CURRENT Essentials of Critical Care.pdf

8 Current Essentials of Critical Care■■■DeliriumEssentials of Diagnosis• Agitation, altered sensorium, disorientation, waxing and waningof level of consciousness, incoherent speech• Common problem, especially with advanced age, neuropsychiatricdisorders, alcoholism, drug overdose, use of multiple medications,anemia; less common: chemical exposure, hepaticencephalopathy, hypoxemia, cerebral hypoperfusion, hyponatremia,hypercalcemia, renal failure• Medications (neuroleptics, corticosteroids, lidocaine, cimetidine,antihistamines, benzodiazepines); withdrawal from alcoholor sedative-hypnotic drugs• ICU environment contributes to sleep deprivation, disorientation,stress, but is almost never the only cause• Delirium prolongs ICU stay, contributes to morbidity and mortalityDifferential Diagnosis• Anxiety, depression, psychosis; treatment with neurolepticagents, neuroleptic malignant syndromeTreatment• Assess for hypoxemia, hypotension, fluid and electrolyte problems,sepsis, meningitis, stroke, intracranial hemorrhage, withdrawalfrom alcohol or sedative-hypnotic drugs• Review medications, blood count, serum electrolytes, arterialblood gases• Protect from falls, disconnection of life support (endotrachealtube, intravenous catheters); orient to location and time• Consider benzodiazepines (lorazepam), haloperidol, or combination,if needed• Complications of treatment: oversedation, respiratory depression,hypotension; for haloperidol–prolonged QT interval, dystonicreactions, rarely neuroleptic malignant syndrome■ PearlDelirium from withdrawal from alcohol or benzodiazepines may beginas late as 5–7 days after stopping consumption.ReferenceMcNicoll L et al: Delirium in the intensive care unit: occurrence and clinicalcourse in older patients. J Am Geriatr Soc 2003;5:591. [PMID: 12752832]