As you know, this week’s education theme at The Alfred ICU is ‘Sedation and Delirium’. As a follow up to our five tips on sedation in the ICU, here are five tips on delirium in the ICU:

Know what delirium is. Definitions may vary, however I find the DSM-IV definition useful. Delirium is a disturbance of consciousness with inattention accompanied by a change in cognition or perceptual disturbance that develops over a short period of time and fluctuates over time. Inattention is the hallmark. Importantly, delirium may present in hyperactive, hypoactive and mixed forms. Hypoactive delirium is easily missed. Delirium is bad… delirious ICU patients have worse outcomes, including higher mortality.

Definitions may vary, however I find the DSM-IV definition useful. Delirium is a disturbance of consciousness with inattention accompanied by a change in cognition or perceptual disturbance that develops over a short period of time and fluctuates over time. Inattention is the hallmark. Importantly, delirium may present in hyperactive, hypoactive and mixed forms. Hypoactive delirium is easily missed. Delirium is bad… delirious ICU patients have worse outcomes, including higher mortality. Use the Confusion Assessment Method for ICU (CAM-ICU) tool to detect delirium. It is more common than we often realise, affecting as many as 80% of ICU patients. At The Alfred ICU we perform CAM-ICU every 6 hours in patients with RASS > -2.

Seek the underlying cause, and treat it. Always assess for predisposing, precipitating and perpetuating factors – especially “pee – poo – pus – pain – poisons”. Whatever you do, don’t miss life-threatening causes of delirium (WHIP x 2): Wernickes encephalopathy, Withdrawal syndromes, Hypertensive encephalopathy, Hypoglycemia and metabolic/endocrine, Infection, Intracranial disease, Poisons, and Porphyria

Always assess for predisposing, precipitating and perpetuating factors – especially “pee – poo – pus – pain – poisons”. Whatever you do, don’t miss life-threatening causes of delirium (WHIP x 2): Use non-pharmacological measures to prevent and treat delirium. These include: Recurrent orientation of patients Early mobilisation and physiotherapy Early removal of catheters Establish day-night routine Sleep hygiene Involve family Noise control at night correct vision and hearing impairment

These include: Don’t make things worse with medications. The Alfred ICU uses a sedation protocol (including sedation interruptions, if safe to perform) to avoid excessive sedation, which is an important contributor to ICU delirium. Benzodiazepine-based ICU sedation, in particular, is associated with worse delirium. To treat symptoms of delirium, we typically use quetiapine, though the evidence that it reduces the duration of ICU delirium is weak. Also, antipsychotic and sedative agents (e.g. haloperidol and midazolam) may be required acutely for the chemical restraint of the unsafe agitated patient when verbal de-escalation fails or is inappropriate.

Check out the Sedation and Delirium SDL page for more resources and references.