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Delirium Management Guideline

Division of Acute Care Surgery
Revised: May 2024

1. Monitoring and Initial Assessment

  • CAM-ICU (Confusion Assessment Method for ICU) should be documented each shift and reviewed during rounds.
  • Only report as "Unable to Assess" if RASS < -3
  • If CAM-ICU is positive, evaluate for possible causes:
    • Hypoxia
    • Sepsis
    • Congestive Heart Failure (CHF)
    • Over-sedation
    • Deliriogenic medications

2. Delirium Classification and Initial Management

A. Hypoactive Delirium

(CAM-ICU positive and RASS 0 to -3)

  • Prioritize non-pharmacologic management
  • Minimize or discontinue sedating medications

B. Hyperactive or Mixed Delirium

(CAM-ICU positive and RASS -3 to +4)

  • See pharmacologic algorithm (Section 4)
  • Ensure goal RASS is clearly defined for all patients

3. Non-Pharmacologic Interventions

A. Orientation and Stimulation

  • Provide visual and hearing aids
  • Reorient frequently
  • Encourage communication
  • Maintain sleep hygiene
  • Provide cognitive stimulation during daytime

B. Environment Optimization

  • Mobilize early and frequently
  • Place familiar objects in the room
  • Minimize overnight noise
  • Remove unnecessary lines and drains

C. Supportive Measures

  • Daily Spontaneous Awakening Trials (SATs)
  • Adequate pain management
  • Correct dehydration and electrolyte imbalances

4. Deliriogenic Medications to Minimize or Avoid

  • Benzodiazepines
  • Anticholinergics:
  • Diphenhydramine, Glycopyrrolate, Metoclopramide
  • H2 blockers, TCAs, Cyclobenzaprine
  • Steroids
  • Opioids (if not the primary cause of pain)
  • Taper dose and use multimodal pain control

5. Hyperactive Delirium Management Algorithm

CAM-ICU Positive with RASS +1 to +2

  • Ensure pain control and sleep hygiene
  • Initiate:
  • Quetiapine 25–50 mg q8–12h
  • OR Olanzapine 2.5 mg q8–12h
  • Haloperidol 1–10 mg IV q4h PRN for breakthrough agitation

CAM-ICU Positive with RASS +3 to +4

If Extubated:

  • Ensure adequate pain control
  • Haloperidol 5–20 mg IV/IM q15min PRN for extreme agitation
  • If no response at 24 hrs or multiple IV haloperidol doses:
  • Reassess analgesia
  • Increase Quetiapine to 50–100 mg q6–8h or Olanzapine to 5–10 mg q6–8h
  • Continue haloperidol for breakthrough

If Intubated/Trached:

  • Start sedative infusion (if not already infusing)
  • Bolus or titrate up current sedative (e.g., propofol)
  • Ensure pain control
  • Haloperidol 5–20 mg IV/IM q15min PRN for extreme agitation
  • Consider Dexmedetomidine

If No Response After 48 Hours

  • RASS remains ≥ +3 with repeated IV haloperidol:
  • Reassess pain control
  • Change atypical antipsychotic
  • Consider alternate sedative
  • Adjust to CAM +, RASS +1 to +2 or +3 to +4 pathways as appropriate

6. Special Populations and Considerations

A. Geriatrics (> 65 years)

  • Reduce initial doses of:
  • Antipsychotics
  • Depakote (Valproic acid)
  • Avoid:
  • Haloperidol >5 mg
  • Quetiapine >100 mg
  • Consider:
  • Trazodone 25–50 mg qHS before antipsychotics if insomnia-related agitation

B. General

  • Maximize one agent before switching or adding others
  • Refractory cases:
  • Trial Geodon (Max: 40 mg BID)
  • If still uncontrolled → Psychiatry consult
  • Monitor QTc:
  • Modify therapy if QTcF > 500 ms

7. Traumatic Brain Injury (TBI)

  • Initiate Valproic acid (Depakote) 250–500 mg q8–6h

  • Titrate up to 60 mg/kg/day as needed

  • Consider early Propranolol 10–20 mg q8–6h

  • Max: 360 mg/day

  • Useful in neurologic storming

  • Avoid high-dose haloperidol

Valproate Monitoring:

  • Obtain baseline and weekly LFTs
  • Discontinue if:
  • AST or ALT >5× ULN
  • Alk Phos >2× ULN (on 2 occasions)
  • T. Bili >2.5 mg/dL with other LFT abnormalities

  • INR >1.5 with elevated transaminases

  • Use caution in hepatic disease

  • Check valproate levels only if toxicity suspected

8. References

  1. Devlin JW, Skrobik Y, Gélinas C, et al. Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Guidelines. Crit Care Med. 2018; 46:825–873.
  2. Girard T, Exline M, Carson S, et al. Haloperidol and Ziprasidone in Delirium. N Engl J Med. 2018; 379(26):2506–2516.
  3. Hughes CG, Mailloux PT, Devlin JW, et al. Dexmedetomidine vs. Propofol in Sepsis. NEJM. 2021; 384:1424–1436.
  4. Marra A, Wesley E, Pandharipande P, et al. The ABCDEF Bundle in Critical Care. Crit Care Clin. 2017; 33(2):225–243.
  5. Plantier D, Luauté J, et al. Drug Therapy for TBI Behavior Disorders. Ann Phys Rehabil Med. 2016; 59(1):42–57.
  6. Williamson D, Frenette A, et al. Agitation in TBI: Systematic Review. BMJ Open. 2019; 9:e029604

9. Authors

  • Jill Streams, MD
  • Bradley Dennis, MD
  • Abby Luffman, MSN, APN, AGACNP-BC
  • Bethany Evans, RN, MSN, ACNP-BC
  • Leanne Atchison, PharmD