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- Deliriogenic drugs should be reduced or withdrawn whenever possible.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
Olanzepine 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.