Current controversies and future perspectives on treatment of intensive care unit delirium in adults

Abstract

Delirium is the most frequent manifestation of acute brain dysfunction in intensive care unit (ICU). Although antipsychotics are widely used to treat this serious complication, recent evidence has emphasized that these agents did not reduce ICU delirium (ICU-D) prevalence and did not improve survival, length of ICU or hospital stay after its occurrence. Of note, no pharmacological strategy to prevent or treat delirium has been identified, so far. In this scenario, new scientific evidences are urgently needed. Investigations on specific ICU-D subgroups, or focused on different clinical settings, and studies on medications other than antipsychotics, such as dexmedetomidine or melatonin, may represent interesting fields of research. In the meantime, because there is some evidence that ICU-D can be effectively prevented, the literature suggests strengthening all the strategies aimed at prevention through no-pharmacological approaches mostly focused on the correction of risk factors. The more appropriate strategy useful to treat established delirium remains the use of antipsychotics managed by choosing the right doses after a careful case-by-case analysis. While the evidence regarding the use of dexmedetomidine is still conflicting and sparse, this drug offers interesting perspectives for both ICU-D prevention and treatment. This paper aims to provide an overview of current pharmacological approaches of evidence-based medicine practice. The state of the art of the on-going clinical research on the topic and perspectives for future research are also addressed.

Tailored sedation in critically ill COVID-19 patients based on lung damage, and pharmacokinetic and pharmacodynamic profiles

“…Zhao et al [15] for instance, underlined the potential effect of DEX in ameliorating the SARS-CoV-2-induced cytokine storm [16]. DEX also has important anti-delirium [17] and opioid-benzodiazepinesparing properties [18].…”

Introductory Chapter: Delirium in Palliative Care

“…Even if it represents the preferred drug in the treatment of delirium, its use is limited by concern for side effects. Usually, the onset of extrapyramidal disorders is dosedependent and cardiotoxicity -QTc prolongation or torsades de pointes (with a QTc > 450-500 ms immediate drug withdrawal is recommended) -generally rarely occurs for low doses [29]. However, in patients under palliative care, many factors such as the severity of the underlying disease and organ damage, comorbidities, cachexia, hypoproteinemia, advanced age, and polytherapy can increase the risk of side effects.…”

Impact of dexmedetomidine supplemented analgesia on delirium in patients recovering from orthopedic surgery: A randomized controlled trial

“…Patients who experience postoperative delirium have worse outcomes including prolonged hospitalization, increased costs, lower odds of home discharge, more readmissions, delayed functional recovery, and increased perioperative and long-term mortality [ 4 , 5 ]. While delirium is now recognized as a serious complication, there is so far no convincing evidence that any preventive strategy is effective [ 6 ].…”