विवरण
Delirium in critical care requires prompt recognition and management due to its association with poor patient outcomes. Multidisciplinary collaboration is essential for effective delirium management in the critical care setting. The use of validated delirium assessment tools, such as the Confusion Assessment Method for ICU (CAM-ICU), aids in early detection. Identifying and addressing underlying causes, such as infections, medication interactions, and metabolic imbalances, is crucial in managing delirium. Non-pharmacological interventions, including maintaining a consistent environment and promoting sleep, can help prevent and manage delirium. When pharmacological intervention is necessary, low-dose antipsychotics like haloperidol or quetiapine are commonly used. However, caution should be exercised with antipsychotic use, especially in elderly patients, due to the risk of adverse effects. Dexmedetomidine, an alpha-2 adrenergic agonist, has shown promise in managing delirium while promoting sedation and analgesia. Regularly reassessing the patient's cognitive status and delirium risk factors is essential to tailor management strategies.
सारांश
- Delirium, a temporary change in attention, awareness, and cognition, affects a significant portion of ICU patients, particularly those on ventilators. It is characterized by fluctuating mental status, inattention, psychomotor disturbance, cognitive impairment, and disorganized thinking.
- Risk factors for delirium are categorized as premorbid, related to present illness, and post-admission. Non-modifiable risk factors include advanced age and dementia history, while modifiable ones include low education, comorbidities, visual/hearing impairment, depression, and substance abuse. Surgical stress, illness severity, sepsis, and electrolyte imbalances also contribute.
- Post-admission factors encompass pain, infection, immobility, metabolic abnormalities, prolonged ICU stay, and blood transfusions. Excessive opioid use, polypharmacy, sleep deprivation, lack of communication, deep sedation, invasive devices, and physical restraints exacerbate the risk.
- Delirium recognition is crucial for preventing adverse outcomes, and missing it can mask underlying issues. The Confusion Assessment Method for ICU (CAM-ICU) is favored over the Intensive Care Delirium Screening Checklist (ICDSC) due to its higher specificity.
- The pathophysiology of delirium involves neurological factors, mental impairment, comorbidities, medical abnormalities, and withdrawal from substances. Pain, sleep deprivation, noise, excessive sedation, and elements of routine ICU care contribute.
- Imbalances in neurotransmitters like choline, GABA, cortisol, glutamate, and serotonin underlie the cognitive, psychomotor, emotional, and attentional disturbances. The "PINCH ME" mnemonic aids in identifying potential causes: Pain, Infection, Nutrition, Constipation, Hydration, Medication, and Environment.
- Delirium differs from dementia in its abrupt onset, fluctuating course, and duration. Attention, sleep-wake cycle, alertness, orientation, behavior, speech, thoughts, and hallucinations distinguish the two conditions. Types of delirium include hyperactive, hypoactive, and mixed, with mixed delirium associated with worse outcomes.
- Non-pharmacological approaches, such as removing risk factors, optimizing blood pressure and water balance, and managing acidemia, are crucial. Early mobilization, sepsis control, and avoiding prolonged mechanical ventilation are vital. The ABCDEF bundle encompasses Pain management, Breathing trials, Choice of sedation, Delirium monitoring, Early mobilization, and Family engagement.
- Although several medications like dexmedetomidine, haloperidol, and atypical antipsychotics have been studied, none have shown consistent mortality benefits or effectively prevented delirium in ICU patients. Dexmedetomidine initially showed promise but subsequent trials did not confirm its effectiveness.
- The Society of Critical Care Medicine guidelines conditionally recommend propofol over benzodiazepines for sedation. Major trials assessing various medications have yielded mixed results, with some showing temporary improvements but lacking long-term benefits. Emerging trends involve exploring acetaminophen, valproic acid, gabapentin, pregabalin, clonidine, and baclofen, but evidence remains limited.
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