Delirium, Sleep and the Post-Intensive Care Syndrome

Also known as ICU delirium · Sleep disruption · Post-intensive care syndrome · Cognitive impairment after critical illness · CAM-ICU · Delirium prevention

Delirium is the acute brain dysfunction of critical illness, affecting over half of ICU patients, and it is independently associated with the longer stay, the higher mortality, and the long-term cognitive impairment. Sleep is disrupted and fragmented in the ICU, contributing to the delirium. This topic builds the examiner's framework on the delirium screening (the CAM-ICU), the prevention (the bundle), the management (the dexmedetomidine, the haloperidol — the REDUCE trial showing no survival benefit), the sleep preservation (the PADIS recommendations), and the post-intensive care syndrome (the PICS — the Pandharipande trial showing the long-term cognitive impairment).

medium8 referencesUpdated 26 July 202618 min readVerification in progress

Practise this topic

8 MCQs

Meet the patient

A 72-year-old man is on day 6 of an ICU admission for severe community-acquired pneumonia with septic shock, extubated 48 hours ago. The nurses report he is "quiet and settled." On examination he lies still with his eyes closed, opens them to voice but does not follow commands consistently, and his RASS is −2. He fumbles the SAVEAHAART letters test. His CAM-ICU is positive.^[3]

The classic trap: everyone calls this "well sedated" or "just tired." It is hypoactive delirium — the common and the lethal form, missed precisely because the patient is not agitated. A quiet ICU patient is not necessarily a settled one, and this is the subtype that predicts the worst outcome.^[2]^[3]

The two questions that decide his week are the two that decide every delirium: is the brain failing? (the CAM-ICU answers every shift) and what is driving it? (the precipitant answers the rest). Hold those two questions and the management slots into place.^[1]

References8Show

[1]van den Boogaard M, Schoonhoven L, van der Hoeven JG, et al. Effect of Haloperidol on Survival Among Critically Ill Adults With a High Risk of Delirium: The REDUCE Randomized Clinical Trial JAMA, 2018.PMID 29466591
[2]Pandharipande PP, Girard TD, Jackson JC, et al. Long-term cognitive impairment after critical illness N Engl J Med, 2013.PMID 24088092
[3]Ely EW, Margolin R, Francis J, et al. Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) Crit Care Med, 2001.PMID 11445689
[4]Bergeron N, Dubois MJ, Dumont M, Dial S, Skrobik Y Intensive Care Delirium Screening Checklist: evaluation of a new screening tool Intensive Care Med, 2001.PMID 11430542
[5]Pandharipande PP, Pun BT, Herr DL, et al. Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial JAMA, 2007.PMID 18073360
[6]Riker RR, Shehabi Y, Bokesch PM, et al. Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial JAMA, 2009.PMID 19188334
[7]Page VJ, Ely EW, Gates S, et al. Effect of intravenous haloperidol on the duration of delirium and coma in critically ill patients (Hope-ICU): a randomised, double-blind, placebo-controlled trial Lancet Respir Med, 2013.PMID 24461612
[8]Andersen-Ranberg NC, Poulsen LM, Perner A, et al. Haloperidol for the Treatment of Delirium in ICU Patients N Engl J Med, 2022.PMID 36286254