Critical Care Pharmacological Management of Delirium
Policy Title: in the Critical Care Unit Executive Summary: This policy provides guidance Pharmacological Management of delirium in the Critical Care Unit Supersedes: V1 Description of N/A Amendment(s): This policy will impact on: Critical care Unit Financial Implications: N/A Policy Area: Critical Care Document Reference: Version Number: 4 Effective Date: January 2019 Issued By: Chair of medicines Review Date: January 2020 Authors: management group Adapted by J Somerville and L Street from Pharmacological guidelines on the management of delirium and sleep disturbances in critical care patients version 5. June 2016. Sheffield Teaching Hospitals NHS Foundation Trust. (Copyright Sheffield Teaching Hospitals NHS Foundation Trust 2007: permission granted) Reviewed by Wendy Lawson, Critical care Pharmacist APPROVAL RECORD Impact Assessment Date: N/A Consultation: Committees / Group Medicine Management Urgent Care SQS Date 11/12/2018 24/10/2018 Approved by: Medicine management Date Received for information: 11/12/2018 2
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 5 June 2016. Sheffield Teaching Hospitals NHS Foundation Trust. Elements of this guideline are derived from STH NHS Foundation Trust Guidelines. 3
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. 4
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 16/10/2018). 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 developing delirium and therefore should be screened for 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 only be considered when other non-pharmacological measures have failed or patient has distressing symptoms https://www.nice.org.uk/guidance/qs63/chapter/quality-statement-3-use-ofantipsychotic-medication-for-people-who-are-distressed#quality-statement-3-useof-antipsychotic-medication-for-people-who-are-distressed. 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 5
pose a risk to themselves or others. Sleep ddisturbances are often regarded as a precipitating factor for causing 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 6
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 1mg tds po 0.5mg tds IV (unlicensed use) Second Line: Olanzapine 5mg at night. Alcohol withdrawal: Chlordiazepoxide as per hospital pathway Pabrinex 2 pairs tds for 72 hours Consider Clonidine and refer to separate policy for infusion rates. 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. 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. 7
General Notes: New evidence is consistent with current recommendations to consider use of haloperidol or olanzapine for short-term treatment of delirium. https://www.nice.org.uk/guidance/cg103/evidence/evidence-update-pdf- 134649181 accessed 16/10/2018 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 There is a risk of QT prolongation in the administration of Haloperidol (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 8
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 9
Pharmacological Management of Sleep Disturbance Delirium positive Delirium negative Trazodone 50mg nocte Zopiclone 3.75mg to 7.5mg nocte 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 Bourne R. Pharmacological guidelines on the management of delirium and sleep disturbance in critical care patients version 5. June 2016. Sheffield Teaching Hospitals NHS Foundation Trust. American Psychiatric association (1994) Diagnostic and Statistical Manual of mental disorders (DSMIV), 4 th Edition. Arlington, VA, US: American Psychiatric Publishing, Inc. Ely EW, Shintani A, Truman B, Speroff T, Gordon SM, Harrell FE, Jr., Inouye SK, Bernard GR, Dittus RS: Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 2004, 291:1753-1762. Delirium; diagnosis, prevention and management. Nice CG 103:63-69. July 2010. 10
http://www.nice.org.uk/nicemedia/live/13060/49909/49909.pdf http://www.medicines.org.uk/ (accessed 18/10/2018) BNF Edition 74 March 2018 Friese R: Sleep and recovery from critical illness and injury: A review of theory, current practice, and future directions. Critical Care Med 2008, 36:697-705. 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 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 11
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. 12
Appendix 2 13