Critical Care Concepts.Pdf

Crit Care Clin 24 (2008) xiii–xiv Preface Jose´R. Maldonano, MD, FAPM, FACFE Guest Editor Critical care units are among the most stressful and psychologically chal- lenging places to be in a general medical hospital, whether you are a health care professional or a patient. The purpose of this volume is to help intensivists, an- esthesiologists, internists, and surgeons understand the complex and diverse psychologic problems their patients face during their stay in the ICU. Drs. Arciniegas (of the University of Colorado) and McAllister (of Dart- mouth Medical School) discuss the neurology of traumatic brain injury with a special focus on the neurobehavioral sequelae of head trauma, including the evaluation and treatment of behavioral problems following trauma. The United States population is increasingly older. Dr. Lee and his colleagues from Johns Hopkins provide an excellent review of the presentation and management of dementia and cognitive impairments in the critical care units. Delirium is the most common neurobehavioral disorder experienced by critically ill patients. It affects patient’s morbidity and mortality, and it also interferes with the safe delivery of care and affects the outcome of treatment. In two separate articles, Dr. Maldonado (of Stanford University School of Medicine) conducts a comprehensive review of the epidemiology, etiologic factors, characteristics, and methods of diagnosis and summarizes the evi- denced-based data on methods of treating and preventing delirium in critical care units. Next, Dr. Maldonado distills years of available research and of- fers a comprehensive theory for understanding the pathophysiology and neurobiology of delirium. Taken together, these models may help guide fu- ture research into effective techniques for preventing and treating delirium. 0749-0704/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.ccc.2008.06.003 criticalcare.theclinics.com xiv PREFACE Drs. Ferrando (of the Weill Medical College of Cornell University) and Freyberg (of Columbia University College of Physicians and Surgeons) review the infectious agents that directly infect the central nervous system and may complicate the assessment and clinical management of ICU patients. They suggest treatments for each disorder covered. Substance abuse and potential withdrawal syndromes are common causes for admission to critical care units and often complicate the management of these patients. In their article, Drs. Tetrault and O’Connor (of the Yale School of Medi- cine) review the epidemiology of substance abuse and provide clinical rec- ommendations regarding the treatment of common withdrawal syndromes. Mood disorders and suicide attempts and their sequelae are unfortunate common causes for admission to the ICU. Drs. Steven Dubovsky (of the University of New York at Buffalo) and Amelia Dubovsky (Harvard Medical School) offer an insight into the aftermath of attempted suicide and the acute management of these patients until stabilization and transfer to the appropri- ate psychiatric facility is made. Similarly, the incidents leading to an admission to an acute care unit and the procedures and process of a critical care unit may render patients and family members liable to suffer a number of anxiety symptoms. Drs. Kross, Gries, and Curtis (of the University of Washington) discuss the presentation and management of posttraumatic stress disorder as a sequela to the critical care environment. Dr. Shapiro and colleagues (of Columbia University) summarize the specific psychiatric challenges that are experienced by patients in acute, intensive, and critical care who have heart and lung disease. They focus on the most common psychiatric presentations of these patients and discuss effective treatment strategies to help optimize care. Patients undergoing organ transplantation invariably are managed in the critical care setting both before and after transplantation. This population, too, is likely to experience a number of psychiatric complications. In their article Drs. DiMartini and Dew (of the University of Pittsburg), Crone (of George Washington University), and Fireman (Oregon Health and Sci- ence University) discuss the pretransplantation psychosocial evaluation and review the psychologic complications commonly seen in patients undergoing transplantation. Finally, during the average critical care unit stay, critically ill patients are exposed to a significant number of medications. Many of these agents are used specifically to affect the patient’s cognition and behav- ior or have psychoactive side effects. Drs. Smith, Wittmann, and Stern (of Massachusetts General Hospital) review the most common medical complications associated with the use of psychoactive agents. Jose´R. Maldonado, MD Department of Psychiatry & Behavioral Sciences Stanford University School of Medicine 401 Quarry Road, Office #2317 Stanford, CA 94305, USA E-mail address: [email protected] Crit Care Clin 24 (2008) 635–656 Medical Complications of Psychiatric Treatment Felicia A. Smith, MDa,b,c,*, Curtis W. Wittmann, MDa,d, Theodore A. Stern, MDa,c aDepartment of Psychiatry, Harvard Medical School, Boston, MA, USA bTransplant Psychiatry Service, USA cThe Avery D. Weisman, MD, Psychiatry Consultation Service, Department of Psychiatry, Massachusetts General Hospital, Warren 605, 55 Fruit Street, Boston, MA 02114, USA dDepartment of Psychiatry, Massachusetts General Hospital, WACC 812, Boston, MA 02114, USA Psychiatric medications are frequently an essential component of care for critically ill patients. Their use may lead to medical complications, however, as a result of (1) direct toxicity from psychotropic medications, (2) drug-drug interactions, or (3) intoxication or withdrawal states. These complications may be a nuisance (eg, dry mouth and nausea) or serious and life-threatening (eg, neuroleptic malignant syndrome [NMS] and cardiac arrhythmias). This article addresses the most important medical complications (organized by organ systems) of psychiatric treatment. Central nervous system Neuroleptic malignant syndrome NMS is a serious and rare idiopathic clinical syndrome that is most often manifest by high fever, muscle rigidity, autonomic instability, and altered mental status. It is caused by a decrease in central nervous system dopamine function and is fatal in approximately 10% of cases [1]. Antipsychotics (eg, haloperidol) that are potent dopamine-blockers are generally impli- cated, although atypical antipsychotics with less dopamine receptor affinity (eg, olanzapine, quetiapine, and risperidone) have also been linked with * Corresponding author. Department of Psychiatry, Massachusetts General Hospital, Warren 605, 55 Fruit Street, Boston, MA 02114. E-mail address: [email protected] (F.A. Smith). 0749-0704/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.ccc.2008.05.004 criticalcare.theclinics.com 636 SMITH et al NMS [2]. Other dopamine-blocking agents frequently used in the medically ill (including metoclopromide, droperidol, and promethazine) may also cause NMS, as can abrupt withdrawal of dopamine agonists (eg, levodopa or amantadine). The incidence of NMS varies (especially in the setting of disparate diagnostic criteria), but it is approximately 0.2% in those treated with neuroleptics [3]. The fact that NMS is rare should not obscure the importance of early recognition and diagnosis of this syndrome given its potentially fatal course. Several risk factors predispose one to NMS: dehydration, a history of underlying brain abnormalities, low serum iron levels, and concomitant use of lithium [4]. The syndrome typically develops over several days and lasts approximately 5 to 10 days [5] even after the offending agent has been discontinued (it is longer with depot neuroleptics). Major clinical manifestations include high fever (often O40C), so-called ‘‘lead-pipe’’ rigidity, confusion or altered level of consciousness, and autonomic instability. Downstream complications (including renal failure caused by elevated creatine phosphokinase or rhabdomyolosis from muscle breakdown in the setting of rigidity and hyperthermia) may be severe. Respiratory failure, pul- monary embolus, and disseminated intravascular coagulation are also seen. The potential manifestations and complications of NMS are as follows: Major features Severe muscle rigidity Fever Associated features Depressed level of consciousness (stupor or coma) Autonomic disturbance Dysphagia Mutism Tremor Incontinence Laboratory results Leukocytosis Elevated creatine phosphokinase Low serum iron Of particular note is that the symptoms of NMS overlap considerably with those of other medical illnesses (eg, central nervous system infection, malignant hyperthermia, and anticholinergic delirium) making it difficult to provide a definitive diagnosis, especially in an ICU setting. When the diagnosis is unclear, the symptoms of NMS should be treated and offending agents discontinued. Care should be provided, at least initially, in an ICU setting, because the complications of the syndrome may be serious. After removing all dopamine-blocking agents, treatment is largely supportive and guided by the particular constellation of symptoms that arise. These include use of antipyretics and cooling blankets for high fevers, rehydration, MEDICAL COMPLICATIONS OF PSYCHIATRIC TREATMENT 637 and use of standard treatments for autonomic instability. Pharmacotherapy (eg, with dantrolene for muscle rigidity or bromocriptine and amantadine to reinforce the

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