Recognition, prevention, and evidence-based management of acute brain dysfunction in critical illness.
A disturbance of consciousness with inattention, accompanied by a change in cognition or perceptual disturbance, that develops over hours to days and fluctuates over time.
Develops over hours–days; waxes and wanes
The cardinal feature — cannot sustain or shift focus
Rambling, illogical, incoherent stream
Anything other than alert & calm
Reported ICU prevalence spans 20–80%
Delirium that clears soon after lightening sedation is not the same as delirium that persists.
Only persistent delirium carried the poor prognosis.
Some — but not all — features. Outcomes sit between no delirium and full delirium.
Pair the CAM-ICU with the daily awakening trial.
The more predisposed the patient, the smaller the precipitant needed to tip into delirium.
Earlier extubation and ICU/hospital discharge, with no increase in adverse outcomes.
ICU Liberation Collaborative: 15,226 patients across 68 ICUs.
Caveat: this is observational. The first pragmatic RCT of the bundle (Sosnowski 2026) found no delirium reduction — the bundle's clearest wins are liberation & function.
Real-time EHR integration, performance feedback, and leadership support drove measurable, sustained gains.
The strongest evidence in delirium is for prevention, not treatment — and it's overwhelmingly non-pharmacologic. These map directly onto the bundle's D–E–F.
CAM-ICU / ICDSC anchored to RASS
Lighten & reassess before calling it delirium
Work through DELIRIUMS →
Reorient, mobilize, sleep, glasses/hearing, family
Light (RASS 0 to −2); avoid benzodiazepines
Brief antipsychotic for dangerous agitation — then stop
Placebo-controlled RCT of haloperidol and ziprasidone for ICU delirium (89% hypoactive).
The practice-changer: routine antipsychotics do not treat ICU delirium. Reserve them for the symptom — distressing agitation — not the diagnosis.
Symptoms wax and wane; hypoactive delirium is easily missed without formal screening
Hard to distinguish from dementia, depression, and primary psychiatric illness
Protocols and compliance vary widely between units and shifts
Pathophysiology is multifactorial and still only partly understood
No agent reliably prevents or treats it; antipsychotics carry real harms
Bundle adherence demands staffing, culture change, and sustained resources
Early dexmedetomidine as the primary sedative did not lower 90-day mortality; more bradycardia & hypotension.
In sepsis, dexmedetomidine vs propofol: no difference in days alive without delirium or coma.
Haloperidol vs placebo for established ICU delirium: no clear benefit in days alive & out of hospital — echoing MIND-USA.
High-intensity early mobilization: no gain in days alive & out of hospital, with more adverse events.
Nightly melatonin did not reduce the prevalence of delirium in ICU adults.
Reaffirms light, benzodiazepine-sparing sedation; suggests dexmedetomidine over propofol for delirium-relevant sedation.
The landmarks still stand. A decade of trials has refined how we sedate — lighter, benzodiazepine-sparing, dexmedetomidine when a sedative is needed — while repeatedly confirming that no drug reliably prevents or treats delirium. Prevention bundles and shift-by-shift screening remain the core.