What is the first line of management for Intensive Care Unit (ICU) delirium?

First-Line Management of ICU Delirium

Early mobilization of adult ICU patients is the first-line non-pharmacological intervention recommended to reduce the incidence and duration of delirium, followed by dexmedetomidine for sedation when required in patients with delirium unrelated to alcohol or benzodiazepine withdrawal. 1

Non-Pharmacological Interventions

Non-pharmacological interventions should be implemented first due to their effectiveness and safety profile:

• Early mobilization - Implement whenever feasible as it significantly reduces delirium incidence and duration, shortens ICU and hospital length of stay, and increases ventilator-free days 1

• Sleep promotion - Optimize the patient's environment by:

  • Controlling light and noise
  • Clustering patient care activities
  • Decreasing nighttime stimuli to protect sleep cycles 1

• Cognitive stimulation and reorientation - Provide:

  • Continuous reorientation
  • Use of familiar objects
  • Cognitive engagement activities 2, 3

• Environmental modifications:

  • Ensure adequate lighting during daytime
  • Reduce sensory deprivation
  • Facilitate family visitation when possible 2, 4

• Systematic delirium screening - Use validated tools such as:

  • Confusion Assessment Method for ICU (CAM-ICU)
  • ICU Delirium Screening Checklist (ICDSC) 1

Pharmacological Management

When non-pharmacological interventions are insufficient and sedation is required:

• Dexmedetomidine is preferred over benzodiazepines for sedation in delirious ICU patients (except in cases of alcohol or benzodiazepine withdrawal) 1

  • Mechanically ventilated patients at risk for delirium have lower delirium prevalence when treated with dexmedetomidine rather than benzodiazepines 1

• Avoid benzodiazepines when possible as they may be a risk factor for developing delirium 1

• Analgesia-first sedation approach is recommended to manage pain before using sedatives 1

• Maintain light levels of sedation through either:

  • Daily sedation interruption
  • Titration of sedative medications 1

Antipsychotic Considerations

• No strong evidence supports haloperidol for reducing delirium duration 1

• Atypical antipsychotics may reduce delirium duration but evidence is limited 1

• Do not use antipsychotics prophylactically to prevent delirium 1

• Avoid antipsychotics in patients with:

  • Baseline QT prolongation
  • History of Torsades de Pointes
  • Concurrent medications known to prolong QT interval 1

• Do not use rivastigmine to reduce delirium duration 1

Multicomponent Approach

The most effective delirium prevention strategies combine multiple interventions:

• Use sedation protocols and daily checklists to integrate management of pain, agitation, and delirium 1

• The most effective combination of interventions includes sleep promotion, cognitive stimulation, early mobilization, pain control, and regular assessment 3

Pitfalls and Caveats

• Failure to identify and address underlying causes of delirium (pain, hypoxemia, low cardiac output, sepsis) can prolong its duration 1

• Overreliance on pharmacological interventions without addressing modifiable environmental factors may worsen outcomes 2, 4

• Benzodiazepines should be used cautiously except in alcohol or benzodiazepine withdrawal delirium 1

• Regular monitoring for delirium using validated tools is essential for early detection and intervention 1

• Delirium is associated with increased mortality, prolonged ICU and hospital length of stay, and post-ICU cognitive impairment, making prevention crucial 1