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Case A: 38 year old female post traumatic brain injury and multiple trauma
The patient is ventilated and receiving fentanyl infusion for pain without any sedation. She is unable to self-report pain and has a CPOT of 1/8. Here VAMASS is 2A based on her ability to open eyes to voice. Her only other movement is localizing to pain (which would be a MASS of 1).
Although this patient meets the criteria to screen for delirium using the ICDSC (her MASS is >2), during your attempt to screen the patient, you realize that her level of consciousness is too low to assess ICDSC criteria 2-8. In this case, you should identify her ICDSC score as U/A with an * to indicate this is not WDL. Document a DAR note to explain why you were unable to complete the ICDSC screen despite a MASS of 2.
Case B: 68 year old man being ventilated for ARDS secondary to pneumonia.
The patient is ventilated and receiving fentanyl and midazolam. He is unable to self-report pain and has a CPOT of 3/8 which does not change with additional analgesia. His VAMASS is a 1B and attempts to wean his sedation are associated with increased respiratory distress. This patient's level of consciousness is too low for delirium screening, therefore, his ICDSC is U/A.
As with all patients whose level of consciousness is < 3, we reassessed his level of sedation and attempted or considered the appropriateness of sedation reduction.