, Critical Care Specialist and one of the foremost experts in intensive care unit (ICU) delirium at Vanderbilt University will be speaking at The Newman Center in Iowa City on April 11, 2019 at 7:00 PM, “Maximizing Dignity at End of Life: Insights from the ICU.” He’ll also deliver the Internal Medicine Grand Rounds at the University of Iowa at noon, “A New Frontier in Critical Care: Saving the Injured Brain.”
I was notified by one of our critical care specialists, Dr. Gregory A. Schmidt, MD, who co-authored the recently published study showing that antipsychotics are not effective treatment for delirium. Wes talks about the study in the video below:
I met Dr. Ely briefly at one of the annual meetings of the American Delirium Society several years ago. He’s enthusiastic, brilliant, and inspiring. He’s published hundreds of articles and book chapters on delirium and taking care of the brain. Along with Dr. Valerie Page (another critical care specialist) he co-authored a book entitled Delirium in Critical Care, originally published in 2011 and I see that there is a 2nd edition available, published in 2015 by Cambridge University Press.
That is the same publisher, incidentally, for the book I co-edited with Dr. Robert G. Robinson, Psychosomatic Medicine: An Introduction to Consultation-Liaison Psychiatry)–shameless plug for my book.
I have a copy of the first edition, which contains a section about the role of the psychiatrist in ICU delirium. It’s very short, which I think is very appropriate. Dr. Alasdair MacLullich, Professor of Geriatric Medicine, Professor of Geriatric Medicine at the University of Edinburgh and past President of the European Delirium Association, wrote the foreword to the 2nd edition and he describes Dr. Ely as “…perhaps the best recognized expert in this field worldwide,” referring to delirium.
Incidentally, about 8 years ago Dr. MacLullich and I corresponded about his research team’s development of the Edinburgh Delirium Test Box (EDTB), an instrument for detecting attentional abnormalities that are a defining feature of delirium. He loaned us the box and I eventually turned it over to a colleague for continuing use of it as part of an ongoing delirium committee project to improve the early detection and prevention of delirium at our hospital. There is now a smartphone application for it.
Regrettably, I probably won’t get to hear Wes give his presentation—because I’m on duty as the general hospital psychiatric consultant and most likely will be trying to help physicians care for delirious patients.
Girard, T. D., et al. (2018). “Haloperidol and Ziprasidone for Treatment of Delirium in Critical Illness.” N Engl J Med 379(26): 2506-2516.
BACKGROUND: There are conflicting data on the effects of antipsychotic medications on delirium in patients in the intensive care unit (ICU). METHODS: In a randomized, double-blind, placebo-controlled trial, we assigned patients with acute respiratory failure or shock and hypoactive or hyperactive delirium to receive intravenous boluses of haloperidol (maximum dose, 20 mg daily), ziprasidone (maximum dose, 40 mg daily), or placebo. The volume and dose of a trial drug or placebo was halved or doubled at 12-hour intervals on the basis of the presence or absence of delirium, as detected with the use of the Confusion Assessment Method for the ICU, and of side effects of the intervention. The primary end point was the number of days alive without delirium or coma during the 14-day intervention period. Secondary end points included 30-day and 90-day survival, time to freedom from mechanical ventilation, and time to ICU and hospital discharge. Safety end points included extrapyramidal symptoms and excessive sedation. RESULTS: Written informed consent was obtained from 1183 patients or their authorized representatives. Delirium developed in 566 patients (48%), of whom 89% had hypoactive delirium and 11% had hyperactive delirium. Of the 566 patients, 184 were randomly assigned to receive placebo, 192 to receive haloperidol, and 190 to receive ziprasidone. The median duration of exposure to a trial drug or placebo was 4 days (interquartile range, 3 to 7). The median number of days alive without delirium or coma was 8.5 (95% confidence interval [CI], 5.6 to 9.9) in the placebo group, 7.9 (95% CI, 4.4 to 9.6) in the haloperidol group, and 8.7 (95% CI, 5.9 to 10.0) in the ziprasidone group (P=0.26 for overall effect across trial groups). The use of haloperidol or ziprasidone, as compared with placebo, had no significant effect on the primary end point (odds ratios, 0.88 [95% CI, 0.64 to 1.21] and 1.04 [95% CI, 0.73 to 1.48], respectively). There were no significant between-group differences with respect to the secondary end points or the frequency of extrapyramidal symptoms. CONCLUSIONS: The use of haloperidol or ziprasidone, as compared with placebo, in patients with acute respiratory failure or shock and hypoactive or hyperactive delirium in the ICU did not significantly alter the duration of delirium. (Funded by the National Institutes of Health and the VA Geriatric Research Education and Clinical Center; MIND-USA ClinicalTrials.gov number, NCT01211522 .).
Tieges, Z., Stíobhairt, A.,
Scott, K., Suchorab, K., Weir, A., Parks, S., . . . MacLullich, A. (2015).
Development of a smartphone application for the objective detection of attentional
deficits in delirium. International Psychogeriatrics, 27(8),