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Critical Care Pharmacological Management of Delirium
Critical Care Pharmacological Management of Delirium Justine Somerville and Dr Ishani Dave 28th July 2016
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Policy Title: Critical Care Pharmacological Management of Delirium in the Critical Care Unit
Executive Summary: This policy provides guidance Pharmacological Management of delirium in the Critical Care Unit
Supersedes: V1
Description of Amendment(s):
N/A
This policy will impact on: Critical care Unit
Financial Implications: N/A
Policy Area: Critical Care Document Reference:
Version Number: 2 Effective Date:
Issued By: Chair of medicines management group
Review Date: August 2018
Authors: Adapted by J Somerville and L Street from Pharmacological guidelines on the management of delirium and sleep disturbances in critical care patients version 3. September 2011. Sheffield Teaching Hospitals NHS Foundation trust. Reviewed by I Dave
Impact Assessment Date:
APPROVAL RECORD
Committees / Group Date
Consultation: Medicine management SQS
9th August 2016 23rd August 2016
Approved by: Medicine management
August 2016
N/A
9th August 2016
ECT002551
Critical Care Pharmacological Management of Delirium Justine Somerville and Dr Ishani Dave 28th July 2016
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CONTENTS Page
Introduction 4
Purpose 4
Scope 4
Duties and responsibilities 4
Pharmacological management of delirium
Background 5
Management of Delirium Flow Chart 7
Pharmacological management of sleep disturbances
Background 9
Management of sleep disturbances Flow Chart 10
Appendices
Appendix 1 Daily Checklist 11
Appendix 2 Delirium Assessment 12
Acknowledgements: Bourne R. Pharmacological guidelines on the management of
delirium and sleep disturbances in critical care patient’s version 3 September 2011.
Sheffield Teaching Hospitals NHS Foundation Trust. Elements of this guideline are
derived from STH NHS Foundation Trust Guidelines.
Critical Care Pharmacological Management of Delirium Justine Somerville and Dr Ishani Dave 28th July 2016
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Introduction
Delirium is an important but easily overlooked problem amongst patients on an ICU.
The aim of this guideline is to ensure patients are comfortable and calm while in
Critical Care, improving their experience and clinical outcomes.
Purpose
To provide guidance on the management of delirium in adult Critical Care patients
Scope
This guidance is for use in Critical Care Department, it is subject to professional
judgement and accountability.
Duties and responsibilities
Implementation of this guidance is the joint responsibility of appropriate Critical Care
medical, nursing and physiotherapy staff.
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Pharmacological Management of Delirium
Background
Delirium is defined as a disturbance of consciousness, with inattention
accompanied by a change in cognition or perceptual disturbance that develops
over a short period of time (hours to days) and fluctuates over time (The
Diagnostic and Statistical Manual of Mental Disorders (DSM IV, 1994)
Up to 80% of mechanically ventilated ICU patients develop delirium and it is
associated with many negative outcomes such as increased lengths of stay,
decreased survival and increased cognitive dysfunction (accessed from
http://www.icudelirium.org/delirium.html 26/07/2016). Three motor subtypes exist
- hypoactive, hyperactive and mixed types. The hypoactive form is the most
common subtype and is often missed, or misdiagnosed.
All patients in ICU are at a high risk of developingng delirium and therefore should
be screened for delirium frequently (on admission and then eight hours
thereafter) Patients may be screened for the presence of delirium using tools such
as the Confusion Assessment Method (CAM), a specific screening tool has been
developed for use on critical care (CAM-ICU) (Appendix 2). A daily checklist
should be filled out to address all the precipitating and augmenting factors
(Appendix 1).
In addition to prevention and non-pharmacological techniques, appropriate drug
management is an important adjunct in the management of patients with delirium.
Drug treatment should be considered when other non-pharmacological measures
have failed or patient has distressing symptoms. Regular drug treatment should
be commenced for patients who are CAM-ICU positive and reviewed daily for
efficacy and adverse effects. When delirium symptoms resolve, antipsychotic
medication can be withdrawn over 48 to 72 hours. Only short treatment courses
(less than a week) should be used. The incidence of delirium is higher if
benzodiazepines are used for sedation, and therefore their primary indication is
treatment of withdrawal delirium e.g. alcoholol withdrawal. However, they remain
a treatment option in patients with severe hyperactive delirium who pose a risk to
themselves or others.
Sleep ddisturbances are often regarded as a precipitating factor for causing
Critical Care Pharmacological Management of Delirium Justine Somerville and Dr Ishani Dave 28th July 2016
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delirium. The cause and effect relationship is not straightforward and therefore
delirium status should be accounted for when attempting to improve nocturnal
sleep quantity in critical care patients. For this reason guidelines on the
pharmacological management of delirium and sleep disorders are included in the
same document.
Further information on the pharmacological management of delirium is also
available from the following links:
https://www.nice.org.uk/Guidance/CG103
http://www.icudelirium.org/delirium.html
References
American Psychiatric association (1994) Diagnostic and Statistical Manual of mental
disorders (DSMIV), 4th Edition. Arlington, VA, US: American Psychiatric Publishing,
Inc.
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Pharmacological Management Flowchart
CAM-ICU delirium Positive
Review drug chart. Prescribe alternative agents where possible to minimise anti-cholinergic activity
Hyperactive
Delirium
Hypoactive
Delirium
Withdrawal
Delirium
First Line: Haloperidol 2.5mg to 5mg qds po and prn max dose (including regular and prn of 30mg daily) OR Haloperidol 1mg to 2.5mg qds IV (unlicensed use) Second Line: Olanzapine 5mg at night.
First Line: Haloperidol 0.5mg tds IV (unlicensed use) Second Line: Olanzapine 5mg at night.
In severe agitation, especially if poses risk to self or others, request specialist advice from Consultant Anaesthetist. If restraints are required refer to restraints policy.
Alcohol withdrawal: Chlordiazepoxide as per hospital pathway Pabrinex® 2 pairs tds for 72 hours Consider Clonidine and refer to separate policy for infusion rates.
Nicotine withdrawal Nicotine replacement patch as per hospital guideline: 25mg patch over 16 hours if smoke over 20 cigarettes per day 15mg patch over 16 hours for patients who smoke less than 20 cigarettes per day. Patches should be removed at 10pm and applied at 6am.
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General Notes:
There is no evidence to support the prophylactic use of haloperidol or other
antipsychotics in the prevention of delirium (Page et al. 2013)
All prescriptions for antipsychotics should be endorsed ‘delirium’ to aid review
of therapy.
Antipsychotics should be gradually withdrawn over 2 to 3 days when the
patient is CAM-ICU negative
Haloperidol there is a risk of QT prolongation (especially with intravenous
administration or with concurrent medication known to cause QT prolongation
e.g. clarithromycin). Obtain baseline 12-lead ECG if not done in the last 48
hours.
Short acting benzodiazepines are associated with delirium and so should be
used as a last resort in alcohol withdrawal
Risperidone may be considered third line if haloperidol and olanzapine have
been tried unsuccessfully
Antipsychotics should be discontinued if patient fully sedated
Patients should not be prescribed more than one antipsychotic concomitantly
Clonidine will not prevent alcohol withdrawal seizures
References
http://www.medicines.org.uk/ (accessed 27/07/2016)
BNF Edition 71 March 2016
Bourne R. Pharmacological guidelines on the management of delirium and sleep
disturbance in critical care patients’ version 3. September 2011. Sheffield Teaching
Hospitals NHS Foundation Trust.
Page V, Ely EW, Gates S, et al. (2013) Effect of intravenous haloperidol on the
duration of delirium and coma in critically ill patients: a randomised, double-blind,
placebo- controlled trial. The Lancet respiratory Medicine; 1(7):515 - 523
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Pharmacological Management of sleep disturbances
Background
Sleep disturbances in Critical Care patients are characterised by sleep
fragmentation. Patients are often sleep deprived; the sleep tends to be
fragmented. It is a problem of sleep continuity and results in reduced quantities of
deeper sleep phases, such as slow wave sleep (SWS) and rapid eye movement
sleep (REM). Sleep disturbances may contribute to patient morbidity including
adverse consequences on respiratory, cardiac, neurological and immunological
function.
Causes of sleep disturbances in critical care patients are multi-factorial and
include: the environment (e.g. noise, light), pain, ventilator dys-synchrony,
delirium, circadian rhythm disturbances, anxiety and medication (e.g. opioids,
benzodiazepines).
Sleep hygiene refers to attempts to make conditions suitable for sleep to occur.
Review all patients who have inadequate sleep (less than 4 hours of continuous
sleep or inability to sleep at night and excessive daytime drowsiness).
Control excessive noise at night
Bright light in the daytime, darkness at night
Encourage regular morning wake up time
Control environmental temperature
Encourage range of motion exercises and activity e.g. patient sitting out
Ensure comfortable position
Avoid caffeine intake by patients in the evening
References
Weinhouse GL, Schwab RJ, Watson PL, et al: Bench-to-bedside review: Delirium in
ICU patients—Importance of sleep deprivation. Crit Care 2009; 13:234
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General Notes:
If the patient has a disruption in normal circadian rhythm and is falling asleep
during the day but is awake at night consider starting Melatonin MR 2mg
nocte. For NG, use unlicensed caps (not MR licenced version)
Annotate prescription with ‘short term sleep aid’. All new prescriptions for
acute treatment should be endorsed “short-term sleep-aid” and reviewed prior
to discharge from Critical Care.
References
http://www.medicines.org.uk/ (accessed 27/07/2016)
BNF Edition 71 March 2016
Bourne R. Pharmacological guidelines on the management of delirium and sleep disturbance
in critical care patients version 3. September 2011. Sheffield Teaching Hospitals NHS
Foundation Trust.
Pharmacological Management of Sleep Disturbance
Delirium positive Delirium negative
Trazodone 50mg nocte Zopiclone 3.75mg to 7.5mg nocte
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Appendix 1 Daily Checklist The care and interventions below are designed to prevent and manage delirium. Please make reference to these 6 elements in your patient assessment documentation.
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Appendix 2