Delirium in the ICU

In the last decade, research has led to an increased awareness that the medication and nonmedication strategies used in a hospital’s intensive-care unit to treat pain, agitation and delirium may have important effects on post-ICU outcomes, according to John Devlin, associate professor of pharmacy practice in Northeastern’s Bouvé College of Health Sciences.

Last month, Devlin was the first critical-care pharmacist to be invited to present at the International Symposium on Intensive Care and Emergency Medicine in Brussels, Belgium, where he spoke about delirium prevention and management and his National Institutes of Aging-funded research in this area.

Eighty percent of ICU patients experience delirium, a condition characterized by sudden confusion and a rapid change in brain function. It is associated with increased mortality, prolonged hospital length of stay and long-term cognitive and functional decline, Devlin said.

“We’ve realized over the last decade that patients who develop delirium while in the ICU are put on a different post-ICU trajectory that can alter their disposition and quality of life,” he said, noting this is particularly true among the elderly.

Later this year, the Society of Critical Care Medicine will publish new consensus guidelines defining best practices for the prevention and treatment of pain, agitation and delirium. Devlin and 15 other leaders in the field, including pharmacists, nurses, intensivists and psychiatrists, developed these evidence-based guidelines as a road map for ICU clinicians at the bedside and to identify the most pressing research questions in this area.

“There are never enough resources in any hospital to have a psychiatrist or neurologist evaluate all ICU patients with suspected delirium on a 24-7 basis.  So bedside clinicians, particularly nurses, must regularly evaluate patients for signs of delirium.” These assessments allow an ICU team to evaluate delirium risk factors and consider treatment strategies.

Additionally, ICU clinicians can do a variety of things to prevent delirium, Devlin said. The guidelines recommend that patients be taken off sedation for short periods every day until they wake up and that they be mobilized, with the help of physiotherapists, early in their ICU stay. The guidelines also recommend that medications shown to reduce delirium be used over those that have not.

“Interventions shown to prevent delirium in the ICU have been found to have a much greater impact on patient outcome than the drug and nondrug therapies that may be implemented after delirium develops,” Devlin said.

Devlin and his colleagues hope that the new guidelines will serve as a valuable tool for initiating conversations between the interdisciplinary ICU teams as they make decisions about how best to maintain their patients’ comfort but also provide the care that will boost post-ICU functionality and psychological health.