Delirium bundle
Basically attention to detail and excellent nursing care, a “delirium bundle” directed at the risk factors (See Table 2 and Table 3) has been shown to decrease the incidence, duration, length of hospitalization and mortality. While admittedly it is not known if this translates to better longer-term outcomes it makes good clinical sense.
- Establish baseline cognitive function from family/friends.
- Improved psychotropic medication use.
- Organization of nursing care to promote continuity of care and personal knowledge.
- Provide visual and hearing aids.
- Reorientate patient verbally and visually - clock/calendar.
- Attention to causes of sleep deprivation.
- Mobilize early.
- Ensure adequate pain control.
- Avoid physical restraints.
- Avoid constipation.
Hi,
it’z amazing blog . I just added you to my News Reader. Keep up.
Thanks
Tom
Hi,
What drugs could I use to make intubated patients comfortable following major surgery complicated by multiple organ dysfunction? (that do not increase the risk of delirium)
How do I ensure that my patient is not sleep deprived in a multibedded area that has a new patient arriving at 2AM?
Jo
I believe all psychotropic drugs have the capacity to precipitate delirium in the vulnerable patient as you describe. However while opioids have been associated with delirium so has pain - so the answer to your question is an opioid and at Watford in the patient with renal impairment we use fentanyl infusions. There is an arguement for alfentanil as an alternative.
The answer to your sleep deprivation - ear plugs have been tried although some patients do not find them comfortable. The hyperactive delirious patient who is up all night and all day shouting and combative is a challenge to others sleep.
Hi, At Maidstone Hospital in Kent we are currently in the middle of implementing a Delirium Care Bundle. We were wondering if you thought it was ever appropriate to give night sedation to facilitate sleep and return patients to a more normal day/night routine, and if so what would be your drug of choice?
Thanks, Ciaran
Good work introducing a bundle. Maybe you would write an account for the Annals of Delirium?!
I am personally not keen on night sedation for sleep. I believe there are a number of strategies to promote sleep such as nurse evening alarm rounds to rationalise how many alarms are going off at night. One reason patients cite that they cannot sleep is interventions - see American Journal of Critical Care Tamburri et al March 2004; 13: 102-113 free text. Some advocate earplugs although if you have ever used them you’ll know they can be quite uncomfortable. Getting patients out of bed during the day helps i.e. routine. We have a natural day lamp we shine for 40 minutes on patients in our area without sufficient windows. Melatonin has been used and we are waiting for the results of a large Dutch study due out soon.
I believe more that delirious patients don’t sleep (or sleep most of the time) rather than sleep deprivation causes delirium.
Ideal night sedation? Trazdone is recommended by some and zopiclone by others.
What are your thoughts on the recent article in CCM regarding haloperidol infusions to prevent delirium in the elderly post-surgical patient? (Wang et al. CCM 2012 Vol. 40 No.3).
Thanks
Fraser
Thanks for your help. We will definatley try these strategies, and would certainly be happy to write an account of our experience for the Annals of Delirium! Ciaran
Hi Fraser. The Wang paper is interesting and adds to the evidence that haloperidol may modify delirium in our ICU patients. It was a large study of 457 patients but 90% of patients were admitted following elective surgery which is reflected in the low APACHE scores - mean around 9. With a dose of less than 2 mgs the incidence of delirium was reduced from around 24% to 16%, the length of stay was significantly different but in actuality was reduced from a median of 23 hours to 21.3 hours. The accompanying editorial is worth reading
In my opinion I do not think this paper alone justifies the use of prophylactic haloperidol in all our ICU patients, but there is an ongoing study at Watford the results of which are eagerly awaited. Watch this space.