Identify and treat the precipitating cause
- Deliriogenic drugs should be reduced or withdrawn whenever possible.
- Use daily sedation targets and spontaneous awakening trials if tolerated.
- Biochemical, hypoxic and haemodynamic derangements should be corrected
- Screen for infection, identify or treat most likely source.
Pharmacological interventions
Delirium once diagnosed should be treated pharmacologically if it is persistent, delays the patients progress e,g, extubation, mobilisation or is hyperactive and distressing.
Haloperidol
Haloperidol, on the current limited evidence available, is the drug of choice in all available guidelines. It is the only antipsychotic given intravenously; starting dose of 2 to 5 mgs depending on patient age and weight. This dose can be doubled and repeated.
Remember a) give it at least 30 minutes to work and b) don’t give it in a patient who has a QTc over 500 msecs and with extreme care if the QTc is over 450msecs.
Alternative antipsychotics
Olanzapine has been shown to work as well in critically ill patients - it can be given intramuscularly as well as enterally.
Other antipsychotics available, but similarly with limited evidence for their use and safety, include risperidone and quetiapine.
Benzodiazepines
Benzodiazepines are deliriogenic. Ideally they should be reserved for the treatment of alcohol withdrawal - for which they are indeed the drugs of choice - or when patient or staff safety may be at risk.
What impact can the reassurance of the familiar have in cases of ICU delirium? Do voices and touches of loved ones help? This has recently been happening to my dear partner and the ICU staff at St George’s Hospital in Tooting welcomed my presence and felt such reassurance was a positive influence as John emerged from emergency surgery and many days of sedation. He has been able to briefly articulate some terrible nightmares and I feel that my being there has been a helpful influence in his being able to begin to rationalise them.
I am sure the presence of a loved one helps when orientating a patient. Even a familiar nurse is considered important. Environmental factors include not too much or little stimulation!
It is also important to allow patients to talk about the nightmares which are very common and commonly distressing but maybe less so when explained as part of a delirious episode.
The dose of haloperidol, according to recent advice by elderly care physicians is 0.5 to 1mg rather than 2-5 mg as suggested. I am not an expert on pharmacology, delirium or ITU care. So I am not finding fault with you but asking your present opinion.
I have a practical experience of treating 2 elderly patients with haloperidol (in last 3 months )- 2 mg given on both occasions and both the pateints are 72 yr old. Both of them developed increasing confusion, motor spasms(involuntary), and other extrapyramidal symptoms!!! with single dose. Both of them were in general wards, with 1-2 predisposing factors.
kishore.
Sorry for the delay in answering! The dose of haloperidol has never been firmly established. The dose required to block the dopamine receptors at the optimum 60% is very variable. Very broadly care of the elderly physicians and psychiatrists do use lower doses than ICU physicians and palliative care consultants. Maybe because for these patients time is not on our side? Among UK consultant intensivists 2.5mgs iv is the standard dose. (Historically very large doses have been used in ICU - 480mgs/24 hours (not now!)). Finally enteral haloperidol causes more EPS than iv.
How do you feel about using droperidol as treatment?
I have no experience of using droperidol as a treatment for delirium. There is limited evidence for all the drugs used. Haloperidol itself is used mainly on the basis of case reports and series albeit large numbers of patients involved. I think if you decide not to use haloperidol to treat delirum for what ever reason then probably it would make more sense to use one from a different drug group rather than substituting droperidol.
I recently attended a seminar in watford on delirum and now hopeing to get delerium screening established at the ITU i work at in the midlands. The first step for us is changing our sedation scoring to RASS as i find the system we use at present very basic. Also need to work on changing staffs attitude to sedation. I find that many staff and relatives have the view it is kinder and safer to increase sedation for pts who get distressed although this obviously causes other problems. Also there are many experiences of haliperidol increaseing pts confussion and agitation. Does giving regular halliperidol improve delirum given to patients who are assesed as becoming delirous before they become unmanageable? Often it is given when the pt is already very agitated and difficult to manage as a PRN dose.
First the RASS is very inuitive and certainly the nurses at Watford found it easy to use and helpful for monitoring sedation so I hope that will be reasonably straight forward. Sedation starts with good analgesia and if the patients can be seen to be comfortable then being awake does not appear to relatives or staff to be so distressing (easy to say and not always achievable but if we have in mind what we want it we will get there more often than not).
Yes with practice you can see the non-agitated delirious patient who is starting to become paranoid and anticipate increasing agitation. In my practice I would give that patient haloperidol after correcting any obvious cause e.g. hypoxia (you may need to give haloperidol to effectively give oxygen). If a patient needs a repeat dose I will often prescribe 6 hourly haloperidol and review at 24 hours. Classically though the very agitated patient is difficult to manage even with relatively large doses of antipsychotics. Treating the cause if you can - thats the key! Good luck with your programme your comments tell me you are on the right track.
ps make sure your patient has normal potassium and check the QTc before giving haloperidol.
sir,he was case of post traumatic delirium (ICH -MINNMAL FRONTO-PARIAL)& ALCHOLIC DID NON RESPOND TO HALOPERIDOL 20 mg /day along with high dose of benzodiazepen .what to do?
Agitated delirium can be extremely difficult to manage so if anyone reading this can assist then do comment. First decrease risk factors, in the case of trauma treat pain, make sure urinary cathether not blocked or remove it (medical restraints). Benzodiazepines are advised in alcoholics although high doses will aggravate delirium (see Cochrane review on Benzodiazepines in delirium). Clonidine enterally or infusions is used frequently in ICUs and dexmedetomidine (not currently available in Europe) has in individuals been very successful. What would help I believe is (and results from specialist delirium wards would bear this out) a sitter just to calm the patient and to prevent removal of essential monitoring and tubes. This is an extra member of staff over and above the nurse caring for the patient and would need to be rotated regularly as it will be a stressful role. We do not currently have the resources for this I’m afraid and resort to low dose propofol infusions with antipsychotics (enteral quetiapine in the last case who got EPS with haloperidol) and clonidine so we can medically treat these patients safely.
Dear Valerie Page
Above you mention that historically vary high doses of haloperidol has been used for treating agitated delirium in the ICU, but not now! what is your practice/ opinion on maximum dose/24h, and secondly: has any evidence been produced.
best wishes
Dear Lars -
OK currently I generally don’t work in 24 periods when managing agitated delirium but to give you an answer I (personally) do not tend to go above 20mgs intravenously in a 24 hour period (but would give that over 2 hours if necessary if that makes sense) mainly because I believe if 20mgs has not settled the agitation then I need to try a different strategy. (The British National Fomulary recommends no more than 18mgs iv and companies are withdrawing the intravenous license)
The evidence for haloperidol working is limited to large case series, case reports and a couple of small RCTs only one of which was run to good research standards. There is much less published on other antipsychotics and most are comparing one with another or haloperidol. Regarding doses there is evidence from PET scans that much lower doses of haloperidol saturate the receptors and that our practice in ICU is heavy handed to say the least.
Here at Watford we are about to embark on a trial which we hope (expect) to add to our knowledge on the clinical effectiveness of haloperidol - not before time. V
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Dear Dr Valerie Page,
I ahve been interested in delirium for several years now and the itu that i work in have several team members that are also keen to implement the CAM-icu and the RASS as recommended by the NICE GUIDELINES july 2010 Delirium.
We are currently sharing information regarding Delirium within the Unit and hopefully to commence the RASS and CAM icu in October 2011.
Although from the comments previously regarding Haloperidol and sitting with the patient when agitated and ensuring other causes are addressed e.g pain, infection, environment.
what is your advice for the patient that is hypoactive what are the best ways to manage these patients as these are the patients that are at a higher risk of experiencing the negative aspects of delirium such as longer hospital stays, higher mortality, residential care.
I shall look forward to your reply.
Thank you for your time to read this post.
Lorraine
I wish you well with implementing the CAM-ICU and RASS, once the staff see the benefits (and they will) then it will become second nature at the very least to think about a patients mental status.
Hypoactive delirium is a difficult one - to give drugs or not to give drugs that is the question. First of course when it comes to delirium find the cause, it is always precipitated by something. Some of the causes are easier to deal with than others - infection or steroid drugs are easier to manage than hyponatraemia. Treat any treatable cause and there may be more than one, treat them all.
You can consider giving an antipsychotic if you believe the delirium is hindering clinical progress (eg not able to extubate because of inability to cough or co-operate with physio) but you need to balance that against side effects. If I am treating I use haloperidol if not contraindicated (long QT, Parkinsons) and I give half the dose e.g. 1.25mgs. There is no robust evidence for this but that is generally the practice for clinicians who use antipsychotics in hypoactive delirium.
Good luck!
Hello, Hi, Hey, great article, post, blog, I, we love, like, loved, liked it !!!
Nice work Dr Page. Over the past ten years I’ve had three open heart surguries, one followed by a month long coma, another preceded by a minor stroke. I have short term memory deficits which now makes me unable to continue a software engineering carreer.
During the worst operation I remember a horrible experience of flashing lights and a horrid machine noise - just as a Josefina described. This was followed by a nightmare about being imprisoned by Homeland Security.
Things did get better, I was released (escaped?) from the desert prison and I built a golf course next to the base. I woke up a month later. I was told I was combative, had to be restrained, then put in an induced coma.
Horrible experience, happy ending.
Regards, Dee
Thanks Dee, personal stories are always powerful when trying to convince ICU clinicians of the importance of delirium. Patients sometimes worry about the stigma associated with what is an essentially psychotic episode, more so if it was traumatic. The more light patients shine on the dark face of delirium by sharing their experiences the better for all.
We welcome contributions from patients to the Annals of Delirium, a European newsletter - contact valerie.page@whht.nhs.uk
Good luck!