Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade

comatose, non-delirious state within 24 hours of corticosteroid administration (odds ratio [OR]

1.52 [1.05–2.21], p=0.03). Delirium was documented on one or more days in 83% of patients, with

a median duration of 7 days. There was no significant association in prednisone-equivalent dose

and transition to delirium. Schreiber et al. recognize that a direct causal relationship could not be

determined between corticosteroid use and delirium from this observational study; however, they

believe that the study adds valuable data toward our understanding of risk factors for delirium in

to delirium in a mixed medical and surgical ICU population (n=1112) found no association between

steroid use and a transition to delirium. The median prednisone equivalent dose was 50 mg (Crit

Outcomes of sedation-related versus illness-related delirium: A single-center study using propofol

and fentanyl timed its CAM-ICU assessments before and after a daily sedation interruption protocol.

Rapidly reversible delirium was defined as delirium while patients were receiving sedation that resolved

within 2 hours after performing an SAT. This type of delirium was rare (12% of the 102 patients), but

these patients has a prognosis that was similar to patients who did not have delirium. Most patients

(75%) had persistent delirium, delirium that did not resolve with cessation of sedatives, a higher risk

both sedation- and illness-related delirium, and additional research in this area is needed to clarify the

differences in short- and long-term outcomes.

tool such as either the CAM-ICU or the ICDSC. The PAD guidelines summarized their review of five

delirium assessment scales used for adult ICU patients. The two scales with the highest psychometric (e.g.,

validity and reliability) scores were the CAM-ICU and the ICDSC. Both scales were designed for patients in

the ICU either on or off mechanical ventilation, and both showed high sensitivity and specificity when tested

against the American Psychiatric Association’s criteria for delirium.

Delirium should be assessed at least every 8-12 hours and documented in the medical chart; results

should be discussed with the medical team. Because these assessment scales cannot distinguish

between sedation- and disease-related causes of delirium, delirium assessments should ideally be timed

both before and after SATs with appropriate time allowed for drug clearance (www.icudelirium.org,

for delirium while receiving ongoing analgesia or sedation, an SAT should be conducted if the patient

passes the safety screen to assist in ruling out a medication-induced cause of delirium.

decrease sedative doses, if safe), decrease ongoing risk factors, address inciting factors (e.g., metabolic

derangements, infection, withdrawal), and try nonpharmacologic treatment and preventive measures

when appropriate.

the PADIS guidelines suggest not using haloperidol, an atypical antipsychotic, dexmedetomidine, a statin,

or ketamine to prevent delirium in critically ill patients. Instead, the recommendations are focused on

nonpharmacologic prevention methods when feasible, particularly for patients at high risk of delirium.

Preventive efforts may help avert 30%–40% of new-onset delirium cases, particularly in older adults.

Recommended nonpharmacologic strategies by the PADIS guidelines include:

Performing rehabilitation or mobilization in critically ill adults

stimulation, use of clocks); improve sleep (e.g., minimize light and noise); improve wakefulness (i.e.,

reduce sedation); reduce immobility (e.g., early rehabilitation/mobilization); and reduce hearing and/or

visual impairment (e.g., enable use of devices such as hearing aids or eyeglasses).