Once delirium is recognized, the use of pharmacologic medication may be better in decreasing the symptoms. Haloperidol and atypical antipsychotics have been suspected to have potential benefits in the treatment of delirium; however, this has yet to be proven. Olanzapine vs haloperidol vs placebo has shown no difference in the number of delirium-free days. Quetiapine has shown a shorter time to resolution of delirium when compared with placebo; however, there was not a significant difference in LOS or days with mechanical ventilation (Jones & Pisani). There is only anecdotal evidence of the use of haloperidol in treating delirium; nevertheless, it may be the medication preferred for preventive treatment. Surgical literature has shown that low dose haloperidol or risperdone has been successful in decreasing the incidence of delirium. Whether this can be generalized to a critically ill medical population still remains to be demonstrated (Reade & Finfer).
Nonpharmacologic modalities should be used in a preventive manner, but some of these methods have been shown to decrease the duration of delirium in those already exhibiting its signs and symptoms. The full medical team should take an active part in helping to minimize disruption of sleep architecture or sleep deprivation, reorientation of the patient to the time, date, and their surroundings throughout the day, timely removal of catheters and physical restraints, use of eye glasses or hearing aids, adequate hydration, scheduled pain control, minimization of unnecessary noise or stimuli, and use of a nonpharmacologic sleep protocol. Allowing a patient to sleep comfortably at night with the lights off, no noise, no cleaning or labs being drawn, will help to prevent disruption of the natural circadian rhythm (Pun & Ely).
The ABCDE method is just one approach that pulls together all aspects of critical care in the prevention of delirium. It highlights the important aspects of daily awakenings and breathing trials, adequate pain management, improvement of sleep cycle, daily monitoring of delirium, and early mobilization and exercise. All aspects of this model have been proven to reduce or lessen the negative course of delirium in the ICU patient as well as positive outcomes in the number of days of mechanical ventilation, LOS in the ICU and the hospital, functional outcomes, and overall survival (Brumel & Girard).
In summary, delirium has become a prominent issue in the care of the critically ill. Implementing a strategy for daily screening and then acting on those results to change treatable risk factors and avoid problematic ones, should become standard practice in the modern day ICU. We are still in the early phases of identifying the full, long-term effects of delirium, but we do recognize that there are detrimental cognitive effects. Delirium is a large burden, not just on the patients lifestyles, but on their families and society as a whole. The future requires us to take a more proactive course in the prevention of delirium and make prevention an integral part of the daily critical care tasks.
Dr. Awerbuch is attending physician, Division of Pulmonary and Critical Care Medicine, Clinical Instructor of Medicine, Icahn School of Medicine, Elmhurst Hospital Center, Elmhurst, New York.
In this the final commentary of my tenure, Dr. Awerbuch describes a most disturbing and severe consequence of critical care—delirium. All the ramifications of delirium and long-term sequelae are not yet known, but it again appears that merely survival should not be our only significant metric. In the last few commentaries, we have discussed early mobilization, ARDS , and now delirium, with its inherent long-term problems. Prevention, as our mothers would have said, is worth a pound of cure, as there is no definitive therapy for this condition per se: so preventive approaches as spelled out here should be an important part of our daily ICU care.
Again, as this is my final commentary as section editor, I wish only success to my successor, Dr. Lee Morrow, and I thank the readers for their interest and attention, of course all the authors for their time and expert effort, and to Pam Goorsky, our publication editor, for all her help and making sure that I was timely and absolutely correct.
I wish all the readers a happy, healthy, and productive 2015 and again thank all of you and CHEST for this opportunity of service.
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In the Critical Care Commentary by Dr. Martin E. Warshawsky, “ARDS: The past, present, and future?” in the October issue of CHEST Physician, the first sentence in the second paragraph of the article should have read: “ARDS is characterized by PO2/FIO2 less than 300, bilateral radiographic opacities not fully explained by effusions, collapse, or nodules, and respiratory failure not fully explained by cardiac failure or fluid overload (ARDS Definition Taskforce. JAMA. 2012;307[23]:2526).”