You are starting your pre-rounds, gathering overnight data, completing physical exams, - when as you enter the room - the Night RN tells you - 'We have a Classic Sun downer here'; Morning RN volunteer's - 'ICU Psychosis' - 'we definitely need something to keep him calm'. 2 diagnosis on the same Pt or a different take on same problem - which one do you quote during rounds (Rounds occur during daytime - so maybe Day RN?).





Prior to entering a Pt's room, you give a brief synopsis to Attending -'Intubated, weaned off vasopressors overnight, alert & interacting'. In room- situation appears different - the Pt though awake refuses to co-operate and interact - Did you mix up patients?





You feel your rounds are not up to the mark today. The Attending however appears to be in good spirit's, he is delighted to have the 2 above cases.





Everyone is rounded up, doors closed - No Escape Route - Power Point presentation switched on (you look at the list of things you have to do...you send a text - lunch date in cafeteria not possible - it's gonna be a long day).Turns out the Attending has just come back form a Conference where PADIS & ABCDEF were show stoppers.





Delirium it seems is a real problem in ICU with > 30% incidence, appears to increase ICU mortality, Length of stay, health care costs, workload of caretakers & is distressing to Family members witnessing it (with acronyms like PADIS; CAM-ICU; ABCDEF - even you are getting distressed).





It appears to involve the dopamine pathway in brain and therefore medications working on those pathways are used to treat it.Turns out there is a spectrum - 'Agitated to Apathy'(your 2 Pt's) & there is a scale to measure it 'CAM-ICU' score.





Seems good - getting interested you Bite - can we prevent it/treat it ?





Turns out there are some Fancy named studies addressing your questions (dammit - there goes your Research Idea).





HOPE-ICU in Lancet Resp Medicine Sept 2013; pp 515-523.

a single center randomized trial - 142 Critically ill Pt's on Mechanical Ventilation were randomized to receive prophylactic Haldol (71) vs placebo (71). CAM-ICU scale was used to identify delirium. The study found no difference in primary outcome of Delirium free days; the secondary outcomes - delirium days, MV days & ICU - LOS were also similar.





REDUCE Trial in JAMA Feb 20th 2018.

A multi-center trial across 21 ICU's in Netherlands.1789 Critically ill Pt's with an anticipated ICU stay of > 2 days were randomized to 1mg Haldol tid (350 Pt's) vs 2mg Haldol tid (732 Pt's) vs Placebo tid (707 Pt's). The 1 mg arm was stopped early due to futility.Primary outcome of Survival at 28 days was similar. Delirium developed equally in both arms 33% vs 30%. MV Duration & LOS were also similar.





MIND-USA in NEJM Dec 27th 2018 tried to address the question of treating Delirium. 1183 Critically ill Pt's ( in Respiratory Failure +/- Shock) were randomized across 16 center's once they developed Delirium (n=566). 184 were treated with Placebo , 192 with Haldol & 190 with Ziprasidone (an Atypical Anti psychotic). No difference in the primary endpoint of days alive without delirium was found.





So what Now: there is a real problem, a scale to measure it - it seems preventing it with medications or treating it with Medications does not work. Simple solutions like re-orientation, reducing noise level, alarms, avoiding excessive sedation(benzodiazepines esp) & of course playing music helps (Do verify the Pt's choice - playing classical to a Rock fan might have an opposite effect).





Even these do not seem to drop the level <30%; 'Houston we have a Problem' & iffy solutions at best.







