A similar trend in reduction of delirium with dexmedetomidine was also seen in the MENDS (Maximizing Efficacy of Targeted Sedation and Reducing Neurological Dysfunction)18 trial. Compared with lorazepam, dexmedetomidine-treated patients with sepsis had 3.2 more delirium/coma-free days, 1.5 more delirium-free days and 6 more ventilator-free days. The
Early mobilization to lessen delirium
The usual practice of deep sedation and bed rest in ICU patients can adversely impair their physical function and quality of life after discharge. On the other hand, there is increasing evidence suggesting that reduced sedation and early mobilization benefit ICU survivors.19,20 One such study shows that whole body rehabilitation, which consists of interruption of sedation plus physical and occupation therapy in the early days of critical illness, results in better functional outcomes at discharge, a shorter duration of delirium, and more ventilator-free days compared with standard care.21
According to Professor Ely, the following criteria assist the team at his hospital to determine if a patient is suitable for early mobilization: myocardial stability, adequate oxygenation, minimal vasopressor and patient engagement to voice commands.
The medical care and management of critically ill patients have evolved tremendously such that the American College of Critical Care Medicine, in conjunction with the Society of Critical Care Medicine and the American Society of Health-System Pharmacists saw a need to update the ICU PAD guidelines to reflect the most current and evidence-based practice in critical care. The ABCDEF bundle succinctly captures the important points of the ICU PAD guidelines and provides a framework that allows healthcare professionals in the critical care team to improve mortality and morbidity in ICU patients.
In the updated guidelines, the adverse impact of delirium on post-ICU survivors is given due recognition and several recommendations are made to improve patient safety and comfort. Most importantly, a less sedation strategy is recommended and the use of nonbenzodiazepine sedatives is preferred.
1. Jacobi J, et al. Crit Care Med 2002;30(1):119–141.
2. Barr J, et al. Crit Care Med 2013;41(1):263–306.
3. Girard TD, et al. Crit Care Med 2010;38(7):1513–1520.
4. Latronico N, Bolton CF. Lancet Neurol 2011;10(10):931–941.
5. Ely EW, et al. JAMA 2004;291(14):1753–1762.
6. Shehabi Y, et al. Crit Care Med 2010;38(12):2311–2318.
7. Pandharipande PP, et al. N Engl J Med 2013;369(14):1306–1316.
8. Gunther ML, et al. Crit Care Med 2012;40(7):2022–2032.
9. ICU Delirium and Cognitive Impairment Study Group. ABCDEF’s of Prevention and Safety. Available at: www.icudelirium.org/medicalprofessionals.html Accessed 15 October 2015.
10. Society of Critical Care Medicine ICU Liberation. ABCDEF Bundle Improvement Collaborative. Available at: www.iculiberation.org/About/collaborative/Pages/default.aspx Accessed 15 October 2015.
11. Dale CR, et al. Ann Am Thorac Soc 2014;11(3):367–374.
12. Balas MC, et al. Crit Care Med 2014;42(5):1024–1036.
13. Needham DM, et al. Arch Phys Med Rehabil 2010;91(4):536–542.
14. Girard TD, et al. Lancet 2008;371(9607):126–134.
15. Klompas M, et al. Am J Respir Crit Care Med 2015;191(3):292–301.
16. Treggiari MM, et al. Crit Care Med 2009;37(9):2527–2534.
17. Riker RR, et al. JAMA 2009;301(5):489–499.
18. Pandharipande PP, et al. Crit Care 2010;14(2):R38.
19. Needham DM. JAMA 2008;300(14):1685–1690.
20. Nydahl P, et al. Crit Care Med 2014;42(5):1178–1186.
21. Schweickert WD, et al. Lancet 2009;373(9678):1874–1882.