University of
Kentucky HealthCare Adult ICU Delirium Guideline
ICU delirium, often referred to as “ICU
psychosis,” is an acute onset of confusion, inattention, and other disturbances
in cognition. It is an often
under-assessed and under-reported complication to hospitalization. It has been found that up to 80% of
adult patients develop delirium while hospitalized post-operatively, especially
in the ICU. Not only is the
development of ICU delirium troublesome to the patients, patients’ family and
the providers, patients who develop delirium have an increased rate of
mortality3,6, a prolonged length of stay3,6, prolonged
ventilator time6, decreased cognition6, and increased
costs27. It is the expectation that delirium prevention, assessment,
and treatment be multidisciplinary.
ICU delirium can be divided into subtypes;
hyperactive, hypoactive, or mixed1. Hyperactive is characterized by agitation or emotional
liability. Hypoactive is the most
common and may have the highest level of mortality6. It is difficult to assess, characterized
by lethargy, decreased responsiveness or flat affect.
Several independent risk factors for the
development of delirium have been suggested including increased age, severity
of illness, and the use of benzodiazepines16 although, there is no
consensus. Delirium development is
most likely multi-factorial and may include among others: hearing and vision
impairment, pain, blood transfusions4, sleep disturbance, cognitive
impairment prior to hospitalization (dementia)3, and alcohol abuse3. The following mnemonics can assist in
remembering common risk factors for the development of delirium7,15.
Toxic (shock, organ failure,
deliriogenic
meds)
Hypoxemia
Infection
Non-pharmacologic causes
K+ or other electrolyte problem
Drugs
Eyes & Ears
Low O2 state (MI, stroke, PE)
Infection
Retention of urine or stool
Ictal
Underhydration/Undernutrition
Metabolic
(S)ubdural
Every patient in an adult ICU3,14 should
be screened at least every shift, and with any abrupt change in level of
consciousness, for the presence of delirium. UK HealthCare has adopted the Confusion Assessment Method
for the ICU (CAM-ICU)5 as our assessment tool in the ICU.
Frequently it is the patient’s loved ones who
identify delirium prior to the assessment by the healthcare provider. In the absence of a known baseline
cognitive status, loved ones are often the best tool for assessing changes and
possible delirium development.
ICU Delirium Appendix A
Prevention Guideline
Because there is no clear treatment of delirium, prevention is
the best practice.
Techniques for prevention of delirium in all care levels include:
§ Consistent purposeful hourly rounding
o Assess for 4 P’s – Pain, Potty, Positioning, and Possessions
o Establish relationship based on patient feeling safe
o Use language such as “I will not be far away,” or “I will be back in one
hour.”
§ Remove all deliriogenic drugs if possible (e.g. benzodiazepines,
anticholinergics, steroids) 3,14,16
§ Use restraint alternative if possible. The use of restraints is linked to higher rates and longer
duration of delirium20.
§ Orient patient to person, place, time & situation14
§ Provide patient with hearing and/or vision correction14
§ Provide sunlight19 or room lights on for first morning
assessment and maintain until lights out around 9pm to reinforce the diurnal cycle3 (exception: head patients)
§ Cluster care to allow for improved rest/sleep
§ Provide early progressive mobility3,14
§ Maintain RASS of -1 to +1 (If
RASS is +2 to +4, may consider mild sedation)
§ Reconcile home medications
§
Review Appendix C – Pharmacologic
Treatment Guideline
ABCDE bundle (ICU Only)
The ABCDE bundle is a best practice bundle which
helps remind us of the most important and helpful topics when preventing and
treating delirium2.
Awakening and Breathing
Trial Coordination
(Spontaneous Breathing Trial guideline)
Delirium Non-pharmacologic Interventions (Pain
control, orientation, Eye/Ears, & Sleep)
Early Mobility
Appendix B
Assessment Guideline
Please see CAM-ICU Worksheet (Appendix D) to
aid in assessment.
There are four features of delirium that are
assessed when utilizing the CAM-ICU. To be considered CAM-ICU positive or
delirium positive, the patient must have positive assessments of Features 1
AND 2 AND either 3 or 4.
Feature 1:
Level of Consciousness (LOC) – Is there a change (last 24 hours)
from baseline LOC?
To assess LOC
for the purpose of the CAM, the Richmond Agitation and Sedation Scale (RASS)
is used for patients in the ICU.
This is a simple linear scale to assess how agitated vs sedated the
patient is. The CAM-ICU cannot be
assessed if the patient has a RASS score of -4 or -5 (deep sedation). If the patient has a score of -3
(moderate sedation) to +4 (combative), continue with the assessment. Keep in mind that medications and
procedures can affect this score. This
feature is positive if the answer to the question is “yes”.
Feature 2:
Inattention – Can the patient maintain
concentration?
This is
done by holding the patient’s hand and reading the following letters (3 seconds
apart).
S A V E A H A A R T
Please keep in
mind of the patient has a hearing deficit you may need to speak very loudly.
Ask the patient
to squeeze your hand every time they hear the letter “A.”
This feature is
positive if the patient makes more than 2 errors.
Feature 3:
Altered Level of Consciousness – Is the
patient anything but alert and calm?
This feature is
positive if the patient’s RASS score is anything but 0. This will likely be positive for many
patients.
Feature 4:
Disorganized Thinking – Is the
patient not thinking clearly?
This feature has
two parts: Yes/No Questions or
Commands.
Yes/No Questions: Ask the following four
questions (if not intubated).
1) Will a stone float on water?
2) Are there fish in the sea?
3) Does one pound weigh more than two pounds?
4) Can you use a hammer to pound a nail?
Command:
“Hold up this many fingers.” Hold up two fingers in front of patient
(if patient has visual difficulty, be aware). Then ask them to repeat on the other side. If they are unable to move one side,
ask the patient to “Add one more finger.”
This feature is
positive if there is more than one error made.
Appendix C
Pharmacologic
Treatment Guideline
Utilize the
prevention guidelines for delirium first
Resume home medications as appropriate
Consider limiting the use of benzodiazepines16
Decrease sedation and pain medications to
keep RASS -1 to +1 as appropriate. Please refer to the UK HealthCare Clinical Practice Guideline for the
Management of Analgesia and Sedation for Adult Mechanically Ventilated Patients
for further assistance.
If CAM-ICU positive despite above interventions, consider the use of
antipsychotics:
· haloperidol (Haldol) 2.5mg IV
every 15 to 30 min, increasing dose as needed to effect
o Consider
scheduling 5mg IV every 8 hours or 2.5mg PO every 8 hours. Increase by 2.5mg
every 8 hours to effect. Max of 30mg/day10,21
o Notable
side effect: reduction of the seizure threshold
· quetiapine (Seroquel) 50mg
PO/PT twice daily
o Increase
by 50mg every 12 hours to effect. Max 400mg/day divided8
· olanzapine (Zyprexa) 5mg
PO/PT at Bedtime
o Increase
by 2.5mg daily to effect. Max of 15mg/day13
· ziprasidone (Geodon) 40mg
PO/PT twice daily22
o Increase
by 20mg twice daily. Max 80mg twice daily.
o Notable side
effects: leukopenia, neutropenia, agranulocytosis
· risperidone (Risperdal) 0.5mg
PO/PT twice daily26
o Increase
by 0.25mg twice daily. Max 3mg twice daily.
All of the above increase the QTc interval
and cause sedation. Caution with QTc > 460 to 500 on EKG.
Risk of QTc
prolongation: haloperidol > ziprasidone > quetiapine > olanzapine
Risk of sedation: quetiapine > X >
olanzapine
Caution in patients with dementia, neurologic
impairment, neurotrauma, alcohol withdrawal, Parkinson’s disease, as these
patient populations have traditionally been excluded from primary literature.
Black boxed warning for use of antipsychotics
in elderly patients with dementia-related psychosis due to increased risk of
death compared to placebo.23, 24, 25
References:
1.
American Psychiatric Association. (2013). Diagnostic
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Balas, M., Vasilevskis, E., Burke, W., Boehm, L.,
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DELIRIUM – Adapted by Vanderbilt University from
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8.
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<http://www.uptodate.com/contents/haloperidol-drug-information?source=search_result&search=haldol&selectedTitle=1%7E116#F178617>
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Online. Quetiapine. Accessed 25 November 2013. <
http://www.uptodate.com/contents/quetiapine-drug-information?source=search_result&search=quetiapine&selectedTitle=1%7E79#F212162
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