Description
The management of ICU delirium involves a combination of preventive strategies, such as early mobilization, minimizing sedation, and addressing underlying medical causes, to reduce the risk and severity of delirium in critically ill patients. Treatment includes optimizing the patient's environment, using non-pharmacological interventions, and, if necessary, medications to manage symptoms while focusing on long-term cognitive recovery.
Summary Listen
- ICU delirium is often underestimated due to the focus on other apparent critical issues. It differs significantly from delirium seen in normal wards or OPD settings. Two key takeaways: actively look for delirium in every patient and recognize that ICU delirium presents uniquely. Delirium is typically categorized as hyperactive, hypoactive, or mixed, with fluctuating cognition being a hallmark. Baseline diseases can mask or complicate the diagnosis.
- Hyperactive delirium is more easily recognized due to agitation and restlessness. Hypoactive delirium, characterized by reduced psychomotor activity, is often missed but associated with poorer outcomes. The incidence of delirium in ICUs varies widely (14-84%), averaging around 30-32% in general ICUs, but can escalate to 70-80% in specialized units like burns or cardiothoracic ICUs.
- Sleep and delirium are interconnected, with sleep deprivation potentially triggering delirium and delirium disrupting sleep. Neurotransmitter imbalances, particularly low acetylcholine and high dopamine, are implicated. Pharmacological sleep induction using agents like benzodiazepines doesn't always result in restorative sleep patterns (slow wave sleep and REM cycles).
- Benzodiazepines are effective in treating delirium linked to alcohol withdrawal only, and may even be risk factors for other delirium types. Regular delirium assessment is crucial, ideally daily, using validated tools like the CAM-ICU score. This score has a good negative predictive value, helping to rule out delirium.
- Managing ICU delirium involves identifying risk factors, comorbidities, and underlying causes. Electrolyte imbalances, infections, and medications (especially anticholinergics) should be addressed. If the cause remains unexplained, delirium is diagnosed by exclusion. Treatment depends on the risk of parkinsonism, with atypical neuroleptics (quetiapine) preferred when the risk is low. In emergencies, haloperidol may be used cautiously.
- Dexmedetomidine and clonidine can be used for both treating and preventing delirium. Sedation holidays are debated but involve periodically interrupting sedation to assess baseline neurology. Non-pharmacological interventions are important, including maintaining a clock, ensuring daylight exposure, minimizing alarms, music therapy, interactive activities, and maintaining adequate hydration. Early mobility and caregiver involvement also help.
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