Does This Critically Ill Patient With Delirium Require Any Drug Treatment? 2018

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Intensive Care Med

https://doi.org/10.1007/s00134-018-5310-x

WHAT’S NEW IN INTENSIVE CARE

Does this critically ill patient with


delirium require any drug treatment?
Jorge I. F. Salluh1,2* and Nicola Latronico3,4

© 2018 Springer-Verlag GmbH Germany, part of Springer Nature and ESICM

Their swaying bodies reflected the agitation of their minds, and they Despite the increasing knowledge on epidemiology,
suffered the worst agony of all, ever just within the reach of safety or risk factors and potential preventive and therapeutic
just on the point of destruction. Thucydides (460 BC–400 BC).
interventions [3], the rates of delirium and its associated
mortality remain elevated. In a recent worldwide sur-
vey, we found that knowledge translation in terms of
Delirium is a severe and frequent condition that occurs the application of the best current available evidence to
in 20–40% of patients admitted to the intensive care prevent delirium is largely incomplete [4]. Recent quality
unit (ICU), with higher rates of 60–80% described in improvement studies also showed that adherence to cur-
mechanically ventilated patients. The accumulated evi- rent recommendations on delirium and sedation man-
dence in the past decades demonstrates that delirium agement is low [5, 6].
is clearly associated with hospital mortality, lengths of In this scenario, a daily challenge for clinicians caring
stay, duration of mechanical ventilation and costs [1, 2]. for the critically ill ensues when, after screening patients
Moreover, the presence of delirium and its duration and for delirium and making the diagnostic, they are faced
severity are risk factors for long-term cognitive impair- with the question: “What should I do now? Does this
ment in patients surviving critical illness [1]. Although patient with delirium require drug treatment?” Let us
agitated (hyperactive) delirium attracts the intensivist’s state that implementation of non-pharmacologic strate-
attention and frequently requires interventions to pre- gies to prevent and treat ICU delirium are of paramount
vent self-harm and control the symptoms, the hypoactive importance (Fig. 1) and should be targeted as main goals
and mixed forms are extremely common and frequently of ICU quality improvement projects. We are far from
associated with poor outcomes. However, to correctly achieving this goal; we only have to consider that the
diagnose patients with delirium regardless of its presen- majority of ICUs worldwide still have restrictive ICU
tation form, it is mandatory to use valid and reproduc- visitation policies for family members despite knowl-
ible screening tools such as the Confusion Assessment edge that an extended visitation policy is associated with
Method for the ICU (CAM-ICU) and Intensive Care reductions in the occurrence of delirium [7].
Delirium Screening Checklist (ICDSC).

*Correspondence: [email protected]
1
D’Or Institute for Research and Education, Rua Diniz Cordeiro, 30,
Botafogo, Rio de Janeiro, RJ 22281‑100, Brazil
Full author information is available at the end of the article
Fig. 1 Flowchart for treating patients with agitated (hyperactive) delirium in the ICU (see Supplementary file for more details). RASS Richmond
Agitation Sedation Scale; CAM-ICU Confusion Assessment Method for the Intensive Care Unit; ICDSC Intensive Care Delirium Screening Checklist.
*Sensitivity of CAM‐ICU and ICDSC varies between 75 and 80%; hence, false-negative cases (delirium undetected) are possible. **Atypical anti-
psychotics (i.e., intramuscular olanzapine) can be considered if haloperidol is contraindicated. #Several mnemonics such as DELIRIOUS (D Drugs; E
Environmental factors; L Labs; I Infection; R Respiratory status; I Immobility; O Organ failure; U Unrecognized dementia; S Shock) are available for the
differential diagnosis in patients developing delirium (http://www.icude​liriu​m.org/termi​nolog​y.html)

In real life, two-thirds of clinicians report the use of differ between groups; however, in the literature several
haloperidol to treat delirium and 53% the use of quetia- side effects of antipsychotics are reported that are worth
pine [4]. However, pharmacologic treatments of ICU knowing, including extrapyramidal side effects such as
delirium have little or no impact on clinically relevant akathisia and oropharyngeal dysfunction, dystonic reac-
outcomes such as mortality and duration of mechanical tions such as laryngospasm and trismus, dysphoria, cog-
ventilation [8]. Even when considering the whole popu- nitive dysfunction and neuroleptic malignant syndromes.
lation of hospitalized patients, most studies do not show To date, we caution against the prophylactic use of anti-
benefit of antipsychotics in decreasing the duration or psychotic drugs [11, 12].
severity of delirium [9]. Recently, a well-designed mul- Concerning pharmacologic prevention, novel data
ticenter RCT demonstrated that in critically ill patients from a small RCT showed that dexmedetomidine may
currently receiving best-practice nonpharmacologic reduce the incidence of delirium when used as a continu-
interventions to prevent delirium, the addition of halop- ous intravenous nocturnal infusion [13]. Although the
eridol as a preventive treatment did not improve survival evidence from this RCT is promising, larger studies with
at 28 days [10]. Delirium- and coma-free days, duration representative ICU patient populations at high risk of
of mechanical ventilation, and ICU and hospital length developing delirium are needed before dexmedetomidine
of stay were also unaffected. In this study, the number prophylaxis is adopted in clinical practice. Internation-
of reported adverse effects was very low and did not ally validated scoring systems such as the PREDELIRIC
and E-PREDELIRIC [14] may help to identify high-risk Author details
1
D’Or Institute for Research and Education, Rua Diniz Cordeiro, 30, Botafogo,
patients who may mostly benefit from nonpharmacologic Rio de Janeiro, RJ 22281‑100, Brazil. 2 Programa de Pós‑Graduação em Clinica
and pharmacologic preventive therapies. By integrating médica, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil. 3 Depart-
easily available clinical data that represent risk factors ment of Medical and Surgical Specialties, Radiological Sciences and Public
Health, University of Brescia, Brescia, Italy. 4 Department of Anesthesia, Critical
for developing delirium, these models reliably predict the Care and Emergency, Spedali Civili University Hospital, Brescia, Italy.
development of delirium early during the ICU stay.
Treatment of significant agitation [as diagnosed by a Funding
Dr. Salluh is supported in part by an individual research grant from CNPq and
+ 2 to + 4 Richmond Agitation Sedation Score (RASS)] FAPERJ.
associated with delirium remains an indication for drug
use in the ICU. Agitation may be due to different causes, Compliance with ethical standards
often interacting with each other (e.g., pain and delirium). Conflicts of interest
Moreover, agitation involves increased intensity not only All authors declare that they have no conflict of interest.
in behavioral dimensions but also in psychologic dimen-
sions so that patients may suffer from severe, distressing Received: 3 June 2018 Accepted: 6 July 2018
psychotic symptoms such as hallucinations and delusions
[15]. We therefore recognize that delirium is only one of
the several possible causes of agitation in the ICU patient.
Thus, agitation is only one aspect of delirium that would
merit attention from some of the caring physicians. On References
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