Management of Delirium in the ICU
Delirium Management Protocol
Protocols and evidence-based strategies for prevention and treatment of delirium will no doubt emerge as more evidence becomes available from ongoing randomized clinical trials of both nonpharmacological and pharmacological strategies. Our group has deliberately put off publishing a delirium management algorithm because it would necessitate incorporation of “expert opinion” and thus aspects that have yet to be adequately tested or proven. However, the requests for such an approach continue to flood our experiences at national and international forums and numerous emails we receive from website visitors. Therefore, we have developed the following Sedation and Delirium Management Protocol, which basically and succinctly summarizes our approach at the current time. We want to emphasize that this approach, which is largely based on the current SCCM Clinical Practice Guidelines, (VUMC Sedation Protocol) is one which needs to be updated regularly with new data and also personalized at each medical center according to thought leaders at that center. This is not a “one-shoe-fits-all” protocol. We hope that this draft protocol helps you form your own integrated approach to CNS monitoring, sedation targeting, and delirium management in critically ill ICU patients.
Primary prevention is preferred; however, some degree of delirium is inevitable in the ICU. Although there are no data on primary prevention (nonpharmacologic) trials in the ICU, the data in non-ICU settings focuses on minimizing risk factors. The strategies include the following interventions:
- Repeated reorientation of patients
- Provisions of cognitively stimulating activities for the patients multiple times a day
- A nonpharmacological sleep protocol
- Early mobilization activities
- Timely removal of catheters and physical restraints
- Use of eye glasses and magnifying lenses, hearing aids and earwax disimpaction
- Early correction of dehydration
- Use of a scheduled pain management protocol
- Minimization of unnecessary noise/stimuli
Strategies for the prevention and management of delirium in the ICU are important areas for future investigation.
The first step in pharmacologic management of of delirium is to assess the patient’s current medications for any offending agents that may be causing or exacerbating the delirium. Inappropriate use of sedatives or analgesics may exacerbate delirium symptoms. Delirious patients may become more obtunded and confused when treated with sedatives, causing a paradoxical increase in agitation as the sedative effects wear off. In fact, benzodiazepines and narcotics that are often used in the ICU to treat “confusion” (delirium) actually worsen cognition and exacerbate the problem. A thorough review of a patient’s medications will help identify any sedatives, analgesics and/or anticholinergic drugs that may be removed or decreased in dose.
The current Pain, Agitation, Delirium, Immobility, and Sleep Disruption (PADIS) Guidelines, recommend against using haloperidol or an atypical antipsychotic to treat delirium. A multicenter, randomized, placebo controlled trial in 566 patients showed that haloperidol and ziprasidone as compared to placebo do not reduce delirium, time on ventilator, ICU or hospital length of stay, or death. Arrhythmias ,Parkinsonism (extrapyramidal symptoms), Neuroleptic Malignant Syndrome, study drug discontinuation, and other safety concerns were extremely low across all three groups. Antipsychotics remain viable for short-term control of agitation (e.g., alcohol or drug withdrawal) or severe anxiety with need to avoid respiratory suppression (e.g., heart failure, COPD, or asthma).
Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU.
Devlin JW, Skrobik Y, Gélinas C, et al. Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Crit Care Med. 2018;46(9):e825-e873.
Effect of Dexmedetomidine Added to Standard Care on Ventilator-Free Time in Patients With Agitated Delirium: A Randomized Clinical Trial
Reade MC, et al., JAMA. 2016 Apr 12;315(14):1460-8
Haloperidol and Ziprasidone for Treatment of Delirium in Critical Illness
Girard TD, Exline MC, Carson SS, et al. Haloperidol and Ziprasidone for Treatment of Delirium in Critical Illness[published online ahead of print, 2018 Oct 22]. N Engl J Med. 2018;10.1056