From the Guidelines
Delirium in the ICU should be managed primarily with non-pharmacological approaches, but when medications are necessary, dexmedetomidine is the preferred first-line agent due to its minimal respiratory depression and shorter duration of mechanical ventilation. The use of dexmedetomidine for sedation in critically ill, mechanically ventilated adults is supported by the most recent guidelines 1.
Key Considerations
- Antipsychotics like haloperidol or atypical antipsychotics such as quetiapine can be used for agitation, but should be administered at the lowest effective dose for the shortest duration possible, as there is no strong evidence to support their use in reducing the duration of delirium 1.
- Benzodiazepines like lorazepam should generally be avoided except in alcohol withdrawal delirium, as they can worsen delirium in other contexts.
- For sleep promotion, melatonin may be beneficial, but its use should be individualized based on patient needs and response.
- It's crucial to identify and treat underlying causes of delirium, maintain normal sleep-wake cycles, provide early mobilization, ensure adequate pain control, and minimize use of physical restraints.
Medication Recommendations
- Dexmedetomidine: 0.2-0.7 mcg/kg/hr for sedation in mechanically ventilated adults.
- Haloperidol: 0.5-2 mg IV every 6 hours for agitation, if necessary.
- Quetiapine: 25-50 mg twice daily for agitation, if necessary.
- Melatonin: 3-10 mg at night for sleep promotion, if necessary.
Monitoring and Assessment
Regular reassessment using validated tools like CAM-ICU is essential to monitor response to interventions and adjust treatment accordingly 1. These medications work through various mechanisms including modulation of neurotransmitters like GABA, dopamine, and norepinephrine, which helps restore normal brain function disrupted during delirium.
From the Research
Delirium ICU Medications
- Delirium in the ICU is characterized by a disturbance of consciousness with accompanying change in cognition, and is extremely common amongst mechanically ventilated patients 2.
- The presence of delirium has important prognostic implications, including a 2.5-fold increase in short-term mortality and a 3.2-fold increase in 6-month mortality 2.
- Pharmacological treatment for delirium traditionally includes haloperidol, however, more data is needed to test its efficacy in the ICU 2.
- Second-generation antipsychotics have emerged as an alternative for the treatment of delirium, and may have a better safety profile 2.
- Dexmedetomidine may prove to be a valuable adjunctive agent for patients with delirium in the ICU 2.
Current Guidelines and Recommendations
- The current Society of Critical Care Medicine (SCCM) guidelines suggest against routine use of antipsychotics for delirium in critically ill adults 3.
- Nonpharmacologic interventions, such as the ABCDEF bundle, remain the cornerstone of delirium management 3, 4, 5.
- The ABCDEF bundle includes assessing and managing pain, both spontaneous awakening trials (SAT) and spontaneous breathing trials (SBT), choice of analgesia and sedation, delirium assessment and management, early mobility and exercise, and family engagement and empowerment 3.
Pharmacologic Management
- A retrospective study of delirious adult ICU patients found that half of patients received pharmacologic treatment for delirium, including 45.4% receiving antipsychotics 6.
- Haloperidol, olanzapine, and quetiapine were associated with greater odds of continued delirium and increased hazard of in-hospital mortality, while quetiapine showed a decreased hazard of in-hospital mortality 6.
- The study suggests that pharmacologic interventions for management of ICU delirium may not portend benefit, may introduce additional harm, and should be used with caution 6.
- Other potential pharmacologic treatments with promising results include dexmedetomidine and ramelteon, but more data is needed before they may be more definitively recommended 4.