icu delirium scales

Delirium is an important and serious problem among critically ill patients of many different disease profiles. While the precise long-term implications of acute delirium are not yet well worked out, strong associations with mortality and duration of hospitalization are well established in the literature. In order to better understand delirium, risk factors, and potential interventions to limit treatments that increase delirium, consensus suggests that routine assessment for delirium should be performed among ICU patients. One of the most common methods for measurement is the Confusion Assessment Method for the ICU (CAM-ICU) test, which evaluates for the presence of delirium in conscious patients. The CAM-ICU, however, cannot be performed on patients who are unconscious. The Richmond Agitation-Sedation Scale (RASS) evaluates patients for the presence of agitation or unduly deep sedation. At and below a RASS score of -4, the patient is too deeply sedated to be able to measure delirium. It is thus not clear whether the patient is delirious. Sedation should be lightened to the point of consciousness before the CAM-ICU is administered (choice C is correct).

The MIND-USA trial showed that for all patients with delirium, neither haloperidol nor ziprasidone was better than placebo for the treatment of delirium in the ICU (choice A is incorrect). Multiple studies of dexmedetomidine vs benzodiazepines have suggested the possibility of briefer duration of mechanical ventilation but not improvement in patient-centered outcomes such as cognitive impairment or survival (choice B is incorrect). Studies of daily awakening trials have suggested that they improve duration of ventilation and even survival. Despite early concerns that daily awakening trials might lead to airway injury or unplanned extubation, these have not been borne out. Daily awakening trials are thus considered an important part of bundles for the management of ventilated patients, with endorsement by academic societies and an accumulating evidence base (choice D is incorrect).1234

Footnotes

  1. SEEK Questionnaires ↩

  2. Devlin JW, Skrobik Y, Gélinas C, et al. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med. 2018;46(9):e825-e873. PubMed ↩

  3. Girard TD, Exline MC, Carson SS, et al; MIND-USA Investigators. Haloperidol and ziprasidone for treatment of delirium in critical illness. N Engl J Med. 2018;379(26):2506-2516. PubMed ↩

  4. Riker RR, Shehabi Y, Bokesch PM, et al; SEDCOM (Safety and Efficacy of Dexmedetomidine Compared With Midazolam) Study Group. Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial. JAMA. 2009;301(5):489-499. PubMed ↩