From the Guidelines
ICU delirium should be managed using a multimodal approach, including early mobility, maintaining day-night cycles, minimizing sedation, and ensuring adequate pain control, as recommended by the most recent guidelines 1. To manage ICU delirium, the following strategies can be implemented:
- Early mobility and physical rehabilitation to reduce the duration of mechanical ventilation and delirium
- Maintaining day-night cycles to promote normal sleep-wake cycles
- Minimizing sedation, especially benzodiazepines, which can worsen delirium
- Ensuring adequate pain control using multimodal analgesia
- Regular orientation and cognitive stimulation
- Ensuring patients have access to glasses and hearing aids
- Promoting family presence and engagement
- Using validated delirium assessment tools, such as the Confusion Assessment Method for the ICU (CAM-ICU) or the Intensive Care Delirium Screening Checklist (ICDSC) The ABCDEF bundle (Assess for pain, Both spontaneous awakening and breathing trials, Choice of sedation, Delirium monitoring, Early mobility, and Family engagement) provides a structured approach to prevention and management of ICU delirium 1, 2, 3. Pharmacological treatment of delirium should be tailored to the individual patient's needs, and haloperidol should not be used as a prophylactic treatment for delirium in ventilated patients, as it has been shown to have no effect on the incidence, severity, or duration of delirium 1. Instead, dexmedetomidine infusion at 0.2-0.7 mcg/kg/hr may be used for sedation, as it has been shown to improve delirium outcomes 2. It is essential to note that prevention of delirium is the best strategy, and a multimodal approach that includes non-pharmacological interventions, such as multimodal sensory, cognitive, and emotional stimulation, should be implemented to prevent delirium in critically ill patients 1.
From the Research
ICU Delirium Overview
- Delirium in ICU patients is a complication associated with many adverse consequences, including increased mortality, longer hospital stays, and increased odds of institutionalization after discharge 4, 5, 6.
- The cause of delirium is multifactorial, and non-pharmacological multicomponent interventions are promising strategies for delirium prevention 4, 7.
Risk Factors and Assessment
- Several risk factors contribute to the development of delirium in patients admitted to the ICU, including age, gender, types of sedation, physical restraints, medical and surgical interventions, pain, and extended stay in the ICU 6, 8.
- Commonly used assessment modules for ICU delirium include the PREdiction of DELIRium in ICu patients (PRE-DELIRIC), Early PREdiction model for DELIRium in ICu patients (E-PRE-DELERIC), and Lanzhou Model, Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), Intensive Care Delirium Screening Checklist (ICDSC), and Delirium Rating Scale (DRS) 8.
Management Strategies
- Non-pharmacological interventions, such as early mobilization, earplugs and blinds at night, music and natural sunlight during the day, continuous reorientation, and increased visitation and family participation, are essential to integrate into the treatment plan for the management of delirium in the ICU 4, 5, 6.
- The ABCDEF bundle (Assess, prevent, and manage pain; Both SAT and SBT; Choice of analgesia and sedation; Delirium: assess, prevent, and manage; Early mobility and exercise; Family engagement and empowerment) is a non-pharmacological approach that remains the cornerstone of delirium management 7, 6.
- Pharmacologic interventions, such as dexmedetomidine, are under investigation, but their impact is not yet clear 7, 6.