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deliriumJosh Farkas MD MSTwitter: @PulmCrit

Blog: www.PulmCrit.orgBook: www.EMCrit.org/IBCC/TOC

Division of Pulmonary & Critical Care MedicineUniversity of Vermont Medical Center

definition

• acute diffuse brain dysfunction

typology epidemiology

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why do we care? causes• CNS catastrophe (CVA, meningitis, seizure)• Medications

• Benzodiazepines, muscle relaxants• Antihistamines• Opioids• Zolpidem • Steroid

• Withdrawal• Metabolic abnormality

• Hypoglycemia• Hypernatremia• Hypercalcemia

• Organ failure• Hepatic encephalopathy• Uremia• Shock• Severe hypercapnia

• Sleep deprivation• Noise• Examinations, lab draws• Uncontrolled pain

Pandharipande 2006 PMID 1639485

evaluation?

Give 10 mg of Haldol and call me in the morning.

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causes• CNS catastrophe (CVA, meningitis, seizure)• Medications

• Benzodiazepines, muscle relaxants• Antihistamines• Opioids• Zolpidem • Steroid

• Withdrawal• Metabolic abnormality

• Hypoglycemia• Hypernatremia• Hypercalcemia

• Organ failure• Hepatic encephalopathy• Uremia• Shock• Severe hypercapnia

• Sleep deprivation• Noise• Examinations, lab draws• Uncontrolled pain

• CNS catastrophe (CVA, meningitis, seizure)• Medications

• Benzodiazepines, muscle relaxants• Antihistamines• Opioids• Zolpidem • Steroid

• Withdrawal• Metabolic abnormality

• Hypoglycemia• Hypernatremia• Hypercalcemia

• Organ failure• Hepatic encephalopathy• Uremia• Shock• Severe hypercapnia

• Sleep deprivation• Noise• Examinations, lab draws• Uncontrolled pain

• Exam• Signs of shock/organ failure?• Focal neuro signs?

• Labs• Fingerstick glucose• Chemistries• ABG/VBG if hypercapnia suspected• Pertinent drug levels (e.g. digoxin, lithium, phenytoin)

• Infectious workup if sepsis suspected• Neuroimaging if…

• Focal signs • CNS trauma• Anticoagulation• Major unexplained change from baseline

• LP• Low yield for ICU-onset delirium• Consider if specific risk factor

• EEG if…• Seizure history• Facial twitching/automatisms• Nystagmoid eye movements

early surveillance vs preventionprevention

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prevention #1: poisonous meds

• benzodiazepines• fluoroquinolones• zolpidem et al.• anticholinergics (diphenhydramine)

opioids & delirium

•Good: titrated to pain

•Bad: calm-down juice

prevention #2: pain strategy

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prevention #3: sleep quality prevention #4: melatonin

OK organs, lights out, it’s time to go to sleep!

-Shilo L et al. 1999 PMID 10334113

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dosage?

• Most patients: 3 mg QHS• Agitated delirium: 6 mg QHS

prevention #5: insomnia plan

Give 10 mg of Haldol and call me in the morning.

insomnia pitfalls

• deleriogenic medications

• delayed therapy

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insomnia pitfalls

• deleriogenic medications

• delayed therapy

insomnia solutions

• nondeleriogenic medications• Quetiapine 25-50 mg• Tradozone 50 mh

• pro-active therapy

prevention #6

• Early mobility• Physical therapy• Daytime stimulation

treatment

• #1 = double down • poisonous meds• pain strategy• sleep quality• melatonin• insomnia plan• mobility, daytime stimulation

treatment

• #2 = treat ALL contributory factors

• CNS catastrophe (CVA, meningitis, seizure)• Medications

• Benzodiazepines, muscle relaxants• Antihistamines• Opioids• Zolpidem • Steroid

• Withdrawal• Metabolic abnormality

• Hypoglycemia• Hypernatremia• Hypercalcemia

• Organ failure• Hepatic encephalopathy• Uremia• Shock• Severe hypercapnia

• Sleep deprivation• Noise• Examinations, lab draws• Uncontrolled pain

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treatment #3

• “antipsychotics”• Sleep disturbance• Dangerous agitation

antipsychotic non-deliriogenic sedatives

• role• Control symptoms• Facilitate sleep

•Avoid deleriogenic sedatives

commonly used antipsychotics

Haloperidol(HALDOL)

Quetiapine(SEROQUEL)

Olanzapine(ZYPREXA)

Route IV preferred

IM possiblePO discouraged

PO only

Rapidly absorbed (within 1 hr)

PO (slowly absorbed)

IV, IMOral disintegrating tablet (ODT)

Half-life ~22 hours ~7 hours ~30 hours

Major advantages Most titratable agent.

Immediately available in most units.

- Shorter half-life makes this a reasonable

drug for insomnia.- High ceiling (800 mg/d)

- No risk of Torsades de Pointes.

Disadvantages Extrapyramidal symptoms

Tardive dyskinesia

PO only Low dose ceiling (30 mg)

Effect on QTc / Torsades Highest Low No risk

Dose - Start with 2-5 mg IV

- Wait 20 min before re-dosing.- If no response to cumulative dose of 10-20 mg try different drug class.

- Insomnia: 25-50 mg QHS

- Vented patients: 50 BID (max 800/d)- Asymmetric dosing to preserve sleep

- Twice strength of haloperidol.

- Delirium in ventilated patient: 5-20 mg QHS

Major roles - Acutely agitated patient.

- Test dose

- Insomnia

- Agitation/delirium on ventilator

-Agitation/delirium on ventilator

-Acutely agitated patient.- Patient with prolonged QTc.

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Lies, all lies

treatment #4

• Refractory agitation?• Severe sundowning?

key points• common & problematic• delirium-preventative measures for ALL patients • poisonous meds• pain strategy• sleep quality• melatonin• insomnia plan• early mobility

• if delirium occurs:• evaluate & treat all causes• symptom control with antipsychotics• ? nocturnal dexmedetomidine

More insanity:Blog: www.PulmCrit.orgiBook: www.emcrit.org/IBCC