Acute Crit Care.  2019 May;34(2):117-125. 10.4266/acc.2019.00451.

Prevention and management of delirium in critically ill adult patients in the intensive care unit: a review based on the 2018 PADIS guidelines

• Park SY
• Lee HB

• KMID: 2449365
• DOI: http://doi.org/10.4266/acc.2019.00451

Abstract

Delirium is an acute, confusional state characterized by altered consciousness and a reduced ability to focus, sustain, or shift attention. It is associated with a number of complex underlying medical conditions and can be difficult to recognize. Many critically ill patients (e.g., up to 80% of patients in the intensive care unit [ICU]) experience delirium due to underlying medical or surgical health problems, recent surgical or other invasive procedures, medications, or various noxious stimuli (e.g., underlying psychological stressors, mechanical ventilation, noise, light, patient care interactions, and drug-induced sleep disruption or deprivation). Delirium is associated with a longer duration of mechanical ventilation and ICU admittance as well as an increased risk of death, disability, and long-term cognitive dysfunction. Therefore, the early recognition of delirium is important and ICU medical staff should devote careful attention to both watching for the occurrence of delirium and its prevention and management. This review presents a brief overview of delirium and an update of the literature with reference to the 2018 Society of Critical Care Medicine Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU.

Keyword

delirium; guidelines; intensive care units; prevention and control

MeSH Terms

Adult*
Consciousness
Critical Care*
Critical Illness*
Delirium*
Humans
Intensive Care Units*
Medical Staff
Noise
Patient Care
Respiration, Artificial

Reference

1. Inouye SK, Rushing JT, Foreman MD, Palmer RM, Pompei P. Does delirium contribute to poor hospital outcomes? A threesite epidemiologic study. J Gen Intern Med. 1998; 13:234–42.

2. Pandharipande P, Cotton BA, Shintani A, Thompson J, Costabile S, Truman Pun B, et al. Motoric subtypes of delirium in mechanically ventilated surgical and trauma intensive care unit patients. Intensive Care Med. 2007; 33:1726–31.

3. Dubois MJ, Bergeron N, Dumont M, Dial S, Skrobik Y. Delirium in an intensive care unit: a study of risk factors. Intensive Care Med. 2001; 27:1297–304.

4. Ely EW, Gautam S, Margolin R, Francis J, May L, Speroff T, et al. The impact of delirium in the intensive care unit on hospital length of stay. Intensive Care Med. 2001; 27:1892–900.

5. Kiely DK, Jones RN, Bergmann MA, Marcantonio ER. Association between psychomotor activity delirium subtypes and mortality among newly admitted post-acute facility patients. J Gerontol A Biol Sci Med Sci. 2007; 62:174–9.

6. Marcantonio E, Ta T, Duthie E, Resnick NM. Delirium severity and psychomotor types: their relationship with outcomes after hip fracture repair. J Am Geriatr Soc. 2002; 50:850–7.

7. Camus V, Gonthier R, Dubos G, Schwed P, Simeone I. Etiologic and outcome profiles in hypoactive and hyperactive subtypes of delirium. J Geriatr Psychiatry Neurol. 2001; 13:38–42.

8. Ely EW, Shintani A, Truman B, Speroff T, Gordon SM, Harrell FE Jr, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA. 2004; 291:1753–62.

9. Barr J, Fraser GL, Puntillo K, Ely EW, Gélinas C, Dasta JF, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013; 41:263–306.

10. Vincent JL, Shehabi Y, Walsh TS, Pandharipande PP, Ball JA, Spronk P, et al. Comfort and patient-centred care without excessive sedation: the eCASH concept. Intensive Care Med. 2016; 42:962–71.

11. Marra A, Ely EW, Pandharipande PP, Patel MB. The ABCDEF bundle in critical care. Crit Care Clin. 2017; 33:225–43.

12. Pandharipande PP, Girard TD, Jackson JC, Morandi A, Thompson JL, Pun BT, et al. Long-term cognitive impairment after critical illness. N Engl J Med. 2013; 369:1306–16.

13. Jackson JC, Gordon SM, Hart RP, Hopkins RO, Ely EW. The association between delirium and cognitive decline: a review of the empirical literature. Neuropsychol Rev. 2004; 14:87–98.

14. Jackson JC, Mitchell N, Hopkins RO. Cognitive functioning, mental health, and quality of life in ICU survivors: an overview. Psychiatr Clin North Am. 2015; 38:91–104.

15. Deutschman CS, Neligan PJ. Evidence-based practice of critical care. 2nd ed. Philadelphia: Elsevier;2016.

16. Ouimet S, Kavanagh BP, Gottfried SB, Skrobik Y. Incidence, risk factors and consequences of ICU delirium. Intensive Care Med. 2007; 33:66–73.

17. Pandharipande P, Shintani A, Peterson J, Pun BT, Wilkinson GR, Dittus RS, et al. Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients. Anesthesiology. 2006; 104:21–6.

18. Inouye SK, Charpentier PA. Precipitating factors for delirium in hospitalized elderly persons: predictive model and interrelationship with baseline vulnerability. JAMA. 1996; 275:852–7.

19. McNicoll L, Pisani MA, Zhang Y, Ely EW, Siegel MD, Inouye SK. Delirium in the intensive care unit: occurrence and clinical course in older patients. J Am Geriatr Soc. 2003; 51:591–8.

20. Lin SM, Huang CD, Liu CY, Lin HC, Wang CH, Huang PY, et al. Risk factors for the development of early-onset delirium and the subsequent clinical outcome in mechanically ventilated patients. J Crit Care. 2008; 23:372–9.

21. McKinley S, Fien M, Elliott R, Elliott D. Sleep and psychological health during early recovery from critical illness: an observational study. J Psychosom Res. 2013; 75:539–45.

22. Kamdar BB, Needham DM, Collop NA. Sleep deprivation in critical illness: its role in physical and psychological recovery. J Intensive Care Med. 2012; 27:97–111.

23. Van Rompaey B, Elseviers MM, Schuurmans MJ, Shortridge-Baggett LM, Truijen S, Bossaert L. Risk factors for delirium in intensive care patients: a prospective cohort study. Crit Care. 2009; 13:R77.

24. Micek ST, Anand NJ, Laible BR, Shannon WD, Kollef MH. Delirium as detected by the CAM-ICU predicts restraint use among mechanically ventilated medical patients. Crit Care Med. 2005; 33:1260–5.

25. Pandharipande P, Cotton BA, Shintani A, Thompson J, Pun BT, Morris JA Jr, et al. Prevalence and risk factors for development of delirium in surgical and trauma intensive care unit patients. J Trauma. 2008; 65:34–41.

26. Litaker D, Locala J, Franco K, Bronson DL, Tannous Z. Preoperative risk factors for postoperative delirium. Gen Hosp Psychiatry. 2001; 23:84–9.

27. Olin K, Eriksdotter-Jönhagen M, Jansson A, Herrington MK, Kristiansson M, Permert J. Postoperative delirium in elderly patients after major abdominal surgery. Br J Surg. 2005; 92:1559–64.

28. Vaurio LE, Sands LP, Wang Y, Mullen EA, Leung JM. Postoperative delirium: the importance of pain and pain management. Anesth Analg. 2006; 102:1267–73.

29. Morrison RS, Magaziner J, Gilbert M, Koval KJ, McLaughlin MA, Orosz G, et al. Relationship between pain and opioid analgesics on the development of delirium following hip fracture. J Gerontol A Biol Sci Med Sci. 2003; 58:76–81.

30. Choi JG. Delirium in the intensive care unit. Korean J Anesthesiol. 2013; 65:195–202.

31. Schreiber MP, Colantuoni E, Bienvenu OJ, Neufeld KJ, Chen KF, Shanholtz C, et al. Corticosteroids and transition to delirium in patients with acute lung injury. Crit Care Med. 2014; 42:1480–6.

32. Kazmierski J, Banys A, Latek J, Bourke J, Jaszewski R. Cortisol levels and neuropsychiatric diagnosis as markers of postoperative delirium: a prospective cohort study. Crit Care. 2013; 17:R38.

33. Trzepacz PT. The neuropathogenesis of delirium: a need to focus our research. Psychosomatics. 1994; 35:374–91.

34. Mach JR Jr, Dysken MW, Kuskowski M, Richelson E, Holden L, Jilk KM. Serum anticholinergic activity in hospitalized older persons with delirium: a preliminary study. J Am Geriatr Soc. 1995; 43:491–5.

35. Hshieh TT, Fong TG, Marcantonio ER, Inouye SK. Cholinergic deficiency hypothesis in delirium: a synthesis of current evidence. J Gerontol A Biol Sci Med Sci. 2008; 63:764–72.

36. Plaschke K, Hill H, Engelhardt R, Thomas C, von Haken R, Scholz M, et al. EEG changes and serum anticholinergic activity measured in patients with delirium in the intensive care unit. Anaesthesia. 2007; 62:1217–23.

37. Campbell N, Boustani M, Limbil T, Ott C, Fox C, Maidment I, et al. The cognitive impact of anticholinergics: a clinical review. Clin Interv Aging. 2009; 4:225–33.

38. Seamans JK, Floresco SB, Phillips AG. D1 receptor modulation of hippocampal-prefrontal cortical circuits integrating spatial memory with executive functions in the rat. J Neurosci. 1998; 18:1613–21.

39. Hirano H, Day J, Fibiger HC. Serotonergic regulation of acetylcholine release in rat frontal cortex. J Neurochem. 1995; 65:1139–45.

40. van Munster BC, Bisschop PH, Zwinderman AH, Korevaar JC, Endert E, Wiersinga WJ, et al. Cortisol, interleukins and S100B in delirium in the elderly. Brain Cogn. 2010; 74:18–23.

41. Pfister D, Siegemund M, Dell-Kuster S, Smielewski P, Rüegg S, Strebel SP, et al. Cerebral perfusion in sepsis-associated delirium. Crit Care. 2008; 12:R63.

42. McGrane S, Girard TD, Thompson JL, Shintani AK, Woodworth A, Ely EW, et al. Procalcitonin and C-reactive protein levels at admission as predictors of duration of acute brain dysfunction in critically ill patients. Crit Care. 2011; 15:R78.

43. Devlin JW, Fong JJ, Howard EP, Skrobik Y, McCoy N, Yasuda C, et al. Assessment of delirium in the intensive care unit: nursing practices and perceptions. Am J Crit Care. 2008; 17:555–65.

44. Ramsay MA. Measuring level of sedation in the intensive care unit. JAMA. 2000; 284:441–2.

45. Riker RR, Picard JT, Fraser GL. Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients. Crit Care Med. 1999; 27:1325–9.

46. Sessler CN, Gosnell MS, Grap MJ, Brophy GM, O’Neal PV, Keane KA, et al. The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med. 2002; 166:1338–44.

47. Ely EW, Truman B, Shintani A, Thomason JW, Wheeler AP, Gordon S, et al. Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS). JAMA. 2003; 289:2983–91.

48. Bergeron N, Dubois MJ, Dumont M, Dial S, Skrobik Y. Intensive Care Delirium Screening Checklist: evaluation of a new screening tool. Intensive Care Med. 2001; 27:859–64.

49. Ely EW, Margolin R, Francis J, May L, Truman B, Dittus R, et al. Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med. 2001; 29:1370–9.

50. Heo EY, Lee BJ, Hahm BJ, Song EH, Lee HA, Yoo CG, et al. Translation and validation of the Korean confusion assessment method for the intensive care unit. BMC Psychiatry. 2011; 11:94.

51. Patel SB, Poston JT, Pohlman A, Hall JB, Kress JP. Rapidly reversible, sedation-related delirium versus persistent delirium in the intensive care unit. Am J Respir Crit Care Med. 2014; 189:658–65.

52. Haenggi M, Blum S, Brechbuehl R, Brunello A, Jakob SM, Takala J. Effect of sedation level on the prevalence of delirium when assessed with CAM-ICU and ICDSC. Intensive Care Med. 2013; 39:2171–9.

53. Jacobson SA, Leuchter AF, Walter DO, Weiner H. Serial quantitative EEG among elderly subjects with delirium. Biol Psychiatry. 1993; 34:135–40.

54. Hemphill JC. Disorders of consciousness in systemic diseases. In : Aminoff MJ, editor. Aminoff’s neurology and general medicine. 3rd ed. New York: Churchill Livingstone;2001. p. 1053.

55. van den Boogaard M, Schoonhoven L, Maseda E, Plowright C, Jones C, Luetz A, et al. Recalibration of the delirium prediction model for ICU patients (PRE-DELIRIC): a multinational observational study. Intensive Care Med. 2014; 40:361–9.

56. Wassenaar A, van den Boogaard M, van Achterberg T, Slooter AJ, Kuiper MA, Hoogendoorn ME, et al. Multinational development and validation of an early prediction model for delirium in ICU patients. Intensive Care Med. 2015; 41:1048–56.

57. Devlin JW, Skrobik Y, Gélinas C, Needham DM, Slooter AJ, Pandharipande PP, et al. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med. 2018; 46:e825–73.

58. Balas MC, Burke WJ, Gannon D, Cohen MZ, Colburn L, Bevil C, 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):S116–27.

59. 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; 45:171–8.

60. Kamdar BB, King LM, Collop NA, Sakamuri S, Colantuoni E, Neufeld KJ, et al. The effect of a quality improvement intervention on perceived sleep quality and cognition in a medical ICU. Crit Care Med. 2013; 41:800–9.

61. Page VJ, Ely EW, Gates S, Zhao XB, Alce T, Shintani A, et al. Effect of intravenous haloperidol on the duration of delirium and coma in critically ill patients (Hope-ICU): a randomised, double-blind, placebo-controlled trial. Lancet Respir Med. 2013; 1:515–23.

62. Girard TD, Pandharipande PP, Carson SS, Schmidt GA, Wright PE, Canonico AE, et al. Feasibility, efficacy, and safety of antipsychotics for intensive care unit delirium: the MIND randomized, placebo-controlled trial. Crit Care Med. 2010; 38:428–37.

63. Needham DM, Colantuoni E, Dinglas VD, Hough CL, Wozniak AW, Jackson JC, et al. Rosuvastatin versus placebo for delirium in intensive care and subsequent cognitive impairment in patients with sepsis-associated acute respiratory distress syndrome: an ancillary study to a randomised controlled trial. Lancet Respir Med. 2016; 4:203–12.

64. Devlin JW, Smithburger P, Kane JM, Fraser GL, Skrobik Y. Intended and unintended consequences of constraining clinician prescribing: the case of antipsychotics. Crit Care Med. 2016; 44:1805–7.

65. Reade MC, Eastwood GM, Bellomo R, Bailey M, Bersten A, Cheung B, et al. Effect of dexmedetomidine added to standard care on ventilator-free time in patients with agitated delirium: a randomized clinical trial. JAMA. 2016; 315:1460–8.

66. Dasta JF, Kane-Gill SL, Durtschi AJ. Comparing dexmedetomidine prescribing patterns and safety in the naturalistic setting versus published data. Ann Pharmacother. 2004; 38:1130–5.

67. Holliday SF, Kane-Gill SL, Empey PE, Buckley MS, Smithburger PL. Interpatient variability in dexmedetomidine response: a survey of the literature. ScientificWorldJournal. 2014; 2014:805013.

68. Skrobik Y, Duprey MS, Hill NS, Devlin JW. Low-dose nocturnal dexmedetomidine prevents ICU delirium: a randomized, placebo-controlled trial. Am J Respir Crit Care Med. 2018; 197:1147–56.