Management of ICU Delirium (Not "ICU Psychosis")
The term "ICU psychosis" should be abandoned—this is delirium, a medical emergency requiring multicomponent nonpharmacologic interventions as first-line management, with early mobilization being the most critical intervention. 1, 2
First-Line Nonpharmacologic Management
Implement a multicomponent bundle focused on modifiable risk factors, with early mobilization as the cornerstone intervention. 3, 1
Core Interventions (in order of priority):
Early mobilization and rehabilitation should be performed whenever feasible—this is the single most effective intervention, reducing both delirium incidence and duration while shortening ICU/hospital length of stay and increasing ventilator-free days 3, 1, 2
Optimize sleep-wake cycles by minimizing light and noise at night, clustering care activities to avoid nighttime interruptions, and ensuring adequate daytime lighting 3, 1, 2
Cognitive stimulation and reorientation using clocks, calendars, familiar objects, and repeated orientation to time/place/person 3, 1
Restore sensory function by ensuring patients have access to hearing aids and eyeglasses 3, 1
Systematic delirium screening using validated tools (CAM-ICU or ICDSC) for all adult ICU patients to enable early detection 1, 2
The evidence supporting multicomponent bundles is robust: the ABCDEF bundle (Assessment of pain, Both spontaneous awakening and breathing trials, Choice of sedation, Delirium monitoring, Early mobilization, Family engagement) demonstrated reduced mortality and more ICU days without coma or delirium in multicenter studies. 3
Sedation Strategy
Target light sedation (RASS -2 to +1) using daily sedation interruption or light sedation protocols in all mechanically ventilated patients. 3, 1, 2
Use dexmedetomidine rather than benzodiazepines for sedation in mechanically ventilated patients with delirium unrelated to alcohol or benzodiazepine withdrawal—this reduces delirium duration 3, 1, 2
Minimize or avoid benzodiazepines entirely as they are a modifiable risk factor for developing delirium 1, 2
Implement analgesia-first sedation—treat pain adequately before administering sedatives 3, 1, 2
Avoid dexmedetomidine loading doses in hemodynamically unstable patients 2
Pharmacologic Treatment of Established Delirium
Do not routinely use haloperidol, atypical antipsychotics, or statins to treat delirium—there is no compelling evidence these reduce delirium duration, ICU length of stay, or mortality. 3, 1, 2
Antipsychotic Considerations:
Haloperidol has no published evidence demonstrating it reduces delirium duration in ICU patients 3, 1
Atypical antipsychotics (quetiapine, ziprasidone, olanzapine) may reduce delirium duration based on limited evidence, but this is weak (grade C) 3, 1, 2
Short-term use of haloperidol or atypical antipsychotics may be warranted in select patients with severe agitation that poses safety risks, despite lack of evidence for routine use 3
Avoid antipsychotics in patients with baseline QTc prolongation, history of torsades de pointes, or concurrent QT-prolonging medications 3, 1
What NOT to Use:
Never use rivastigmine—a multicenter trial was stopped early for futility and potential harm, showing longer and more severe delirium with increased mortality trend 3, 2
Do not use antipsychotics prophylactically to prevent delirium—no compelling data support this practice 3, 1
Critical Pitfalls to Avoid
Never abruptly discontinue sedatives after prolonged use (>several days)—taper over several days to prevent withdrawal symptoms including agitation, seizures, and rebound delirium 3, 2
Avoid lorazepam continuous infusions due to propylene glycol toxicity risk 2
Do not overlook underlying organic causes—delirium is a symptom requiring identification of metabolic disturbances, infections, medications, or other physiologic derangements 1, 2, 4
Recognize that hypoactive ("quiet") delirium is more common than hyperactive delirium and is grossly underrecognized—systematic screening is essential 4
Risk Stratification
Four baseline factors significantly predict ICU delirium: preexisting dementia, history of hypertension, history of alcoholism, and high severity of illness at admission. Coma is an independent risk factor. 2
Clinical Significance
Delirium is associated with 10% increased risk of death per day of delirium (after adjusting for covariates), prolonged mechanical ventilation, increased ICU and hospital length of stay, higher costs, and long-term post-ICU cognitive impairment. 3, 1, 2, 4 This makes prevention through nonpharmacologic interventions paramount, as pharmacologic treatment options remain limited and largely ineffective.