Drugs may be considered as the most easily reversible trigger factor; most common are benzodiazepines, anticholinergic drugs and high dose narcotics.
Analgesics:
Codeine
Fentanyl
Morphine
Pethidine
Antidepressants:
Amitryptyline
Paroxetine
Anticonvulsants:
Phenytoin
Antihistamines:
Chlorphenamine
Promethazine
Antiemetics:
Prochlorperazine
Benzodiazepines:
Midazolam
Lorazepam
Cardiovascular agents:
Atenolol
Digoxin
Dopamine
Lidocaine
Corticosteroids
Furosemide
Ranitidine
sir/madam
after compliments
am working at dubai.
do you have a standard drug strategy for sedating patients on mechanical ventilator? we always use a combination of dormicum+fentanyl/morphine for sedating patients during mechanical ventilation and we find >80% of patients becomes agitated and very restless on extubation. we uses haloperidol+ dormicum to control them. if you can highlight on these, it will be highly useful
thanking you
dr Pramod
Its not so much what you use as how you use it. A fairly basic article in Care of the Critically Ill. December 2008 Volume 24.6 describes the use of sedation scores with sedation breaks or “holidays”. Midazolam, while having useful proporties for sedation, is deliriogenic. The Intensive Care Society are due to produce new guidelines on sedation. In the meantime more analgesia, less sedative drug and monitor for delirium. Good luck!
hello, i am “deliriously” happy to find this web site! Please, what is the correct way of giving haldol to delirious patients? i have learned in a few seminars that one can start with 2mg iv, then double dose if first doesnt work, and may continue to double dose to a max of 75 mg until the patient is “comfortable” yet safe (ie still breathing). however our intensivists have only ordered haldol iv every 6 hours prn; i have seen another order iv q6, then q4 if pt is still agitated, then q2 if still agitated, etc. our psychiatrist orders it iv q6. this is very frustrating for me as i work nights, and the patients in this state can truly be out of control. i want to help these patients and nurses as best as i can by making the right pharmacologic choices and writing the orders correctly. Please help. Thank you. Sooooo Looking forward to your response,
Baby NP
Thank you for your enthusiasm. Frankly I do not know the answer to your question. Agitated delirium is extremely difficult to manage. The number one thing to do would be to get to the bottom of why they are delirious and treat that.
I am of the opinion that the only sure fire way is for the patient to have a 24 hour sitter. The sitters would have to rotate every couple of hours as it is a very stressful job. Usually someone sitting with the patient reassuring them, distracting them and gently preventing them from removing lines and support devices is sufficient. But leave them alone for so much as a moment and the arterial line or tracheostomy tube is waving in the breeze - and remember hyperactive delirious patients never really sleep. The 24 hour individual sitter is, however, in virtually all cases an impossible resource to provide so we usually resort to drugs.
The correct dose of haloperidol is not known but there are a number of standard ways in which it is used. Note a word of caution care of the elderly physicians/psychiatrists would start with 0.5mg and probably have a maximum of 2mgs.
Personally I usually start with 2.5mgs iv unless the patient is fairly young and fit in which case I use 5mgs, I would double that after 1 hour (it takes 40 minutes to maximum effect) then on occasion double it again to 10mgs OR more often if the total 7.5mgs has not worked I add in olanzapine 5 mgs im. I do not double up to more than 10mgs a single dose because I do not believe a bigger dose is going to work if 10mgs has not. I have seen much bigger doses used - mind 75mgs is an impressive dose - but less often now. If I am writing a regular dose I use 2.5mgs 6 hourly then an additional 10mgs can be used in between. I like to have an ECG before using haloperidol at all.
I am not surprised that benzodiazepines are often resorted to in these cases even though they are likely to aggravate the delirium itself they can aid in the short term keeping the patient, and staff, safe.
Hi, I’m from Argentina, and very happy to find you!!! I’m doing a research about “delirium as cause of weaning failure”, I’ve been reading abuot this topic and I found a reference of this site.
I was wondering if you could help me with some papers, reviews, or any data about this topic.
I would read the information on this web site, but I would like to read your opinion about this: on patients with difficult weaning, delirium is a suspected diagnosis? CAM ICU is already validated, so… once you have made the diagnosis, what are the options? haloperidol and dex? we don’t have olanzapine IM, so… do we have an option? quetiapine? risperidone? clorpromazine? prometazine?
thank you so much
Try: The impact of delirium on clinical outcomes in mechanically ventilated surgical and trauma patients. I Lat, W McMillian, S Taylor et al. Critical Care Medicine 2009; 37: 1898-1905
Hypoactive delirium after cardiac surgery as an independent risk factor for prolonged mechanical ventilation Stransky et al. Journal Cardiothoracic vasc anesth 2011; 25: 968-74
Delirium is often a contributing factor delaying extubation although the weaning itself may be straight forward. Treating any cause you can is the key to ICU delirium - new infection? drugs e.g. steroids - do they need them?, pain?, increasing uraemeia? Treat the cause. Then my first choice is small dose iv haloperidol if hypoactive delirium and not contraindicated. I also use enteral quetiapine starting 25mgs 12 hourly reviewing daily. More intuition than evidence based!
Hello,
It’s been a while since I visited this website, but there is always something new to discover. Thank you for your efforts.
I was recently told by a nurse that propofol also causes ITU delirium; is this so? Can you point me to any references to illustrate this? I find that so many of our patients are on propofol for quite some time. I would hate to think that we are overlooking a factor in the cause of delirium.
Thank you.