Assessment and Treatment of Agitation/Delirium within Adult Critical Care

Publication: 01/07/2018  --
Last review: 01/01/1900  
Next review: 01/07/2021  
Clinical Guideline
CURRENT 
ID: 5570 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2018  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Assessment and Treatment of Agitation/Delirium within Adult Critical Care

This guideline is for Adult Critical Care patients only. Please click here for the 'Clinical Guideline for the Diagnosis and Management of Delirium in Adults' (non Critical Care).

Aims

To improve the management of patients within Adult Critical Care experiencing acute confusion and or delirium.

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Background

A high incidence of delirium is reported in Adult critical care - reportedly up to 70-80%.
 
Delirium is associated with higher morbidity and mortality than age-matched controls.
 
Delirium consistently features in follow-up clinics one of the most vivid and distressing elements of the patients’ critical care experience, and is associated with longer-term cognitive impairment in critical care survivors.

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Definition

A neuropsychiatric syndrome characterised by acute onset of fluctuating cognition and inattention associated with triggering factors.

Subtypes

Hyperactive - Features include heightened arousal, restlessness, agitation, and aggression.

Hypoactive - Features include sleepiness, lack of interest in daily activities, being quiet and withdrawn. Often underdiagnosed especially in elderly patients.

Mixed - Features vary between hyperactive and hypoactive.

Traumatic Brain Injury (TBI) associated.

Precipitants:-  ‘DELIRIUMS

  • Drugs/Dehydration
  • Electrolyte imbalance
  • Level of pain
  • Infection/Inflammation
  • Respiratory failure
  • Impaction of faeces
  • Urinary retention
  • Metabolic disorder/Myocardial Infarction
  • Subdural Haematoma/Sleep deprivation

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Treatment / Management

Risk factors (not exhaustive)

  • Age
  • Severe illness
  • Cognitive impairment (e.g. traumatic brain injury)

Additional list of risk factors.

  • Advanced age.
  • Underlying brain diseases such as dementia, stroke, or Parkinson disease, particularly when there are current problems with memory.
  • Use of multiple medications (particularly psychiatric drugs and sedatives), or multiple medical problems.
  • Sudden withdrawal of a regular medication or cessation of regular alcohol use.
  • Frailty, malnutrition, immobility.
  • Advanced cancer.
  • Undertreated pain (although excessive use of opioid pain medication for pain control can also impair brain function).
  • Immobilization, including physical restraints.
  • Use of bladder catheters.
  • Limb fractures.
  • Interventions, including diagnostic tests.
  • Poor eyesight or hearing.
  • Sleep deprivation.
  • Organ failure, e.g. chronic lung disease, heart, kidney, or liver failure.
  • ……i.e. nearly all critically ill patients.

Screening / Diagnosis SOP  - see Appendix 1

Differential diagnosis

  • Dementia (may coexist)
  • Depression
  • Schizophrenia/Psychosis
  • Dysphasia
  • Non-convulsive epilepsy
  • Mania

CAMS -  Helpful mnemonic

C hangeable course
A cute onset and poor Attention
M uddled thinking
S hifting consciousness

CA2MS - diagnosis requires CA2 and either M or S

Fuller description and application of CAM-ICU see Appendix 2 and suggested video in references

Do’s and Don’ts of preventative and non- pharmacological treatments / approaches 

DOs and DON’Ts

DO…

DON’T…

Rationalise medications (see appendix for list of deleriogenic medications)

Argue/confront

Promote normal sleep pattern (day/night)

Move ward/bay

Ensure hydration

Expose to excess noise/light disturbances

Re-orientate/reassure patient regularly

Catheterise unnecessarily

Monitor bowels/treat constipation

Use physical restraint

Monitor for and treat pain adequately

Use antipsychotics unless other interventions have failed

Utilise familiar nursing staff

Use large doses of antipsychotics, particularly in the elderly

Encourage early supervised mobilisation

Give antipsychotics to patients with prolonged QTc, with Parkinsonism or Lewy body dementia - use lorazepam instead (see below)

Optimise sensory impairment (glasses/hearing aids)

Wake unnecessarily

Monitor for and treat infection

Prescribe haloperidol without a maximum daily dose

Optimise nutrition

Forget nicotine withdrawal as a precipitant of agitation

Pharmacological Treatment - Use when other non- pharmacological intervention have not succeed -

 

If the Patient is aggressive or severely agitated-

Suggested regime only - at senior clinician’s discretion but consider the benefits to consistency in approach and allowing adequate time for medication to become effective i.e. atypical antipsychotics. Ensure airway skilled personnel/equipment available within the critical care environment.

NB As dexmedetomidine’s use becomes more widespread/less expensive it will likely replace many of the above agents.

Check QTc interval before and after starting QT prolonging antipsychotics, and review any existing QT prolonging medications (e.g. macrolides, antifungals).

Initial dose guidance
Haloperidol - 1- 5mg IV 1-2 hourly until control achieved (up to a max of 15mg/day, elderly 5mg).
Olanzapine - 5 - 10mg OD (oro-dispersible tablet).
Quetiapine - 25 - 50mg BD. (can be increased in 25mg BD increments every few days)
Risperidone - 0.5 - 1.0 mg BD.
Seek BNF/pharmacy advice re further dose escalation - with care in the elderly.

Prescriptions should be limited to a maximum of 7 days and state “not for long term use

Clonidine infusion 0.5 - 1 microgram/kg/hr (alternatively up to 150microgram po/NGT TDS)
Dexmedetomidine infusion up to 1.4 microgram/kg/hr.
Propofol infusion up to 4mg/kg/hr.

Rescue for severe agitation
Midazolam 5 mg IV. Repeat every 10 minutes if necessary, or lorazepam 0.5 - 1mg.
Propofol infusion (with/without an initial bolus).

If no IV access - consider ketamine 2.5 - 5mg/kg IM, haloperidol 1 - 5mg IM, midazolam 2.5-5mg IM or lorazepam 2mg IM - preferably after discussion with senior critical care medical staff.

Indications for first line benzodiazepine
Parkinsonism/disease, Lewy body dementia, seizures, pronlonged QTc interval (>470 ms), alcohol withdrawal, recreational drug withdrawal.

Sleep deprivation treatment
Trazodone 50 - 100mg po/NGT nocte.
Zopiclone 3.75 - 15mg po or Zolpidem 5-10mg po via NGT.

Nicotine withdrawal treatment
Nicotine patch (refer to BNF for guidance).
Consider clonidine IV or po/NGT (typically 50microgram TDS).

Alcohol withdrawal
Chlordiazepoxide (tapering regime). See separate Trust guidance via intranet.

De-escalation
Once acute phase of delirium has subsided ensure a tapered withdrawal of antipsychotics.

Drug charts should be clearly marked any relevant drugs that are started on critical care are only for short term use and not long term. i.e. a planned de-escalation regime should be documented.

Common deliriogenic drugs

Analgesics:

  • Codeine
  • Fentanyl
  • Morphine
  • Pethidine

Antidepressants:

  • Amitriptyline
  • Paroxetine

Antiepileptics:

  • Phenytoin

Antihistamines:

  • Chlorphenamine
  • Promethazine

Antiemetics:

  • Prochlorperazine

 

Benzodiazepines:

  • Midazolam
  • Lorazepam

Cardiovascular agents:

  • Atenolol
  • Digoxin
  • Dopamine
  • Lidocaine

Corticosteroids

Furosemide

Ranitidine

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Appendix 1

Delirium SOP - Screening/Diagnosis

Prevention / non-pharmacological treatment

DO…

DON’T…

Rationalise medications (see appendix for list of deleriogenic medications)

Argue/confront

Promote normal sleep pattern (day/night)

Move ward/bay

Ensure hydration

Expose to excess noise/light disturbances

Re-orientate/reassure patient regularly

Catheterise unnecessarily

Monitor bowels/treat constipation

Use physical restraint

Monitor for and treat pain adequately

Use antipsychotics unless other interventions have failed

Utilise familiar nursing staff

Use large doses of antipsychotics, particularly in the elderly

Encourage early supervised mobilisation

Give antipsychotics to patients with prolonged QTc, with Parkinsonism or Lewy body dementia - use lorazepam instead (see below)

Optimise sensory impairment (glasses/hearing aids)

Wake unnecessarily

Monitor for and treat infection

Prescribe haloperidol without a maximum daily dose

Optimise nutrition

Forget nicotine withdrawal as a precipitant of agitation

Pharmacological Treatment - Use when other non- pharmacological intervention have not succeed.
Drug charts should be clearly marked any relevant drugs are only for short term use.

If the Patient is aggressive or severely agitated follow the advice below:-
Suggested regime only - at senior clinician’s discretion but consider the benefits to consistency in approach and allowing adequate time for medication to become effective i.e. atypical antipsychotics. Check QTc interval before and after starting QT prolonging antipsychotics, and review any QT prolonging medications (e.g. macrolides, antifungals).

Initial dose guidance

  • Haloperidol - 1- 5mg IV 1-2 hourly until control achieved (up to a max of 15mg/day, elderly 5mg).
  • Olanzapine - 5 - 10mg OD (oro-dispersible tablet).
  • Quetiapine - 25 - 50mg BD. (can be increased in 25mg BD increments every few days)
  • Risperidone - 0.5 - 1.0 mg BD.
  • Prescriptions should be limited to a maximum of 7 days and state “not for long term use

Seek BNF/pharmacy advice re further dose escalation - with care in the elderly.

  • Clonidine infusion 0.5 - 1 microgram/kg/hr (alternatively up to 150mcg po/NGT TDS)
  • Dexmedetomidine infusion up to 1.4 microgram/kg/hr.
  • Propofol infusion up to 4mg/kg/hr.

Rescue for severe agitation

  • Midazolam 5 mg IV. Repeat every 10 minutes if necessary, or lorazepam 0.5 - 1mg.
  • Propofol infusion (with/without an initial bolus).

If no IV access consider ketamine 2.5 - 5mg IM or haloperidol 1 - 2mg IM.

Indications for first line benzodiazepine
Parkinsonism/disease, Lewy body dementia, seizures, prolonged QTc interval (>470 ms), alcohol withdrawal, recreational drug withdrawal.

Sleep deprivation treatment

  • Trazodone 50 - 100mg po/NGT nocte.
  • Zopiclone 3.75 - 15mg po or Zolpidem 5 - 10mg via NGT.

Nicotine withdrawal treatment

  • Nicotine patch - refer to BNF for guidance.
  • Consider clonidine IV or po/NGT (50microgram TDS).

Alcohol withdrawal

  • Chlordiazepoxide (tapering regime). See separate Trust guidance via intranet.

De-escalation
Once acute phase of delirium has subsided ensure a tapered withdrawal of antipsychotics.

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Appendix 2

SOP   CAM - ICU

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Appendix 3

Provenance

Record: 5570
Objective:
Clinical condition:

Agitation/Delirium

Target patient group:
  • Patients within Adult Critical Care
  • NB for patients outside of Adult Critical Care please refer to separate Trust guidance (reference for LHP staff to complete)
Target professional group(s): Secondary Care Nurses
Registered Nurses Working in Critical Care
Secondary Care Doctors
Adapted from:

Evidence base

Further reading

CAM-ICU assessment video
https://www.youtube.com/watch?v=6WyJ0zL7VkI

http://www.ics.ac.uk/ICS/guidelines-and-standards.aspx - ICS guidance on detection and treatment of delirium (due to be updated as written in 2006).

Evidence Base:   

Reade, Michael C., et al. "Effect of dexmedetomidine added to standard care on ventilator-free time in patients with agitated delirium: A randomized clinical trial." JAMA 315.14 (2016): 1460-1468.
Jakob SM, Ruokonen E, Grounds RM, et al. Dexmedetomidine vs midazolam or propofol for sedation during prolonged mechanical ventilation: two randomized controlled trials. JAMA 2012;307:1151-1160.
Pandharipande PP, Pun BT, Herr DL, et al. Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial. JAMA 2007;298:2644-2653.
Riker RR, Shehabi Y, Bokesch PM, et al. Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial. JAMA 2009;301:489-499   
Best Practice Guidance - Delirium. Adult Critical Care Collaborative Regional Benchmarking Group - (2017)
NICE (2010) Delirium: prevention, diagnosis and management (CG103) https://www.nice.org.uk/guidance/cg103
Linder LM, Ross CA, Weant KA. Ketamine for acute management of excited delirium and agitation in the prehospital setting. Pharmacotherapy 2018; Jan 38(1): 139-151.

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

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