Critical Care Pharmacological Management of Delirium

Critical Care Pharmacological Management of Delirium Justine Somerville and Dr Ishani Dave 28th July 2016

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Policy Title: Critical Care Pharmacological Management of Delirium in the Critical Care Unit

Executive Summary: This policy provides guidance Pharmacological Management of delirium in the Critical Care Unit

Supersedes: V1

Description of Amendment(s):

N/A

This policy will impact on: Critical care Unit

Financial Implications: N/A

Policy Area: Critical Care Document Reference:

Version Number: 2 Effective Date:

Issued By: Chair of medicines management group

Review Date: August 2018

Authors: Adapted by J Somerville and L Street from Pharmacological guidelines on the management of delirium and sleep disturbances in critical care patients version 3. September 2011. Sheffield Teaching Hospitals NHS Foundation trust. Reviewed by I Dave

Impact Assessment Date:

APPROVAL RECORD

Committees / Group Date

Consultation: Medicine management SQS

9th August 2016 23rd August 2016

Approved by: Medicine management

August 2016

N/A

9th August 2016

ECT002551

Critical Care Pharmacological Management of Delirium Justine Somerville and Dr Ishani Dave 28th July 2016

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CONTENTS Page

Introduction 4

Purpose 4

Scope 4

Duties and responsibilities 4

Pharmacological management of delirium

Background 5

Management of Delirium Flow Chart 7

Pharmacological management of sleep disturbances

Background 9

Management of sleep disturbances Flow Chart 10

Appendices

Appendix 1 Daily Checklist 11

Appendix 2 Delirium Assessment 12

Acknowledgements: Bourne R. Pharmacological guidelines on the management of

delirium and sleep disturbances in critical care patient’s version 3 September 2011.

Sheffield Teaching Hospitals NHS Foundation Trust. Elements of this guideline are

derived from STH NHS Foundation Trust Guidelines.

Critical Care Pharmacological Management of Delirium Justine Somerville and Dr Ishani Dave 28th July 2016

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Introduction

Delirium is an important but easily overlooked problem amongst patients on an ICU.

The aim of this guideline is to ensure patients are comfortable and calm while in

Critical Care, improving their experience and clinical outcomes.

Purpose

To provide guidance on the management of delirium in adult Critical Care patients

Scope

This guidance is for use in Critical Care Department, it is subject to professional

judgement and accountability.

Duties and responsibilities

Implementation of this guidance is the joint responsibility of appropriate Critical Care

medical, nursing and physiotherapy staff.

Critical Care Pharmacological Management of Delirium Justine Somerville and Dr Ishani Dave 28th July 2016

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Pharmacological Management of Delirium

Background

Delirium is defined as a disturbance of consciousness, with inattention

accompanied by a change in cognition or perceptual disturbance that develops

over a short period of time (hours to days) and fluctuates over time (The

Diagnostic and Statistical Manual of Mental Disorders (DSM IV, 1994)

Up to 80% of mechanically ventilated ICU patients develop delirium and it is

associated with many negative outcomes such as increased lengths of stay,

decreased survival and increased cognitive dysfunction (accessed from

http://www.icudelirium.org/delirium.html 26/07/2016). Three motor subtypes exist

- hypoactive, hyperactive and mixed types. The hypoactive form is the most

common subtype and is often missed, or misdiagnosed.

All patients in ICU are at a high risk of developingng delirium and therefore should

be screened for delirium frequently (on admission and then eight hours

thereafter) Patients may be screened for the presence of delirium using tools such

as the Confusion Assessment Method (CAM), a specific screening tool has been

developed for use on critical care (CAM-ICU) (Appendix 2). A daily checklist

should be filled out to address all the precipitating and augmenting factors

(Appendix 1).

In addition to prevention and non-pharmacological techniques, appropriate drug

management is an important adjunct in the management of patients with delirium.

Drug treatment should be considered when other non-pharmacological measures

have failed or patient has distressing symptoms. Regular drug treatment should

be commenced for patients who are CAM-ICU positive and reviewed daily for

efficacy and adverse effects. When delirium symptoms resolve, antipsychotic

medication can be withdrawn over 48 to 72 hours. Only short treatment courses

(less than a week) should be used. The incidence of delirium is higher if

benzodiazepines are used for sedation, and therefore their primary indication is

treatment of withdrawal delirium e.g. alcoholol withdrawal. However, they remain

a treatment option in patients with severe hyperactive delirium who pose a risk to

themselves or others.

Sleep ddisturbances are often regarded as a precipitating factor for causing

Critical Care Pharmacological Management of Delirium Justine Somerville and Dr Ishani Dave 28th July 2016

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delirium. The cause and effect relationship is not straightforward and therefore

delirium status should be accounted for when attempting to improve nocturnal

sleep quantity in critical care patients. For this reason guidelines on the

pharmacological management of delirium and sleep disorders are included in the

same document.

Further information on the pharmacological management of delirium is also

available from the following links:

https://www.nice.org.uk/Guidance/CG103

http://www.icudelirium.org/delirium.html

References

American Psychiatric association (1994) Diagnostic and Statistical Manual of mental

disorders (DSMIV), 4th Edition. Arlington, VA, US: American Psychiatric Publishing,

Inc.

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Pharmacological Management Flowchart

CAM-ICU delirium Positive

Review drug chart. Prescribe alternative agents where possible to minimise anti-cholinergic activity

Hyperactive

Delirium

Hypoactive

Delirium

Withdrawal

Delirium

First Line: Haloperidol 2.5mg to 5mg qds po and prn max dose (including regular and prn of 30mg daily) OR Haloperidol 1mg to 2.5mg qds IV (unlicensed use) Second Line: Olanzapine 5mg at night.

First Line: Haloperidol 0.5mg tds IV (unlicensed use) Second Line: Olanzapine 5mg at night.

In severe agitation, especially if poses risk to self or others, request specialist advice from Consultant Anaesthetist. If restraints are required refer to restraints policy.

Alcohol withdrawal: Chlordiazepoxide as per hospital pathway Pabrinex® 2 pairs tds for 72 hours Consider Clonidine and refer to separate policy for infusion rates.

Nicotine withdrawal Nicotine replacement patch as per hospital guideline: 25mg patch over 16 hours if smoke over 20 cigarettes per day 15mg patch over 16 hours for patients who smoke less than 20 cigarettes per day. Patches should be removed at 10pm and applied at 6am.

Critical Care Pharmacological Management of Delirium Justine Somerville and Dr Ishani Dave 28th July 2016

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General Notes:

There is no evidence to support the prophylactic use of haloperidol or other

antipsychotics in the prevention of delirium (Page et al. 2013)

All prescriptions for antipsychotics should be endorsed ‘delirium’ to aid review

of therapy.

Antipsychotics should be gradually withdrawn over 2 to 3 days when the

patient is CAM-ICU negative

Haloperidol there is a risk of QT prolongation (especially with intravenous

administration or with concurrent medication known to cause QT prolongation

e.g. clarithromycin). Obtain baseline 12-lead ECG if not done in the last 48

hours.

Short acting benzodiazepines are associated with delirium and so should be

used as a last resort in alcohol withdrawal

Risperidone may be considered third line if haloperidol and olanzapine have

been tried unsuccessfully

Antipsychotics should be discontinued if patient fully sedated

Patients should not be prescribed more than one antipsychotic concomitantly

Clonidine will not prevent alcohol withdrawal seizures

References

http://www.medicines.org.uk/ (accessed 27/07/2016)

BNF Edition 71 March 2016

Bourne R. Pharmacological guidelines on the management of delirium and sleep

disturbance in critical care patients’ version 3. September 2011. Sheffield Teaching

Hospitals NHS Foundation Trust.

Page V, Ely EW, Gates S, et al. (2013) Effect of intravenous haloperidol on the

duration of delirium and coma in critically ill patients: a randomised, double-blind,

placebo- controlled trial. The Lancet respiratory Medicine; 1(7):515 - 523

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Pharmacological Management of sleep disturbances

Background

Sleep disturbances in Critical Care patients are characterised by sleep

fragmentation. Patients are often sleep deprived; the sleep tends to be

fragmented. It is a problem of sleep continuity and results in reduced quantities of

deeper sleep phases, such as slow wave sleep (SWS) and rapid eye movement

sleep (REM). Sleep disturbances may contribute to patient morbidity including

adverse consequences on respiratory, cardiac, neurological and immunological

function.

Causes of sleep disturbances in critical care patients are multi-factorial and

include: the environment (e.g. noise, light), pain, ventilator dys-synchrony,

delirium, circadian rhythm disturbances, anxiety and medication (e.g. opioids,

benzodiazepines).

Sleep hygiene refers to attempts to make conditions suitable for sleep to occur.

Review all patients who have inadequate sleep (less than 4 hours of continuous

sleep or inability to sleep at night and excessive daytime drowsiness).

Control excessive noise at night

Bright light in the daytime, darkness at night

Encourage regular morning wake up time

Control environmental temperature

Encourage range of motion exercises and activity e.g. patient sitting out

Ensure comfortable position

Avoid caffeine intake by patients in the evening

References

Weinhouse GL, Schwab RJ, Watson PL, et al: Bench-to-bedside review: Delirium in

ICU patients—Importance of sleep deprivation. Crit Care 2009; 13:234

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General Notes:

If the patient has a disruption in normal circadian rhythm and is falling asleep

during the day but is awake at night consider starting Melatonin MR 2mg

nocte. For NG, use unlicensed caps (not MR licenced version)

Annotate prescription with ‘short term sleep aid’. All new prescriptions for

acute treatment should be endorsed “short-term sleep-aid” and reviewed prior

to discharge from Critical Care.

References

http://www.medicines.org.uk/ (accessed 27/07/2016)

BNF Edition 71 March 2016

Bourne R. Pharmacological guidelines on the management of delirium and sleep disturbance

in critical care patients version 3. September 2011. Sheffield Teaching Hospitals NHS

Foundation Trust.

Pharmacological Management of Sleep Disturbance

Delirium positive Delirium negative

Trazodone 50mg nocte Zopiclone 3.75mg to 7.5mg nocte

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Appendix 1 Daily Checklist The care and interventions below are designed to prevent and manage delirium. Please make reference to these 6 elements in your patient assessment documentation.

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Appendix 2