What are the recommended strategies for preventing and managing delirium in Intensive Care Unit (ICU) patients?

From the Guidelines

Preventing and managing delirium in ICU patients requires a multifaceted approach combining non-pharmacological and pharmacological strategies, with a focus on early identification of at-risk patients and implementation of comprehensive bundles like the ABCDEF bundle. Early identification of at-risk patients through validated screening tools like CAM-ICU or ICDSC should be performed daily 1. Non-pharmacological interventions form the foundation of prevention and include:

• Maintaining normal sleep-wake cycles by reducing nighttime disruptions and providing natural light during daytime
• Early mobilization and physical therapy
• Frequent reorientation with clocks and calendars
• Ensuring patients have access to hearing aids and glasses
• Minimizing use of physical restraints
• Promoting family presence Environmental modifications such as noise reduction and maintaining appropriate room temperature are also important 1. For pharmacological management, dexmedetomidine (0.2-0.7 mcg/kg/hr) is preferred for sedation over benzodiazepines, which can worsen delirium 1. Antipsychotics like haloperidol should not be used prophylactically to prevent delirium in ICU patients, as they have been shown to have no significant effect in incidence, severity, duration, or outcome of delirium 1. Pain management with non-opioid analgesics when possible helps reduce delirium risk. Addressing underlying causes such as infections, metabolic disturbances, or medication side effects is crucial. Daily sedation interruption protocols and minimizing the duration of mechanical ventilation through spontaneous breathing trials can significantly reduce delirium incidence. Implementation of comprehensive bundles like the ABCDEF bundle has shown effectiveness in reducing delirium duration and improving outcomes 1.

From the Research

Strategies for Preventing and Managing Delirium in ICU Patients

• Non-pharmacological nursing interventions are effective in preventing and reducing the duration of delirium in ICU patients 2
• Multicomponent interventions, including the patient's family in the delirium prevention scheme, are the most promising methods in preventing delirium 2
• Light therapy can improve the patient's circadian rhythm and thus contribute to reducing the incidence of delirium 2
• The ABCDEF bundle (Assess, prevent, and manage pain; Both SAT and SBT; Choice of analgesia and sedation; Delirium: assess, prevent, and manage; Early mobility and exercise; Family engagement and empowerment) is a cornerstone of delirium management 3

Importance of Early Recognition and Prevention

• Delirium is associated with a longer duration of mechanical ventilation and ICU admittance, as well as an increased risk of death, disability, and long-term cognitive dysfunction 4
• Early recognition of delirium is important, and ICU medical staff should devote careful attention to both watching for the occurrence of delirium and its prevention and management 4
• Predisposing factors for delirium include smoking, hypertension, cardiac disease, sepsis, and premorbid dementia, while precipitating factors include respiratory failure and shock, metabolic disturbances, prolonged mechanical ventilation, pain, immobility, and sedatives 3

Effectiveness of Multifaceted Care Approaches

• Multifaceted care approaches, including care bundles, are associated with improved patient outcomes, including reduced incidence and duration of delirium, improvements in functional status, and reductions in coma and ventilator days, hospital length of stay, and/or mortality rates 5
• Implementation strategies for multifaceted care approaches include structured quality improvement approaches with ongoing audit and feedback, multidisciplinary care teams, intensive training, electronic reporting systems, and local support teams 5

Pharmacological Management of Delirium

• The current Society of Critical Care Medicine (SCCM) guidelines suggest against routine use of antipsychotics for delirium in critically ill adults 3
• A pharmacological management of delirium (PMD) bundle consisting of reducing the exposure to anticholinergic medications and benzodiazepines and prescribing low-dose haloperidol did not reduce delirium duration or severity among critically ill patients 6