From the Guidelines
Management of ICU-related delirium requires a multimodal approach combining non-pharmacological and pharmacological interventions, with a focus on prevention and early detection using validated tools like CAM-ICU or ICDSC. The approach should include early mobilization, maintaining sleep-wake cycles, minimizing noise and unnecessary interruptions, frequent reorientation, ensuring presence of familiar objects and family members, and optimizing sensory input with glasses and hearing aids 1. Addressing underlying causes is crucial, such as treating infections, correcting metabolic abnormalities, managing pain, minimizing sedation (especially benzodiazepines), and reviewing medications that might contribute to delirium.
- Key non-pharmacological interventions:
- Early mobilization to reduce the incidence and duration of delirium 1
- Maintaining sleep-wake cycles
- Minimizing noise and unnecessary interruptions
- Frequent reorientation
- Ensuring presence of familiar objects and family members
- Optimizing sensory input with glasses and hearing aids
- For pharmacological management, dexmedetomidine (0.2-0.7 mcg/kg/hr) is preferred for sedation in delirious patients as it causes less delirium than benzodiazepines 1. Antipsychotics may be used for severe agitation - haloperidol (0.5-2mg IV every 6 hours as needed) or atypical antipsychotics like quetiapine (25-50mg orally twice daily) can be effective, though evidence for mortality benefit is limited 1. Avoid benzodiazepines except in alcohol withdrawal. Regular delirium screening helps with early detection and monitoring response to interventions. This comprehensive approach is important because delirium is associated with increased mortality, longer ICU stays, and long-term cognitive impairment.
From the Research
Management Approach for ICU-Related Delirium
The management of ICU-related delirium involves a multifaceted approach that includes both non-pharmacological and pharmacological interventions.
- Non-pharmacological interventions: These are considered the cornerstone of delirium management in the ICU setting 2. The ABCDEF bundle is a widely recommended approach that includes:
- Assess, prevent, and manage pain
- Both SAT (spontaneous awakening trial) and SBT (spontaneous breathing trial)
- Choice of analgesia and sedation
- Delirium: assess, prevent, and manage
- Early mobility and exercise
- Family engagement and empowerment
- Multicomponent interventions: These have been shown to be effective in reducing the incidence of delirium in ICU patients 3, 4. Such interventions may include:
- Re-orientation (including use of familiar objects)
- Cognitive stimulation
- Sleep hygiene
- Attention to nutrition and hydration
- Oxygenation
- Medication review
- Assessment of mood and bowel and bladder care
- Pharmacological interventions: While non-pharmacological interventions are preferred, pharmacological interventions may be necessary in some cases. Atypical antipsychotics have been shown to be effective in the treatment of delirium, although their use should be carefully considered due to potential side effects 5.
- Quality improvement interventions: Implementing quality improvement interventions, such as those aimed at improving sleep-wake disruption, can also be effective in reducing delirium in ICU patients 6.
Key Considerations
- Early identification and prevention: Early identification and prevention of delirium are critical in reducing its incidence and severity.
- Individualized approach: A tailored approach to delirium management, taking into account the individual patient's needs and risk factors, is essential.
- Family engagement: Family engagement and empowerment are important components of delirium management, as they can provide emotional support and help with re-orientation and cognitive stimulation.
- Ongoing research: Further research is needed to better understand the pathobiology of ICU-related delirium and to develop more effective prevention and treatment strategies.