Managing ICU delirium

Department of Anaesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany.
Current opinion in critical care (Impact Factor: 2.62). 02/2011; 17(2):131-40. DOI: 10.1097/MCC.0b013e32834400b5
Source: PubMed


ICU delirium is a common and serious acute brain dysfunction with adverse outcome and high risk of mortality. The awareness of ICU delirium as a problem, which immediately requires therapeutic intervention, has been increased in the past years. This article aims to provide information in order to increasingly modify the management of this severe problem, that is, its detection, prevention, and treatment toward algorithm-based and protocol-driven procedures.
The bundle of target-controlled and protocol-driven management of sedation, analgesia, and delirium and its monitoring included in this work offer the opportunity to improve the outcome of ICU patients based on the best evidence available to date. Moreover, the knowledge about precipitating and predisposing factors to prevent ICU delirium is essential and is represented in this review. Unresolved seems the pharmacological therapy of delirium because of the contradictory results of research published so far, especially regarding neuroleptics and cholinesterase inhibitors.
The management of ICU delirium must be a key aspect to improve the outcome of critically ill patients. The development of pharmacological treatment strategies and deeper understanding of the underlying pathophysiology will require further research.

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Available from: Claudia Spies, Sep 29, 2015
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    • "Correcting the acidosis alone was not enough to manage the delirium and the treatment was challenging. Delirium in patients treated in intensive care unit has been reported as a common and serious acute brain dysfunction with adverse outcome and high risk of mortality (1). Delirium is characterized by four features: 1) inattention and disturbance of consciousness, 2) change in cognition, 3) acute onset and fluctuating course, and 4) presence of a pathophysiological cause (2). "
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    ABSTRACT: A 15-year-old female patient with known type 1 diabetes mellitus was referred because of abdominal pain. On admission, she was alert but dehydrated with marked Kussmaul breathing. Blood glucose was 414 mg/dL (23 mmol/L). Blood gas analysis revealed severe metabolic acidosis (pH: 6.99) with an elevated anion gap (29.8 mmol/L) and an increased base excess (-25.2 mmol/L). At the sixth hour of treatment with intravenous fluids and insulin, the patient became delirious. The delirium persisted despite the normalization of the acidosis and became difficult to manage. Brain imaging studies revealed neither brain edema nor other intracranial pathology. No evidence of intoxication could be found. The patient gradually regained consciousness and was diagnosed as a case of severe diabetic ketoacidosis (DKA) associated with infection. We were unable to find a similar case in the pediatric literature and thought that reporting this unusual case would be a contribution to the literature on DKA in children. Conflict of interest:None declared.
    Journal of Clinical Research in Pediatric Endocrinology 03/2012; 4(1):39-41. DOI:10.4274/Jcrpe.478
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    ABSTRACT: Delirium is a common problem in intensive care patients, frequently underdiagnosed and resulting in prolonged hospital stay and a high risk of morbidity and mortality. On the other hand, reversibility of the condition points to the importance of prevention, early diagnosis and immediate therapy. Management strategy is directed to nonpharmacological interventions as preventive measures and pharmacological treatment, which includes typical and atypical neuroleptics. Delirium management includes haloperidol as the first line medication, but also olanzapine and risperidone as atypical neuroleptics. Benzodiazepines are used in delirium caused by alcohol withdrawal.
    Acta medica Croatica: c̆asopis Hravatske akademije medicinskih znanosti 03/2012; 66(1):49-53.
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    ABSTRACT: A wide variability in the approach towards delirium prevention and treatment in the critically ill results from the dearth of prospective randomised studies. We launched a two-stage prospective observational study to assess delirium epidemiology, risk factors and impact on patient outcome, by enrolling all patients admitted to our Intensive Care Unit (ICU) over a year. The first step - from January to June 2008 was the observational phase, whereas the second one from July to December 2008 was interventional. All the patients admitted to our ICU were recruited but those with pre-existing cognitive disorders, dementia, psychosis and disability after stroke were excluded from the data analysis. Delirium assessment was performed according with Confusion Assessment Method for the ICU twice per day after sedation interruption. During phase 2, patients underwent both a re-orientation strategy and environmental, acoustic and visual stimulation. We admitted a total of respectively 170 (I-ph) and 144 patients (II-ph). The delirium occurrence was significantly lower in (II-ph) 22% vs. 35% in (I-ph) (P=0.020). A Cox's Proportional Hazard model found the applied reorientation strategy as the strongest protective predictors of delirium: (HR 0.504, 95% C.I. 0.313-0.890, P=0.034), whereas age (HR 1.034, 95% CI: 1.013-1.056, P=0.001) and sedation with midazolam plus opiate (HR 2.145, 95% CI: 2.247-4.032, P=0.018) were negative predictors. CONCLUSION; A timely reorientation strategy seems to be correlated with significantly lower occurrence of delirium.
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