Critical Care for Non-intensivists: Making a Case for the Value of Psychiatry in the Intensive Care Unit

The Intensive Care Unit (ICU) is an environment marked by high medical and psychiatric acuity. Historically, psychiatric consultation has been less utilized in this setting despite high rates of psychiatric comorbidity, substance use, and delirium, as well as significant reliance on psychiatric medications for management. Recent achievements in critical care such as the A-F Bundle have prioritized the early recognition and treatment of delirium, however these patients are routinely managed without the involvement of psychiatric consultants. In this workshop we present the work of four C-L psychiatrists who have developed liaisons in the ICU setting who, along with one chief resident, will review evidence-based principles for optimizing the management of psychopathology within critical care and who demonstrate reproducible models for the emerging roles for Consult-Liaison Psychiatry within the ICU.

1. A-F Bundle: Dr. Bui will provide an overview of the A-F bundle, an interdisciplinary collaboration focusing on early optimization of delirium, sedation and other aspects of critical illness which has been demonstrated to improve outcomes and reduce mortality among ICU patients. This talk will give an overview of the model and describe opportunities for psychiatry to play an active role in its successful implementation. (15 min)

2. Analgesia and Sedation: What a C-L psychiatrist should know. Dr. Rosen will outline the literature behind Spontaneous Awakening and Breathing Trials, discuss the current guidelines for analgesia and sedation in critical care, and describe considerations around the common agents used with a focus on pharmacokinetics and complications. He will then examine the unique perspective and added benefit an embedded psychiatrist can offer to primary teams. (15 min)

3. Ventilators: Modes and parameters that matter. Dr. Fedotova will discuss common ventilation parameters and modes that help guide consultants in understanding when psychiatric medications might facilitate different phases of care with an emphasis on the peri-extubation period. (10 minutes)

4. Atypical Delirium: Dr. Wilson will review the unique role the C-L psychiatrist can offer in prevention, recognition and management of delirium and catatonia in the critical care setting. (15 min)

5. Neurocritical care: Dr. Zabinski will review the history of neurocritical care, the growth in neurocritical care unit availability, and special considerations for the C-L psychiatrist. Specifically, he will focus on psychopharmacology following cerebral hemorrhage, including the state of research and practice in starting or restarting SSRIs and VPA, with practical clinical applications for the C-L psychiatrist in this setting. (15 min)

References
1. Huyse FJ, Herzog T, Lobo A, et al: Consultation-Liaison psychiatric service delivery: results from a European study. Gen Hosp Psychiatry; 23: 124-132.
2. Abrams TE, Vaughan-Sarrazin M, Rosenthal GE: Preexisting comorbid psychiatric conditions and mortality in nonsurgical intensive care patients. Am J Crit Care 2010; 19:241–249.