Intensive Care Unit Delirium
Section snippets
Incidence
The incidence of ICU delirium varies widely from 16% to 89%.3, 4, 5, 6, 7, 8, 9, 10 The variation is primarily attributable to differences in study population, use and choice of screening instrument, diagnostic criteria, and risk factors, such as sedative agents administered. Fig. 2 illustrates the varying incidence of ICU delirium in various subpopulations using the Confusion Assessment Method for the ICU (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC), 2 validated
Pathophysiology and risk factors
The pathophysiology of ICU delirium is not well understood. It is thought to be multifactorial and many theories have been postulated including a local inflammatory response of the brain to insult, such as infection, resulting in alterations in neuronal activity; imbalances in the neurotransmitters modulating cognition (ie, dopamine, acetylcholine, γ-aminobutyric acid, and/or serotonin), with predominately a relative excess of dopamine in relation to acetylcholine; reduced cerebral perfusion;
Clinical relevance: morbidity and mortality
ICU delirium has been directly correlated with patient morbidity and mortality. In a single-center, prospective, cohort study including 224 mechanically ventilated adult MICU or coronary ICU (CICU) patients, the presence of delirium (CAM-ICU positive) was associated with a 3.2-times higher risk of death within 6 months compared with patients who were never delirious (adjusted hazard ratio 3.2 [1.4–7.7], P<.05). The absolute 6-month mortality in the delirious and never-delirious study groups was
ICU Delirium assessment
In the past 5 years, there has been an increase in the awareness and assessment of ICU delirium. A survey of critical care professionals (n = 912) conducted in 2001–2002 aimed to assess the practices and beliefs of the medical community regarding ICU delirium.30 Overall, 92% of respondents reported that delirium is a significant ICU problem, and 78% believed delirium is underdiagnosed; however, only 40% routinely screened for delirium, with a mere 16% reporting use of a specific delirium
Nonpharmacologic Treatment
Nonpharmacologic treatment should be incorporated into the management of ICU delirium in all patients, regardless of delirium subtype. The key to nonpharmacologic management is first recognition of potential and existing problem areas followed by intervention to correct or modify the situation. This process entails evaluation and assessment of 3 major areas: the presence of barriers between patient and practitioner, environmental modification, and ICU care (Fig. 5). The ensuing discussion of
Practice implications
Health care professionals in the ICU are becoming more aware of the effect of delirium on critical care outcomes, as shown by an increase in self-reported delirium assessment. However, in order for an institution to be successful in addressing delirium in the ICU, several key components must be present. It is vital to appoint champions to help spearhead delirium initiatives. A delirium champion representative from each critical care discipline (eg, nursing, physician, pharmacy) should be
Summary
Identification and prompt management of ICU delirium are vital in promoting safety for patients and their caregivers. Critically ill adult patients, both mechanically ventilated and non-mechanically ventilated, are at a high risk for the development of delirium during their ICU stay with an incidence of up to 89%. ICU delirium has been linked to long-term cognitive impairment and has been shown to significantly increase 6-month mortality, ICU length of stay, time on the ventilator, and ICU and
References (57)
- et al.
The importance of diagnosing and managing ICU delirium
Chest
(2007) - et al.
Risk factors for the development of early-onset delirium and the subsequent clinical outcome in mechanically ventilated patients
J Crit Care
(2008) - et al.
Risk factors for delirium after major trauma
Am J Surg
(2008) - et al.
Emergency use of intravenous haloperidol
Gen Hosp Psychiatry
(1979) - et al.
Torsades de Pointes associated with intravenous haloperidol in critically ill patients
Am J Cardiol
(1998) - et al.
A double-blind trial of risperidone and haloperidol for the treatment of delirium
Psychosomatics
(2004) - et al.
Monitoring delirium in critically ill patients
Crit Care Nurse
(2003) - et al.
Intensive care unit delirium is an independent predictor of longer hospital stay: a prospective analysis of 261 non-ventilated patients
Crit Care
(2005) - et al.
Large-scale implementation of sedation and delirium monitoring in the intensive care unit: a report from two medical centers
Crit Care Med
(2005) - et al.
A research algorithm to improve detection of delirium in the intensive care unit
Crit Care
(2006)
Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit
JAMA
Motoric subtypes of delirium in mechanically ventilated surgical and trauma intensive care unit patients
Intensive Care Med
Intensive Care Delirium Screening Checklist: evaluation of a new screening tool
Intensive Care Med
Multicentre study of delirium in ICU patients using a simple screening tool
Aust Crit Care
Comparison of the confusion assessment method for the intensive care unit (CAM-ICU) with the Intensive Care Delirium Screening Checklist (ICDSC) for delirium in critical care patients gives high agreement rate(s)
Intensive Care Med
Delirium and its motoric subtypes: a study of 614 critically ill patients
J Am Geriatr Soc
Intensive care unit syndrome: a dangerous misnomer
Arch Intern Med
Delirium in an intensive care unit: a study of risk factors
Intensive Care Med
Predisposing factors for delirium in the surgical intensive care unit
Crit Care
Incidence, risk factors and consequences of ICU delirium
Intensive Care Med
Delirium: acute cognitive dysfunction in the critically ill
Curr Opin Crit Care
Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients
Anesthesiology
Delirium assessment in the critically ill
Intensive Care Med
Prevalence and risk factors for development of delirium in surgical and trauma intensive care unit patients
J Trauma
Risk factors for delirium in intensive care patients: a prospective cohort study
Crit Care
Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult
Crit Care Med
Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial
JAMA
Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial
JAMA
Cited by (25)
Post-ICU psychological morbidity in very long ICU stay patients with ARDS and delirium
2018, Journal of Critical CareCitation Excerpt :Consensus agreement was achieved that based on the available data, an ICU stay > 75 days constitutes a very-long ICU stay in this region of Iran. The inclusion criteria were: (1) age ≥ 18 years, (2) ICU LOS > 75 days, (3) full-code status, and if (4) occurrence of delirium according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) and Confusion Assessment Method for the ICU (CAM-ICU) during the hospitalization period [48-50], and (5) informed consent obtained from the patient, legal guardian, or healthcare surrogate. Patients with pre-ICU psychiatric comorbidity, and those admitted for a primary psychiatric diagnosis were excluded.
Promoting sleep in the adult surgical intensive care unit patients to prevent delirium
2014, Nursing Clinics of North AmericaCitation Excerpt :In the SICU at the author’s tertiary hospital, sleep promotion for ICU patients is particularly challenging because of frequent nursing interventions, high noise levels related to clinical alarms, medical equipment, and staff conversations. Disruption of the sleep/wake cycle can interfere with healing and may contribute to delirium in the SICU patient.17 This SICU lacked a culture of prioritizing sleep for the critically ill patients on a consistent basis.
A meta-analysis of analgesic and sedative effects of dexmedetomidine in burn patients
2013, BurnsCitation Excerpt :Dexmedetomidine is a potent alpha-2-adrenergic agonist, more selective than clonidine, with widespread actions on the mammalian brain that include sedation, anesthetic-sparing, analgesia and sympatholytic properties [18]. A large body of recent work supports its favorable profile in improving outcome from ICU delirium [19], for opioid, benzodiazepine, and alcohol withdrawal [20], as well as for sedation during monitored anesthesia care and regional anesthesia [21]. In a recent meta-analysis on the analgesic and sedative effects of DEX on patients requiring mechanical ventilation in the ICU, Tan and Ho [22] showed that DEX may reduce the length of stay of some ICU patients but had no effect on days of ventilation.
Incidence, prevalence, risk factor and outcome of delirium in intensive care unit: A study from India
2012, General Hospital PsychiatryCitation Excerpt :The precipitating factors are further subdivided into those related to the critical illness and those related to therapeutic interventions. Although the risk factors for delirium have been studied to certain extent in the non-ICU patients, studies that have evaluated the risk factors in ICU setting are small in number [16–19]. Delirium in general is considered to be associated with high mortality [20–22].
Adherence to the CAM-ICU Scale and evaluation of methods for diagnosis of delirium by physicians working in intensive care units in Medellin city
2019, Acta Colombiana de Cuidado Intensivo
The authors have no conflicts of interest regarding this publication.