ICU Delerium

Links:

Guidelines:
Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

Protocol:
Delerium Protocol (PDF figure)

Delirium can be HYPO or HYPERactive.  Both lead to longer and more complicated hospitalizations as well as long-term sequelae.  Patients who develop delirium are at risk for having the equivalent of Alzheimer’s or TBI cognitive deficits 1 year out of discharge from an ICU.  Be alert for hypoactive delirium

  • Initial considerations
    • safety – do you need chemical or physical restraints
    • look for the underlying cause!
    • consider repeating blood cultures, chest X-ray, UA, basic labs, head scanning, LP, EEG
    • nonpharm/nonrestraint interventions
      • frequent reorientation
      • family at the bedside, a sitter (if available)
      • lights on during the day (natural light), off at night, minimize nighttime interruptions
      • human touch (massage, ideally)
    • Minimize deliriogenic meds (anticholinergic meds, benzodiazepines, medications with GABA activity)
    • Chemical before physical restraints, discontinue physical restraints ASAP (consider dexmedetiomidine)
    • assess – with baseline CAM-ICU and reassess regularly

COMABATIVE/AGITATED/DELIRIOUS PATIENT

  • Safety – of patient and staff – number 1 priority
    • Is the environment safe? do you need to involve security?
  • Goal
    • Calm without over-sedating
  • Assess for cause of agitation
    • secondary to AMS? a PEC they disagree with?
    • workup for AMS
    • do you need to reassess capacity/involve psychiatry?
  • Treatment
    • Nonpharm measures – verbal de-escalation
    • Chemical before physical restraints – always try PO first
    • Restraints
      • Assess for discontinuation of restraints often. Close nursing monitoring is required of all restrained patients. 1:1 sitter is required
Agent Dose Half-life Precautions
Dexmedetomidine 1 mcg/kg over 10 min 1.8 – 3.1 hr Bradycardia, loss of airway reflexes, rebound hypertension when discontinued
0.2 – 0.7 mcg/kg/hr
Haloperidol 1 – 40 mg IVP 21 – 24 hr QTc prolongation, extrapyramidal symptoms
Quetipine 12.5 – 200mg po 6 – 7 hr QTc prolongation, extrapyramidal symptoms
Olanzapine 2.5 – 20mg po (there is an orally disintegrating option) 21 – 54 hr QTc prolongation and sedation, extrapyramidal symptoms
Aripiprazole 10 – 30mg po 75 hr Extrapyramidal symptoms
9.75mg IM
  • Avoid benzodiazepines unless patient is in alcohol or benzodiazepine withdrawal. Benzodiazepines should never be your first choice for a combative patient.
  • Different antipsychotics prolong QTc to different degrees: olanzapine < risperidone < quetiapine < haloperidol
  • QTc prolongation – most dangerous risk is for Torsades de pointes (2 hit hypothesis – long QT + another risk for arrhythmia = increased risk)
  • Discontinue antipsychotics if QTc > 500 or increases by > 25%
    • Monitor baseline and 24 hours after initiation of meds
    • Be aware of other meds that prolong the QT interval (Zofran, Antibiotics, Antihistamines, Amiodarone, Albuterol, SSRIs)
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