Written by Clay Smith
Lighter sedation of intubated patients, use of validated screening tools, and use of non-pharmacologic interventions decrease the risk of delirium in our patients.
Why does this matter?
Delirium is common in critically ill patients, occurring in up to 60-80% of mechanically ventilated patients and 20-50% of other critically ill patients. It is associated with greater mortality, length of stay, and cost and is often associated with long term cognitive deficits. Delirium often starts in the ED, and what we do impacts a patient’s course in the ICU. What can we do in the ED to prevent and treat delirium?
It’s more common than we might think.
There are three best practices: sedation protocols, delirium screening, and non-pharmacological interventions first-line.
Sedation protocols – Lighter sedation is usually better when we need to put patients on mechanical ventilation. Using a sedation score, preferably the same as your ICU, can really help. Oversedation is probably harmful. Using a score like the RASS and targeting light sedation is best.
Use a validated tool to detect delirium – CAM-ICU is often used in the ICU setting. An abbreviated version is also useful in the ED called bCAM for non-ICU patients. Inattention is the chief thing to look for. See this helpful page for other scores and guides to download. If you don’t look for it, you may miss it.
First-line focus on non-pharmacologic interventions – Family presence, early mobilization, clocks and calendars, uninterrupted sleep, avoiding restraints if at all possible, keeping it dark and quiet at night, having sunlight in the day, providing hearing and vision aids, and pruning or avoiding sedating medications are all effective at reducing in-hospital delirium. It is also our job to identify electrolyte abnormalities and other illnesses or infections that might contribute to delirium.
Special situation, agitated delirium – Antipsychotics are most often used when patients are very distressed or at risk of self-harm or harming others. No pharmacologic agents are useful in preventing delirium. If intubated, the authors recommend dexmedetomidine. If not, the lowest dose of an antipsychotic, such as haloperidol, for the shortest duration would be a reasonable choice. Avoid benzodiazepines, as these agents are associated with worsening delirium.
How We Do It: How We Prevent and Treat Delirium in the ICU. Chest. 2021 Jun 5;S0012-3692(21)01091-6. doi: 10.1016/j.chest.2021.06.002. Online ahead of print.