Prevention and Management of Delirium in the Intensive Care Unit

Matthew F. Mart; Shawniqua Williams Roberson; Barbara Salas; Pratik P. Pandharipande; E. Wesley Ely

doi:10.1055/s-0040-1710572

Seminars in Respiratory and Critical Care Medicine, Table of Contents

Semin Respir Crit Care Med 2021; 42(01): 112-126
DOI: 10.1055/s-0040-1710572

Review Article

Prevention and Management of Delirium in the Intensive Care Unit

Matthew F. Mart^∗

¹Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee

²Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, Tennessee

,

Shawniqua Williams Roberson^∗

²Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, Tennessee

³Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee

⁴Department of Bioengineering, Vanderbilt University, Nashville, Tennessee

,

Barbara Salas

⁵The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom

,

Pratik P. Pandharipande

²Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, Tennessee

⁶Division of Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee

,

E. Wesley Ely

¹Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee

²Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, Tennessee

⁷Vanderbilt Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee

⁸VA Tennessee Valley Healthcare System Geriatric Research Education and Clinical Center (GRECC), Nashville, Tennessee

› Author Affiliations

Abstract

Delirium is a debilitating form of brain dysfunction frequently encountered in the intensive care unit (ICU). It is associated with increased morbidity and mortality, longer lengths of stay, higher hospital costs, and cognitive impairment that persists long after hospital discharge. Predisposing factors include smoking, hypertension, cardiac disease, sepsis, and premorbid dementia. Precipitating factors include respiratory failure and shock, metabolic disturbances, prolonged mechanical ventilation, pain, immobility, and sedatives and adverse environmental conditions impairing vision, hearing, and sleep. Historically, antipsychotic medications were the mainstay of delirium treatment in the critically ill. Based on more recent literature, the current Society of Critical Care Medicine (SCCM) guidelines suggest against routine use of antipsychotics for delirium in critically ill adults. Other pharmacologic interventions (e.g., dexmedetomidine) are under investigation and their impact is not yet clear. Nonpharmacologic interventions thus remain the cornerstone of delirium management. This approach is summarized in the ABCDEF bundle (Assess, prevent, and manage pain; Both SAT and SBT; Choice of analgesia and sedation; Delirium: assess, prevent, and manage; Early mobility and exercise; Family engagement and empowerment). The implementation of this bundle reduces the odds of developing delirium and the chances of needing mechanical ventilation, yet there are challenges to its implementation. There is an urgent need for ongoing studies to more effectively mitigate risk factors and to better understand the pathobiology underlying ICU delirium so as to identify additional potential treatments. Further refinements of therapeutic options, from drugs to rehabilitation, are current areas ripe for study to improve the short- and long-term outcomes of critically ill patients with delirium.

Keywords

delirium - ABCDEF bundle - cognitive impairment - critical illness - intensive care - early mobility - antipsychotics - dementia

Full Text

References

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