Define delirium and describe your management approach to this problem in the ICU.
The acute onset of a disturbance of consciousness with inattention, changes in cognition and/orperception, that fluctuates over time, occurs as a consequence of a general medical condition and isnot better accounted for by a pre-existing, established or evolving dementia.
- Early recognition of delirium.
- Stabilise and ensure safety of the patient:
- Attend to airway, breathing and circulation issues as required.
- Consider and rule out any potentially life-threatening causes of delirium (comprehensive history and physical examination will provide clues):
- Intra-cerebral haemorrhage
- Wernicke’s Encephalopathy
- Infection: local (wound, anastomotic leaks etc.), UTI, lung etc.
- Withdrawal from drugs
- Hypertensive encephalopathy
- Metabolic derangements – sodium, renal, liver.
- Consider non-pharmacological strategies to control symptoms:
- Application of hearing aids, spectacles and dentures if worn.
- Continuous re-orientation of patient - verbal, visual with photographs etc.
- Enlist help of family members and/or interpreters.
- Ensure as close to normal as possible sleep/wake cycles in a quiet and calm environment.
- Treat pain, constipation, urinary retention if present.
- Check drug chart and beware/attend to poly-pharmacy and cessation of drugs associated with delirium.
- Mobilise early.
- Avoid physical restraints if safe to do so.
- Obtain pharmacological control of symptoms if necessary:
- Anti-psychotics are first line agents e.g. haloperidol, olanzepine, quetiapine.
- Haloperidol 1-5mg iv q30 PRN. Dose can be doubled and repeated. Beware long QTc.
- Benzodiazepines as first line agents for alcohol withdrawal only. Often used in combination with anti-psychotics in difficult to control symptoms in non-alcohol withdrawal delirium.
- Treat cause if found:
- O2, antibiotics, thiamine, glucose, electrolyte replacement, intra-venous fluids if dehydrated.
Directed by history, physical examination and differential diagnosis but include/consider;
FBC, EUC, Glucose, LFT, ABG, CXR, ECG, Urinalysis + Dipstick, Septic screen, Urinary Drug Screen.
CT Brain, LP, TTE.
Delirium is a favourite of the examiners. It is discussed in greater depth elsewhere ("Delirium in the ICU")
In order to simplify revision, I reproduce the salient points here:
A systematic approach to this question would resemble the following:
Urgently exclude and manage any lifethreatening aetiologies of delirium:
A) - Look for airway compromise due to decreased level of consciousness
B) - Assess for hypoxia and hypercapnea
C) - Assess for hypotension (thus cortial hypoperfusion) or hypertension (thus, hypertensive encephalopathy)
D) - Exclude hypoglycaemia and intoxication or poisoning; investigate for focal intracranial causes of delirium, such as intracranial haemorrhage or space-occupying lesion. Think about non-convulsive status epilepticus as the cause of delirium. Also consider withdrawal from alcohol and other drugs.
E) - Evaluate electrolytess, looking for hyponatremia
F) - Assess renal function, looking for uremia and dehydration
G) - Assess hepatic function, suspecting hepatic encephalopathy. Don't forget Wernicke's.
H) - Assess bone marrow function - cytopenia may be a clue to a space-occupying metastatic lesion, whereas blood film findings such as macrocytosis may suggest a chronic nutritional deficiency associated with alcoholism or IV drug abuse.
I) - Assess temperature, inflammatory markers and features of sepsis, ranging from UTI to septic shock (thinking about septic encephalopathy). Consider neurosyphilis and think about meningitis or encephalitis.
Investigation of delirium:
Stemming from the abovementioned differentials,
- Blood film
- Inflammatory markers
- CT brain
- Lumbar puncture
Management of delirium
- Good analgesia
- Clear and firm communication with the patient
- Frequent re-orientation
- Family presence
- Low-noise environment
- Restoration of hearing aids and spectacles
- Avoidance of sleep disturbance, promotion of normal sleep–wake cycle.
- Avoidance of physical restraints
- Early removal of IV lines and IDCs
- Atypical antipsychotics
- Classical antipsychotics
- Benzodiazepines (if withdrawing from alcohol or benzodiazepines)
Oh's Intensive Care manual: Chapter 49 (pp. 549) Disorders of consciousness by Balasubramanian Venkatesh
Girard, Timothy D., Pratik P. Pandharipande, and E. Wesley Ely. "Delirium in the intensive care unit." Critical Care 12.Suppl 3 (2008): S3.
Ely, E. Wesley, et al. "Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU)."Critical care medicine 29.7 (2001): 1370-1379.
O'Keeffe, SHAUN T., and JOHN N. Lavan. "Clinical significance of delirium subtypes in older people." Age and ageing 28.2 (1999): 115-119.
Barr, Juliana, et al. "Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit." Critical care medicine 41.1 (2013): 263-306.
Ouimet, Sébastien, et al. "Incidence, risk factors and consequences of ICU delirium." Intensive care medicine 33.1 (2007): 66-73.
Girard, Timothy D., et al. "Delirium as a predictor of long-term cognitive impairment in survivors of critical illness." Critical care medicine 38.7 (2010): 1513.
Hopkins, Ramona O., and James C. Jackson. "Long-term neurocognitive function after critical illness." CHEST Journal 130.3 (2006): 869-878.
van den Boogaard, Mark, et al. "Incidence and short-term consequences of delirium in critically ill patients: a prospective observational cohort study."International journal of nursing studies 49.7 (2012): 775-783.
Stevens, Robert D., Karin J. Neufeld, and Tarek Sharshar. "Delirium in the ICU: time to probe the hard questions." Crit Care 15.1 (2011): 118.
van Boogaard, M., et al. "Development and validation of PRE-DELIRIC (PREdiction of DELIRium in ICu patients) delirium prediction model for intensive care patients: observational multicentre study." BMJ: British Medical Journal344 (2012).
Van Rompaey, Bart, et al. "Risk factors for intensive care delirium: a systematic review." Intensive and Critical Care Nursing 24.2 (2008): 98-107.
Schweickert, William D., et al. "Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial."Lancet (London, England) 373.9678 (2009): 1874-1882.
Skrobik, YoannaK, et al. "Olanzapine vs haloperidol: treating delirium in a critical care setting." Intensive care medicine 30.3 (2004): 444-449.
Milbrandt, Eric B., et al. "Haloperidol use is associated with lower hospital mortality in mechanically ventilated patients*." Critical care medicine 33.1 (2005): 226-229.
Moots, R. J., et al. "Old drug, new tricks: haloperidol inhibits secretion of proinflammatory cytokines." Annals of the rheumatic diseases 58.9 (1999): 585-587.
Page, Valerie J., et al. "Effect of intravenous haloperidol on the duration of delirium and coma in critically ill patients (Hope-ICU): a randomised, double-blind, placebo-controlled trial." The Lancet Respiratory Medicine 1.7 (2013): 515-523.
Gilchrist, Neil A., Ifeoma Asoh, and Bruce Greenberg. "Atypical antipsychotics for the treatment of ICU delirium." Journal of intensive care medicine 27.6 (2012): 354-361.
Jasiak, Karalea D., et al. "Evaluation of discontinuation of atypical antipsychotics prescribed for ICU delirium." Journal of pharmacy practice 26.3 (2013): 253-256.
Inouye, Sharon K., et al. "A multicomponent intervention to prevent delirium in hospitalized older patients." New England journal of medicine 340.9 (1999): 669-676.
Girard, Timothy D., et al. "Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial." The Lancet 371.9607 (2008): 126-134.
Mehta, Sangeeta, et al. "Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol: a randomized controlled trial." JAMA 308.19 (2012): 1985-1992.
Devlin, John W., et al. "Efficacy and safety of quetiapine in critically ill patients with delirium: A prospective, multicenter, randomized, double-blind, placebo-controlled pilot study*." Critical care medicine 38.2 (2010): 419-427.
Kim, Sung‐Wan, et al. "Risperidone versus olanzapine for the treatment of delirium." Human Psychopharmacology: Clinical and Experimental 25.4 (2010): 298-302.
Grover, Sandeep, Vineet Kumar, and Subho Chakrabarti. "Comparative efficacy study of haloperidol, olanzapine and risperidone in delirium." Journal of psychosomatic research 71.4 (2011): 277-281.
Yoon, Hyung-Jun, et al. "Efficacy and safety of haloperidol versus atypical antipsychotic medications in the treatment of delirium." BMC psychiatry 13.1 (2013): 1-11.