Elsevier

Critical Care Clinics

Volume 29, Issue 1, January 2013, Pages 51-65
Critical Care Clinics

Preventing Delirium in the Intensive Care Unit

https://doi.org/10.1016/j.ccc.2012.10.007Get rights and content

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Key points

  • Delirium in the intensive care unit (ICU) is exceedingly common, and risk factors for delirium among the critically ill are nearly ubiquitous.

  • Addressing modifiable risk factors including sedation management, deliriogenic medications, immobility, and sleep disruption can help to prevent and reduce the duration of this deadly syndrome.

  • The ABCDE approach to critical care is a bundled approach that clinicians can implement for many patients treated in their ICUs to prevent the adverse outcomes

Risk factors for delirium

The average medical ICU patient has 11 or more risk factors for developing delirium,11 which can be divided into baseline (predisposing) and hospital-related (precipitating) factors.21 Baseline risk factors are those relating to a patient’s underlying characteristics and comorbidities, and hospital-related factors are those relating to the patient’s acute illness, its treatment, and ICU management (Table 1). These risk factors combine to cause delirium in a given patient such that a highly

Delirium prevention in non-ICU patients

Multicomponent strategies to prevent the development of delirium have yet to be fully developed and studied in the ICU, but an overview of strategies for delirium prevention that have been examined carefully in other populations in which delirium is prevalent, namely hospitalized elderly patients and those undergoing hip-fracture repair (Fig. 1), is likely informative for ICU clinicians despite the current paucity of evidence in this setting. Inouye and colleagues,22 for example, studied a

Delirium prevention in ICU patients

On the whole, the constellation of risk factors for delirium affecting individual ICU patients varies from patient to patient and thus an individualized strategy for delirium prevention should be sought. Nonetheless, 3 risk factors in particular, sedatives, immobility, and sleep disruption, are widespread in the ICU as a result of clinical practice habits in most ICUs and therefore serve as important targets for delirium prevention. In addition, antipsychotics and cholinesterase inhibitors

Summary

Delirium in the ICU is exceedingly common, and risk factors for delirium among the critically ill are nearly ubiquitous. Nevertheless, addressing modifiable risk factors including sedation management, deliriogenic medications, immobility, and sleep disruption can help to prevent and reduce the duration of this deadly syndrome. The ABCDE approach to critical care is a bundled approach that can be implemented by clinicians for many patients treated in their ICUs to prevent the adverse outcomes

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References (68)

  • M.M. van Eijk et al.

    Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients: a multicentre, double-blind, placebo-controlled randomised trial

    Lancet

    (2010)
  • E.E. Vasilevskis et al.

    Reducing iatrogenic risks: ICU-acquired delirium and weakness—crossing the quality chasm

    Chest

    (2010)
  • American Psychiatric Association

    Diagnostic and statistical manual of mental disorders. Fourth edition, text revision

    (2000)
  • E.W. Ely et al.

    Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU)

    JAMA

    (2001)
  • M.J. Dubois et al.

    Delirium in an intensive care unit: a study of risk factors

    Intensive Care Med

    (2001)
  • N. Bergeron et al.

    Intensive Care Delirium Screening Checklist: evaluation of a new screening tool

    Intensive Care Med

    (2001)
  • P.P. Pandharipande et al.

    Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial

    JAMA

    (2007)
  • P. Pandharipande et al.

    Prevalence and risk factors for development of delirium in surgical and trauma intensive care unit patients

    J Trauma

    (2008)
  • S.T. Micek et al.

    Delirium as detected by the CAM-ICU predicts restraint use among mechanically ventilated medical patients

    Crit Care Med

    (2005)
  • Y. Shehabi et al.

    Delirium duration and mortality in lightly sedated, mechanically ventilated intensive care unit patients

    Crit Care Med

    (2010)
  • E.W. Ely et al.

    The impact of delirium in the intensive care unit on hospital length of stay

    Intensive Care Med

    (2001)
  • E.W. Ely et al.

    Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit

    JAMA

    (2004)
  • S. Ouimet et al.

    Incidence, risk factors and consequences of ICU delirium

    Intensive Care Med

    (2007)
  • J.W. Thomason 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)
  • E.B. Milbrandt et al.

    Costs associated with delirium in mechanically ventilated patients

    Crit Care Med

    (2004)
  • S.M. Lin et al.

    The impact of delirium on the survival of mechanically ventilated patients

    Crit Care Med

    (2004)
  • M.A. Pisani et al.

    Days of delirium are associated with 1-year mortality in an older intensive care unit population

    Am J Respir Crit Care Med

    (2009)
  • B. Van Rompaey et al.

    Long term outcome after delirium in the intensive care unit

    J Clin Nurs

    (2009)
  • T.D. Girard et al.

    Delirium as a predictor of long-term cognitive impairment in survivors of critical illness

    Crit Care Med

    (2010)
  • N.E. Brummel et al.

    Does duration of ICU delirium predict long-term functional impairment?

    Am J Respir Crit Care Med

    (2011)
  • S.K. Inouye et al.

    Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability

    JAMA

    (1996)
  • S.K. Inouye et al.

    A multicomponent intervention to prevent delirium in hospitalized older patients

    N Engl J Med

    (1999)
  • F.T. Martinez et al.

    Preventing delirium in an acute hospital using a non-pharmacological intervention

    Age Ageing

    (2012)
  • E.R. Marcantonio et al.

    Reducing delirium after hip fracture: a randomized trial

    J Am Geriatr Soc

    (2001)
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    Funding source: NIH (Grant numbers: K23AG034257; T32HL087738).

    The authors have no financial conflicts to disclose.

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