Delirium primary prevention: Difference between revisions

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Revision as of 05:42, 18 February 2014

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vishal Khurana, M.B.B.S., M.D. [2]; Pratik Bahekar, MBBS [3]

Overview

Primary Prevention

It is important to prevent delirium as delirium is itself neurotoxic. It is associated with global brain atrophy and white matter disruption. Various pharmacological interventions have shown promising results in prevention of delirium, which are as follows,

Post operative delirium,
Haloperidol

Second-generation antipsychotics

Iliac fascia block

Gabapentin

Lower levels of intraoperative propofol sedation

A single dose of ketamine during anesthetic induction

Mechanically ventilated medical and surgical ICU patients,
Continuous intravenous infusion of dexmedetomidine

Acutely ill general medical patients population,
Melatonin^[1]

Haloperidol

Delirium possibly causes exhaustion leading to respiratory difficulties and a higher incidence of re-intubations. Low dose haloperidol, if given prophylactically in lower doses, following benefits were observed,

Prophylactic treatment and early treatment seem to have a better prognosis than treatment of delirium.
Lower mortality
Lower delirium incidence
More delirium free days
Patients are less likely to remove their tubes or catheters
Patients with a higher risk of developing delirium benefited more.
ICU readmission rate was lower

Drawbacks for prophylactic treatment with haloperidol

Uneccesary treatment to patients who were not destined to develop delirium
Side effects of treatment, however during clinical studies there was only marginal prolongation of QTc and no one developed ventricular arrhythmias.

Targeted delirium prophylaxis is key to the future management of delirium. More studies are needed on this topic. ^[2]

Prediction of Delirium in ICU

Early prediction of development of delirium in intensive care is very crucial to start non pharmacological treatment and starting prophylactic haloperidol treatment. PRE-DELIRIC model is used to predict delirium in ICU. Automatic version of the PRE-DELIRIC model (Excel and web based) can be downloaded at http://www.umcn.nl/Research/Departments/intensive%20care/Documents/Pre-deliric%20model.htm?language=english, Complete information is available at http://www.umcn.nl/Research/Departments/intensive%20care/Pages/vandenBoogaard.aspx

^[3]

References

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[1] "http://ajp.psychiatryonline.org/article.aspx?articleID=1795082". External link in |title= (help)

[2] "Haloperidol prophylaxis in critically ill patients... [Crit Care. 2013] - PubMed - NCBI".

[3] "Development and validation of PRE-DELIRIC (PREdiction of... [BMJ. 2012] - PubMed - NCBI".

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[2]

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@@ Line 42: / Line 42: @@
 PRE-DELIRIC model is used to predict delirium in ICU.  Automatic version of the PRE-DELIRIC model (Excel and web based) can be downloaded at http://www.umcn.nl/Research/Departments/intensive%20care/Documents/Pre-deliric%20model.htm?language=english,
 Complete information is available at http://www.umcn.nl/Research/Departments/intensive%20care/Pages/vandenBoogaard.aspx
+{|
-Risk of delirium = 1/(1+exp−(−6.31
+|-
-+ 0.04 × age
+|[[Image:Delirium2.PNG|thumb|800px]]
-+ 0.06 × APACHE-II score
+|-
-+ 0 for non-coma or 0.55 for drug induced coma or 2.70 for miscellaneous coma or 2.84 for combination coma
+|}
-+ 0 for surgical patients or 0.31 for medical patients or 1.13 for trauma patients or 1.38 for neurology/neurosurgical patients
+<ref>{{Cite web  | last =  | first =  | title = Development and validation of PRE-DELIRIC (PREdiction of... [BMJ. 2012] - PubMed - NCBI | url = http://www.ncbi.nlm.nih.gov/pubmed/22323509 | publisher =  | date =  | accessdate = }}</ref>
-+ 1.05 for infection
-+ 0.29 for metabolic acidosis
-+ 0 for no morphine use or 0.41 for 0.01-7.1 mg/24 h morphine use or 0.13 for 7.2-18.6 mg/24 h morphine use or 0.51 for >18.6 mg/24
-h morphine use
-+ 1.39 for use of sedatives
-+ 0.03 × urea concentration (mmol/L)
-+ 0.40 for urgent admission))
-The scoring system’s intercept is expressed as −6.31; the other numbers represent the shrunken regression coefficients
-(weight) of each risk factor.<ref>{{Cite web  | last =  | first =  | title = Development and validation of PRE-DELIRIC (PREdiction of... [BMJ. 2012] - PubMed - NCBI | url = http://www.ncbi.nlm.nih.gov/pubmed/22323509 | publisher =  | date =  | accessdate = }}</ref>