Delirium Management in the ICU

Abstract

Purpose of review Delirium occurs frequently in critically ill patients and is associated with adverse outcomes in both the short and long term. In this review, we aim to highlight recent study findings on the prevention and treatment of delirium, provide additional recommendations based on expert guidelines, and indicate knowledge gaps deserving of future study. Recent findings Multicomponent non-pharmacologic interventions have been shown to be efficacious in non-ICU populations, and multicomponent strategies such as the ABCDEF bundle have been adopted in the ICU with several studies showing a potential benefit in delirium outcomes. Meanwhile, two negative randomized clinical trials of antipsychotics in ICU patients (REDUCE and MIND-USA) have provided strong evidence that such medications neither prevent nor shorten the duration of delirium. Other potential pharmacologic treatments with promising results include dexmedetomidine and, to a lesser extent, ramelteon, but more data is needed before they may be more definitively recommended. Summary Effective and proven delirium management strategies are still largely lacking, though there is evidence to support the use of some non-pharmacologic interventions. Future studies of novel non-pharmacologic interventions and pharmacologic agents other than antipsychotics are warranted.

Effect of early cognitive interventions on delirium in critically ill patients: a systematic review

“…In general, pharmacologic management has not been proven to prevent or shorten the duration of delirium in critically ill patients; in fact, evidence shows certain medication classes should be avoided because of the risk of potentiating delirium (e.g., benzodiazepines, anticholinergics, tricyclic antidepressants, and first generation antihistamines). 11,12 While antipsychotic medications have no proven efficacy, dexmedetomidine may decrease the duration of delirium when compared with placebo in mechanically ventilated patients with agitated delirium. 12,13 Table 1 Components of cognitive interventions…”

“…11,12 While antipsychotic medications have no proven efficacy, dexmedetomidine may decrease the duration of delirium when compared with placebo in mechanically ventilated patients with agitated delirium. 12,13 Table 1 Components of cognitive interventions…”

“…40 Specific interventions such as minimizing restraint use, reducing noise, increasing daylight exposure, and promoting orientation and sleep are non-pharmacologic options for delirium prevention as part of a multimodal bundle. 12 The application of individual components of delirium prevention bundles in critically ill patients (specifically early physical and occupational therapy with a focus on functional mobility and activities of daily living) have shortened the duration of delirium. 23 Notably, it has been deemed safe and feasible to conduct physiotherapy even on patients receiving advanced life support treatments such as extracorporeal membrane oxygenation.…”

Pharmacokinetics of Haloperidol in Critically Ill Patients: Is There an Association with Inflammation?

“…Delirium is quite common in intensive care unit (ICU) patients and is associated with poor clinical prognosis [ 1 , 2 , 3 , 4 , 5 ]. Currently the treatment of delirium may include pharmacological agents, including antipsychotics, melatonin, alpha-2 agonists (dexmedetomidine and clonidine), next to nonpharmacological interventions [ 6 , 7 , 8 ]. Among antipsychotics, haloperidol is the most commonly used.…”

Barriers and facilitators of early mobilisation for intensive care unit delirium: perspectives from patients, family members and carers. A qualitative study protocol

“…For the purpose of this study, early mobilisation will be defined as mobilisation such as in or out of bed physical activities, initiated as early as possible during ICU admission (Parry, et al, 2016). Evidence has demonstrated early mobilisation is an efficacious, safe and achievable intervention for mechanically ventilated patients (Hayhurst, Pandharipande and Hughes, 2016;Reznik and Slooter, 2019). Despite this evidence and the clinical practice guidelines concerning early mobilisation, application of early mobilisation remains infrequent (Sibilla et al, 2020;Fontela et al, 2018;Jolley et al, 2017).…”