open access

Vol 50, No 2 (2018)
Review articles
Published online: 2018-06-11
Submitted: 2018-03-25
Accepted: 2018-04-30
Get Citation

ICU delirium ― a diagnostic and therapeutic challenge in the intensive care unit

Katarzyna Kotfis, Annachiara Marra, Eugene Wesley Ely
DOI: 10.5603/AIT.a2018.0011
·
Pubmed: 29882581
·
Anaesthesiol Intensive Ther 2018;50(2):160-167.

open access

Vol 50, No 2 (2018)
Review articles
Published online: 2018-06-11
Submitted: 2018-03-25
Accepted: 2018-04-30

Abstract

ICU delirium is a common medical problem occurring in patients admitted to the intensive care units (ICUs). Studies
have shown that ICU delirium is associated with increased mortality, prolonged hospitalization, prolonged mechanical
ventilation, costs and the occurrence of cognitive disoders after discharge from ICU.
The tools available for ICU delirium screening and diagnosis are validated tests available for all members if the medical
team (physicians, nurses, physiotherapists). Their use for routine patient assessment is recommended by international
medical and scientific societies. They have been implemented as Pain, Agitation, Delirium (PAD) Guidelines by the
Society of Critical Care Medicine. Apart from monitoring, a strategy of prevention and treatment is recommended,
based on non-pharmacological approach (restoration of senses, early mobilization, physiotherapy, improvement in
sleep hygiene and family involvement) as well as pharmacological treatment (typical and atypical antipsychotics
and dexmedetomidine). In this article, we present the risk factors of ICU delirium, available tools for monitoring, as
well as options for prevention and treatment of delirium that can be used to improve care over critically ill patients.

Abstract

ICU delirium is a common medical problem occurring in patients admitted to the intensive care units (ICUs). Studies
have shown that ICU delirium is associated with increased mortality, prolonged hospitalization, prolonged mechanical
ventilation, costs and the occurrence of cognitive disoders after discharge from ICU.
The tools available for ICU delirium screening and diagnosis are validated tests available for all members if the medical
team (physicians, nurses, physiotherapists). Their use for routine patient assessment is recommended by international
medical and scientific societies. They have been implemented as Pain, Agitation, Delirium (PAD) Guidelines by the
Society of Critical Care Medicine. Apart from monitoring, a strategy of prevention and treatment is recommended,
based on non-pharmacological approach (restoration of senses, early mobilization, physiotherapy, improvement in
sleep hygiene and family involvement) as well as pharmacological treatment (typical and atypical antipsychotics
and dexmedetomidine). In this article, we present the risk factors of ICU delirium, available tools for monitoring, as
well as options for prevention and treatment of delirium that can be used to improve care over critically ill patients.

Get Citation

Keywords

delirium, CAM-ICU, monitoring, critical care, ICU

About this article
Title

ICU delirium ― a diagnostic and therapeutic challenge in the intensive care unit

Journal

Anaesthesiology Intensive Therapy

Issue

Vol 50, No 2 (2018)

Pages

160-167

Published online

2018-06-11

DOI

10.5603/AIT.a2018.0011

Pubmed

29882581

Bibliographic record

Anaesthesiol Intensive Ther 2018;50(2):160-167.

Keywords

delirium
CAM-ICU
monitoring
critical care
ICU

Authors

Katarzyna Kotfis
Annachiara Marra
Eugene Wesley Ely

References (61)
  1. Ely EW, Shintani A, Truman B, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA. 2004; 291(14): 1753–1762.
  2. Girard TD, Jackson JC, Pandharipande PP, et al. Delirium as a predictor of long-term cognitive impairment in survivors of critical illness. Crit Care Med. 2010; 38(7): 1513–1520.
  3. Pandharipande PP, Girard TD, Jackson JC, et al. BRAIN-ICU Study Investigators. Long-term cognitive impairment after critical illness. N Engl J Med. 2013; 369(14): 1306–1316.
  4. Kotfis K, Zegan-Barańska M, Żukowski M, et al. Multicenter assessment of sedation and delirium practices in the intensive care units in Poland - is this common practice in Eastern Europe? BMC Anesthesiol. 2017; 17(1): 120.
  5. Morandi A, Piva S, Ely EW, et al. Worldwide Survey of the "Assessing Pain, Both Spontaneous Awakening and Breathing Trials, Choice of Drugs, Delirium Monitoring/Management, Early Exercise/Mobility, and Family Empowerment" (ABCDEF) Bundle. Crit Care Med. 2017; 45(11): e1111–e1122.
  6. Carrothers KM, Barr J, Spurlock B, et al. American College of Critical Care Medicine. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013; 41(1): 263–306.
  7. Baron R, Binder A, Biniek R, et al. DAS-Taskforce 2015. Evidence and consensus based guideline for the management of delirium, analgesia, and sedation in intensive care medicine. Revision 2015 (DAS-Guideline 2015) - short version. Ger Med Sci. 2015; 13: Doc19.
  8. Vincent JL, Shehabi Y, Walsh TS, et al. Comfort and patient-centred care without excessive sedation: the eCASH concept. Intensive Care Med. 2016; 42(6): 962–971.
  9. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th edition. Washington, D.C., American Psychiatric Association, 2013.
  10. Peterson JF, Pun BT, Dittus RS, et al. Delirium and its motoric subtypes: a study of 614 critically ill patients. J Am Geriatr Soc. 2006; 54(3): 479–484.
  11. Card E, Pandharipande P, Tomes C, et al. Emergence from general anaesthesia and evolution of delirium signs in the post-anaesthesia care unit. Br J Anaesth. 2015; 115(3): 411–417.
  12. Salluh JI, Soares M, Teles JM, et al. Delirium Epidemiology in Critical Care Study Group. Delirium epidemiology in critical care (DECCA): an international study. Crit Care. 2010; 14(6): R210.
  13. Robinson TN, Raeburn CD, Tran ZV, et al. Motor subtypes of postoperative delirium in older adults. Arch Surg. 2011; 146(3): 295–300.
  14. Marra A, Ely EW, Pandharipande PP, et al. The ABCDEF Bundle in Critical Care. Crit Care Clin. 2017; 33(2): 225–243.
  15. Hayhurst CJ, Pandharipande PP, Hughes CG. Intensive Care Unit Delirium: A Review of Diagnosis, Prevention, and Treatment. Anesthesiology. 2016; 125(6): 1229–1241.
  16. Vasilevskis EE, Han JH, Hughes CG, et al. Epidemiology and risk factors for delirium across hospital settings. Best Pract Res Clin Anaesthesiol. 2012; 26(3): 277–287.
  17. Jones RN, Fong TG, Metzger E, et al. Aging, brain disease, and reserve: implications for delirium. Am J Geriatr Psychiatry. 2010; 18(2): 117–127.
  18. Vaurio LE, Sands LP, Wang Y, et al. Postoperative delirium: the importance of pain and pain management. Anesth Analg. 2006; 102(4): 1267–1273.
  19. Pandharipande PP, Pun BT, Herr DL, et al. Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial. JAMA. 2007; 298(22): 2644–2653.
  20. Van Rompaey B, Schuurmans MJ, Shortridge-Baggett LM, et al. Risk factors for intensive care delirium: a systematic review. Intensive Crit Care Nurs. 2008; 24(2): 98–107.
  21. Riker RR, Shehabi Y, Bokesch PM, et al. SEDCOM (Safety and Efficacy of Dexmedetomidine Compared With Midazolam) Study Group. Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial. JAMA. 2009; 301(5): 489–499.
  22. Steinberg BE, Sundman E, Terrando N, et al. Neural Control of Inflammation: Implications for Perioperative and Critical Care. Anesthesiology. 2016; 124(5): 1174–1189.
  23. Schreiber MP, Colantuoni E, Bienvenu OJ, et al. Corticosteroids and transition to delirium in patients with acute lung injury. Crit Care Med. 2014; 42(6): 1480–1486.
  24. Flacker JM, Lipsitz LA. Neural mechanisms of delirium: current hypotheses and evolving concepts. J Gerontol A Biol Sci Med Sci. 1999; 54(6): B239–B246.
  25. Hshieh TT, Fong TG, Marcantonio ER, et al. Cholinergic deficiency hypothesis in delirium: a synthesis of current evidence. J Gerontol A Biol Sci Med Sci. 2008; 63(7): 764–772.
  26. Luetz A, Heymann A, Radtke FM, et al. Different assessment tools for intensive care unit delirium: which score to use? Crit Care Med. 2010; 38(2): 409–418.
  27. Ely EW, Inouye SK, Bernard GR, et al. Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA. 2001; 286(21): 2703–2710.
  28. Bergeron N, Dubois MJ, Dumont M, et al. Intensive Care Delirium Screening Checklist: evaluation of a new screening tool. Intensive Care Med. 2001; 27(5): 859–864.
  29. Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med. 1990; 113(12): 941–948.
  30. Gusmao-Flores D, Salluh JI, Chalhub RÁ, et al. The confusion assessment method for the intensive care unit (CAM-ICU) and intensive care delirium screening checklist (ICDSC) for the diagnosis of delirium: a systematic review and meta-analysis of clinical studies. Crit Care. 2012; 16(4): R115.
  31. Brummel NE, Vasilevskis EE, Han JHo, et al. Implementing delirium screening in the ICU: secrets to success. Crit Care Med. 2013; 41(9): 2196–2208.
  32. van den Boogaard M, Slooter AJC, Brüggemann RJM, et al. REDUCE Study Investigators. Effect of Haloperidol on Survival Among Critically Ill Adults With a High Risk of Delirium: The REDUCE Randomized Clinical Trial. JAMA. 2018; 319(7): 680–690.
  33. Hakim SM, Othman AI, Naoum DO. Early treatment with risperidone for subsyndromal delirium after on-pump cardiac surgery in the elderly: a randomized trial. Anesthesiology. 2012; 116(5): 987–997.
  34. Sauër AMC, Slooter AJC, Veldhuijzen DS, et al. Intraoperative dexamethasone and delirium after cardiac surgery: a randomized clinical trial. Anesth Analg. 2014; 119(5): 1046–1052.
  35. Liptzin B, Laki A, Garb JL, et al. Donepezil in the prevention and treatment of post-surgical delirium. Am J Geriatr Psychiatry. 2005; 13(12): 1100–1106.
  36. Gamberini M, Bolliger D, Lurati Buse GA, et al. Rivastigmine for the prevention of postoperative delirium in elderly patients undergoing elective cardiac surgery--a randomized controlled trial. Crit Care Med. 2009; 37(5): 1762–1768.
  37. Page VJ, Davis D, Zhao XB, et al. Statin use and risk of delirium in the critically ill. Am J Respir Crit Care Med. 2014; 189(6): 666–673.
  38. Morandi A, Hughes CG, Thompson JL, et al. Statins and delirium during critical illness: a multicenter, prospective cohort study. Crit Care Med. 2014; 42(8): 1899–1909.
  39. Shehabi Y, Grant P, Wolfenden H, et al. Prevalence of delirium with dexmedetomidine compared with morphine based therapy after cardiac surgery: a randomized controlled trial (DEXmedetomidine COmpared to Morphine-DEXCOM Study). Anesthesiology. 2009; 111(5): 1075–1084.
  40. Pandharipande PP, Pun BT, Herr DL, et al. Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial. JAMA. 2007; 298(22): 2644–2653.
  41. Riker RR, Shehabi Y, Bokesch PM, et al. SEDCOM (Safety and Efficacy of Dexmedetomidine Compared With Midazolam) Study Group. Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial. JAMA. 2009; 301(5): 489–499.
  42. Djaiani G, Silverton N, Fedorko L, et al. Dexmedetomidine versus propofol sedation reduces delirium after cardiac surgery: a randomized controlled trial. Anesthesiology. 2016; 124(2): 362–368.
  43. Strøm T, Martinussen T, Toft P. A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial. Lancet. 2010; 375(9713): 475–480.
  44. Patel SB, Poston JT, Pohlman A, et al. Rapidly reversible, sedation-related delirium versus persistent delirium in the intensive care unit. Am J Respir Crit Care Med. 2014; 189(6): 658–665.
  45. Morandi A, Brummel NE, Ely EW. Sedation, delirium and mechanical ventilation: the 'ABCDE' approach. Curr Opin Crit Care. 2011; 17(1): 43–49.
  46. Balas MC, Vasilevskis EE, Olsen KM, et al. Implementing the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle into everyday care: opportunities, challenges, and lessons learned for implementing the ICU Pain, Agitation, and Delirium Guidelines. Crit Care Med. 2013; 41(9 Suppl 1): S116–S127.
  47. Barnes-Daly MA, Phillips G, Ely EW. Improving Hospital Survival and Reducing Brain Dysfunction at Seven California Community Hospitals: Implementing PAD Guidelines Via the ABCDEF Bundle in 6,064 Patients. Crit Care Med. 2017; 45(2): 171–178.
  48. Skrobik YK, Bergeron N, Dumont M, et al. Olanzapine vs haloperidol: treating delirium in a critical care setting. Intensive Care Med. 2004; 30(3): 444–449.
  49. Devlin JW, Roberts RJ, Fong JJ, et al. Efficacy and safety of quetiapine in critically ill patients with delirium: a prospective, multicenter, randomized, double-blind, placebo-controlled pilot study. Crit Care Med. 2010; 38(2): 419–427.
  50. Reade MC, Eastwood GM, Bellomo R, et al. DahLIA Investigators, Australian and New Zealand Intensive Care Society Clinical Trials Group. Effect of Dexmedetomidine Added to Standard Care on Ventilator-Free Time in Patients With Agitated Delirium: A Randomized Clinical Trial. JAMA. 2016; 315(14): 1460–1468.
  51. Carrasco G, Baeza N, Cabré L, et al. Dexmedetomidine for the Treatment of Hyperactive Delirium Refractory to Haloperidol in Nonintubated ICU Patients: A Nonrandomized Controlled Trial. Crit Care Med. 2016; 44(7): 1295–1306.
  52. Azoulay E, Vincent JL, Angus DC, et al. Recovery after critical illness: putting the puzzle together-a consensus of 29. Crit Care. 2017; 21(1): 296.
  53. Pohlman MC, Schweickert WD, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet. 2009; 373(9678): 1874–1882.
  54. Litton E, Carnegie V, Elliott R, et al. The Efficacy of Earplugs as a Sleep Hygiene Strategy for Reducing Delirium in the ICU: A Systematic Review and Meta-Analysis. Crit Care Med. 2016; 44(5): 992–999.
  55. Kondili E, Alexopoulou C, Xirouchaki N, et al. Effects of propofol on sleep quality in mechanically ventilated critically ill patients: a physiological study. Intensive Care Med. 2012; 38(10): 1640–1646.
  56. Alexopoulou C, Kondili E, Diamantaki E, et al. Effects of dexmedetomidine on sleep quality in critically ill patients: a pilot study. Anesthesiology. 2014; 121(4): 801–807.
  57. Hatta K, Kishi Y, Wada K, et al. DELIRIA-J Group. Preventive effects of ramelteon on delirium: a randomized placebo-controlled trial. JAMA Psychiatry. 2014; 71(4): 397–403.
  58. Hatta K, Kishi Y, Wada K, et al. DELIRIA-J Group. Preventive Effects of Suvorexant on Delirium: A Randomized Placebo-Controlled Trial. J Clin Psychiatry. 2017; 78(8): e970–e979.
  59. Skrobik Y, Duprey MS, Hill NS, et al. Low-dose nocturnal dexmedetomidine prevents ICU delirium. A randomized, placebo-controlled trial. Am J Respir Crit Care Med. 2018; 197(9): 1147–1156.
  60. Inouye SK, Bogardus ST, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999; 340(9): 669–676.
  61. Jacobi J, Fraser GL, Coursin DB, et al. Task Force of the American College of Critical Care Medicine (ACCM) of the Society of Critical Care Medicine (SCCM), American Society of Health-System Pharmacists (ASHP), American College of Chest Physicians. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med. 2002; 30(1): 119–141.

Important: This website uses cookies. More >>

The cookies allow us to identify your computer and find out details about your last visit. They remembering whether you've visited the site before, so that you remain logged in - or to help us work out how many new website visitors we get each month. Most internet browsers accept cookies automatically, but you can change the settings of your browser to erase cookies or prevent automatic acceptance if you prefer.

VM Media sp. z o.o. VM Group sp.k., Grupa Via Medica, Świętokrzyska 73 St., 80–180 Gdańsk

tel.:+48 58 320 94 94, faks:+48 58 320 94 60, e-mail: viamedica@viamedica.pl