This Article Full Text Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My Personal Article Archive Download to citation manager Citing Articles Citing Articles via ISI Web of Science (2) Citing Articles via Google Scholar Google Scholar Articles by Pun, B. T. Articles by Ely, E. W. Search for Related Content PubMed PubMed Citation Articles by Pun, B. T. Articles by Ely, E. W. Related Content Recent Advances in Chest Medicine

The Importance of Diagnosing and Managing ICU Delirium^*

^* From Vanderbilt University and the Tennessee Valley VA Geriatric Research Education and Clinical Center, Nashville, TN.

Correspondence to: Brenda T. Pun, RN, MSN, Center for Health Services Research, Vanderbilt Medical Center, Nashville, TN 37232-8300; e-mail: Brenda.Pun{at}vanderbilt.edu or www.ICUdelirium.org

Abstract

ICU delirium represents a form of brain dysfunction that in many cohorts has been diagnosed in 60 to 85% of patients receiving mechanical ventilation. This organ dysfunction is grossly underrecognized because a majority of patients have hypoactive or "quiet" delirium characterized by "negative" symptoms (eg, inattention and a flat affect) not alarming the treating team. Hyperactive delirium, formerly called ICU psychosis, stands out because of symptoms such as agitation that may cause harm to self or staff, but is actually rare relative to hypoactive delirium and associated with a better prognosis. Delirium is often incorrectly thought to be transient and of little consequence. After adjusting for numerous covariates, delirium is a strong, independent predictor of prolonged length of stay, reintubation, higher mortality, and cost of care. Expanded work on patient safety and recommendations by professional societies have established the importance of delirium monitoring and recommended it as standard practice in ICUs all over the world. This evidence-based review for physicians, nurses, respiratory therapists, and pharmacists will outline why it is imperative that patients be routinely monitored for delirium. This review will discuss modifiable risk factors for delirium, such as metabolic disturbances or potent sedative and analgesic medications. Attention to mitigating risk factors, along with recommended pharmacologic approaches such as antipsychotic medications, may provide resolution of delirium in some patients, while others will persist with refractory brain dysfunction and long-term cognitive impairment following critical illness.

Key Words: aging • analgesia • cognitive impairment • critical care • delirium • encephalopathy • mechanical ventilation • protocols • respiratory failure • sedation