What medications can be used in the ICU for agitation and delirium?

From the Guidelines

Dexmedetomidine is the preferred medication for managing agitation and delirium in ICU patients, as it reduces the duration of delirium compared to benzodiazepines. In the ICU, several medications can effectively manage agitation and delirium. First-line agents include dexmedetomidine (0.2-1.4 mcg/kg/hr) and propofol (5-80 mcg/kg/min), which provide sedation while allowing neurological assessment 1. Benzodiazepines like midazolam (1-4 mg/hr) or lorazepam (0.5-4 mg IV q1-4h) should be used cautiously as they may worsen delirium but remain useful for alcohol withdrawal or seizures. Antipsychotics such as haloperidol (0.5-10 mg IV q2-6h), quetiapine (25-100 mg PO q12h), or olanzapine (2.5-10 mg daily) help manage delirium symptoms, although their use should be carefully considered due to potential side effects such as extrapyramidal symptoms and QT prolongation 1. For severe agitation, ketamine (0.1-0.5 mg/kg IV) provides rapid control. Non-pharmacological approaches should always complement medication, including reorientation, sleep promotion, early mobility, and family presence. The goal is to achieve light sedation (RASS -1 to +1) rather than deep sedation, as this improves outcomes. Daily sedation interruptions and regular delirium assessments using tools like CAM-ICU help optimize management. Addressing underlying causes of delirium such as pain, infection, or metabolic disturbances is essential for effective treatment.

Some key points to consider when managing agitation and delirium in the ICU include:

• Using standardized assessment tools like CAM-ICU to evaluate delirium 1
• Minimizing possible causes of delirium, including drug-induced delirium, and optimizing pain control before implementing pharmacological approaches 1
• Considering the use of haloperidol or droperidol in hyperactive or hypoactive delirium with or without hallucinations, although with caution due to potential side effects 1
• Prioritizing non-pharmacological approaches and addressing underlying causes of delirium to improve patient outcomes.

It's also important to note that atypical antipsychotics may reduce the duration of delirium in adult ICU patients, and rivastigmine is not recommended to reduce the duration of delirium in ICU patients 1. Overall, the management of agitation and delirium in the ICU requires a multifaceted approach that prioritizes patient safety, comfort, and outcomes.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Medications for Agitation and Delirium in the ICU

Medications used in the ICU for agitation and delirium include:

• Haloperidol, a neuroleptic, which is often used for rapid control of delirium and agitation 2, 3
• Benzodiazepines, such as lorazepam and midazolam, which can be used alone or in combination with haloperidol 3
• Narcotic analgesics, which may be used in patients with both agitation and pain 3
• Other antipsychotic medications, such as olanzapine, quetiapine, iloperidone, and ziprasidone, which may cause QTc prolongation 4

Considerations for Medication Use

When using these medications, it is essential to consider the following:

• The risk of QTc prolongation, which can increase the risk of ventricular arrhythmias 4
• The potential for extrapyramidal symptoms with haloperidol 3
• The need for close monitoring of the QTc interval and ECG monitoring 4
• The importance of using the lowest effective dose, especially in older patients 5

Specific Medication Recommendations

• Haloperidol is recommended as a first-line agent for rapid control of delirium and agitation 3
• Lorazepam is recommended as a first-line benzodiazepine 3
• Midazolam is suitable for administration by continuous IV infusion in the ICU setting 3
• Aripiprazole and lurasidone may have a lower risk of QTc prolongation compared to other antipsychotics 4