Delirium in Critical Care

Topic Progress:

Why is Delirium so Important?

Bruce is an ICU survivor and advocate for aggressive delirium prevention.

DELIRIUM PREVENTS PATIENTS FROM GETTING OUT OF CRITICAL CARE

We all know that COVID-19 is lethal for those admitted to critical care units. There’s so much about the disease we can’t control. But what we can control is how aggressive nurses can be in trying to prevent delirium!


Cognitive Decline

  • Critical illness is believed to play a part in long-term cognitive impairment1
  • The BEDSIDE NURSE is pivotal for assessing and identifying delirium.
  • Delirium is severely underestimated in critical care2!
  • Delirium is a predictor for mortality in mechanically ventilated patients3.
  • Use the lowest amount of sedation and anaglesia to meet your goals4

ICU Delirium is Associated with Long-Term Cognitive Impairment

Screen for Delirium

The best way to screen for delirium is using a peer-reviewed, evidence based screening tool such as CAM-ICU5-6.

The best team member to identify and treat delirium is the bedside nurse.

There are two types7.

Hyperactive Delirium

Chacterized by:

  • Aggression
  • Violence
  • Agitation
  • Sleeplessness

Common treatment:

  • Physiotherapy
  • Mobilize
  • Promote wake-sleep cycle
  • Verbal de-escalation (yes, it works)2-5,13
  • Food
  • Windows for daylight
  • Reduce noise
  • Treat pain and agitation with pharmacological agents
  • Family (in COVID-19 times, use video calling, etc)

Hypoactive Delirium

Characterized by:

  • Flat affect
  • Expressionless
  • Inappropriate sleep
  • Hallucinations

Common treatment:

  • Physiotherapy
  • Mobilize
  • Promote wake-sleep cycle (it needs to be a regular cycle, not an inappropriate cycle of wake-sleep)
  • Verbal reorientation
  • Interaction with the patient, such as music, television
  • Food
  • Windows for daylight
  • Reduce noise
  • Treat pain
  • Family (in COVID-19 times, use video calling, etc)

Methods to Combat Delirium

The ABCDEF bundle is a good place to start (video below). Guidelines here.

In general, nursing care for the PREVENTION and TREATMENT of delirium is incredibly valuable. This includes:

  • Treat pain appropriately and separately from sedation.
  • Pain causes delirium4. Treat pain and you may be able to avoid delirium altogether.
  • Use the lowest amount of sedation needed to achieve RASS goal.
  • Sedation vacations are a bit old school and have not been found to reduce ICU stay8-10. Remember, use the lowest amount of sedation to achieve your RASS goal.
  • Mobilize, mobilize, mobilize. Change your mindset from the patient is so sick they need to stay in bed to the patient is too sick to stay in bed11-13.

Protip for Delirium Surveillance and Treatment

Treat all critically ill patients as if they have delirium regardless of their delirium score.

1. Aggressively mobilize your patient is possible.
2. Treat pain before agitation.
3. PATIENTS NEED TO SLEEP TO GET BETTER14.

Here’s a Summary from the Society of Critical Care Medicine’s ABCDEF bundle to combat delirium.

References

1. Pandharipande, P.P., et al. “Long-Term Cognitive Impairment after Critical Illness: NEJM.” New England Journal of Medicine, 3 Oct. 2013, www.nejm.org/doi/full/10.1056/NEJMoa1301372.

2. Spronk PE, Riekerk B, Hofhuis J, Rommes JH. Occurrence of delirium is severely underestimated in the ICU during daily care. Intensive Care Med. 2009;35(7):1276–1280. doi:10.1007/s00134-009-1466-8

3. Ely EW, Shintani A, Truman B, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA. 2004;291(14):1753–1762. doi:10.1001/jama.291.14.1753

4. Barr J, Fraser GL, Puntillo K, 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(1):263–306. doi:10.1097/CCM.0b013e3182783b72

5. ICU Delirium. Monitoring Delirium in the ICU. https://www.icudelirium.org/medical-professionals/delirium/monitoring-delirium-in-the-icu

6. Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med. 1990;113(12):941–948. doi:10.7326/0003-4819-113-12-941

7. Arumugam, S., El-Menyar, A., Al-Hassani, A., Strandvik, G., Asim, M., Mekkodithal, A., Mudali, I., & Al-Thani, H. (2017). Delirium in the Intensive Care Unit. Journal of emergencies, trauma, and shock, 10(1), 37–46. https://doi.org/10.4103/0974-2700.199520

8. Burry L, Rose L, McCullagh IJ, Fergusson DA, Ferguson ND, Mehta S. Daily sedation interruption versus no daily sedation interruption for critically ill adult patients requiring invasive mechanical ventilation. Cochrane Database Syst Rev. 2014;2014(7):CD009176. Published 2014 Jul 9. doi:10.1002/14651858.CD009176.pub2

9. Aitken LM, Bucknall T, Kent B, Mitchell M, Burmeister E, Keogh SJ. Protocol-directed sedation versus non-protocol-directed sedation to reduce duration of mechanical ventilation in mechanically ventilated intensive care patients. Cochrane Database Syst Rev. 2015;1:CD009771. Published 2015 Jan 7. doi:10.1002/14651858.CD009771.pub2

10. Aitken LM, Bucknall T, Kent B, Mitchell M, Burmeister E, Keogh SJ. Protocol-directed sedation versus non-protocol-directed sedation in mechanically ventilated intensive care adults and children. Cochrane Database Syst Rev. 2018;11(11):CD009771. Published 2018 Nov 12. doi:10.1002/14651858.CD009771.pub3

11. Adler, Joseph, and Daniel Malone. “Early mobilization in the intensive care unit: a systematic review.” Cardiopulmonary physical therapy journal vol. 23,1 (2012): 5-13.

12. Dirkes SM, Kozlowski C. Early Mobility in the Intensive Care Unit: Evidence, Barriers, and Future Directions. Crit Care Nurse. 2019;39(3):33–42. doi:10.4037/ccn2019654

13. Marra, Annachiara et al. “The ABCDEF Bundle in Critical Care.” Critical care clinics vol. 33,2 (2017): 225-243. doi:10.1016/j.ccc.2016.12.005

14. Kamdar, Biren B et al. “Sleep deprivation in critical illness: its role in physical and psychological recovery.” Journal of intensive care medicine vol. 27,2 (2012): 97-111. doi:10.1177/0885066610394322

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