Concise Definitive Review
Series Editor, Jonathan E. Sevransky, MD, MHS
Treatment of four psychiatric emergencies in the intensive care unit
O. Joseph Bienvenu, MD, PhD; Karin J. Neufeld, MD, MPH; Dale M. Needham, MD, PhD Objectives: To review the diagnosis and management of four dopamine agonists, and/or dantrolene) or electroconvulsive ther-
selected psychiatric emergencies in the intensive care unit: agi-
apy, if indicated. Serotonin syndrome should be treated by dis-
tated delirium, neuroleptic malignant syndrome, serotonin syn-
continuing al serotonergic agents, providing supportive therapy,
drome, and psychiatric medication overdose.
control ing agitation with benzodiazepines, and possibly admin-
Data Sources: Review of relevant medical literature.
istering serotonin antagonists. It is often unnecessary to restart
Data Synthesis: Standardized screening for delirium should be psychiatric medications upon which a patient has overdosed in the
routine. Agitated delirium should be managed with an antipsychotic intensive care unit, though withdrawal syndromes should be pre-
and, possibly, dexmedetomidine in treatment-refractory cases. vented, and communication with outpatient prescribers is vital.
Delirium management should also include ensuring a calming envi-
Conclusions: Understanding the diagnosis and appropriate
ronment and adequate pain control, minimizing benzodiazepines management of these four psychiatric emergencies is important
and anticholinergics, normalizing the sleep-wake cycle, provid-
to provide safe and effective care in the intensive care unit. (Crit
ing sensory aids as required, and providing early physical and Care Med 2012; 40:2662–2670)
occupational therapy. Neuroleptic malignant syndrome should be
KEY WORDS: delirium; depression; dexmedetomidine; intensive
treated by discontinuing dopamine blockers, providing supportive care units; neuroleptic malignant syndrome; mental disorders;
therapy, and possibly administering medications (benzodiazepines, posttraumatic stress disorder; serotonin syndrome; overdose
Critical care physicians fre- DELIRIUM
tation–Sedation Scale -3 to 0 during all Delirium has many causes (4). The assessments), or mixed (both positive and Box 1). In this article, we patient in the case study (Box 1) was delir- ious due to serotonin toxicity, though Scale scores, over time, during a delirium gencies in the intensive care unit (ICU): other etiologies were considered. In this episode).
agitated delirium, neuroleptic malignant section, we will focus on the recogni- syndrome (NMS), serotonin syndrome, tion and management of delirium, which Risk Factors
and psychiatric medication overdose. affects up to 75% of critically ill patients Other neuropsychiatric emergencies are (5–9).
In critically ill patients, the etiology of discussed elsewhere (1–3). Early psychi- delirium is often multifactorial. The mne- atric consultation, whenever possible, is Recognition
monic “I WATCH DEATH” may be helpful indicated to assist in each of these psychi- in thinking systematically about risk fac- tors (Table 1) (3, 4, 14). Other risk factors of consciousness in which patients have include immobilization, urinary/fecal a reduced ability to focus, sustain, or shift retention, and sensory or sleep depriva- tion (5). Note that some predisposing fac- tion (e.g., memory deficit, disorientation, From the Department of Psychiatry and Behavioral tors for delirium are not reversible, e.g., Sciences (OJB, KJN), Outcomes After Critical Illness and Surgery Group (OJB, KJN, DMN), Division of Pulmonary tual disturbance (e.g., visual hallucina- and Critical Care Medicine (DMN), and Department of tions), that is not better accounted for Physical Medicine and Rehabilitation (DMN), Johns Consequences
Hopkins University School of Medicine, Baltimore, MD; and Department of Mental Health (OJB), Johns Hopkins University Bloomberg School of Public Health, to fluctuate throughout the day (10). of mortality (9, 15–20) and long-term Simple and reliable instruments have cognitive impairment (21–23). Delirium Drs. Bienvenu, Neufeld, and Needham contributed been validated to screen for delirium in is also associated with self-extubation and to the conception and design of this manuscript. Dr. the ICU setting, including the Confusion removal of catheters (24), longer hospi- Bienvenu drafted the manuscript, and all authors criti- cally revised it for important intellectual content and Assessment Method for the ICU (7) and tal stays (17, 20, 25), and higher medical approved the final version to be submitted.
the Intensive Care Delirium Screening costs (26).
The authors have not disclosed any potential con- Checklist (6). Additional instruments like the Richmond Agitation–Sedation Scale long-term psychiatric morbidity (27–31). For information regarding this article, E-mail: (11) can be used to characterize episodes Critical illness and ICU management are Copyright 2012 by the Society of Critical Care of delirium in terms of motoric subtypes inherently stressful (32), especially when Medicine and Lippincott Williams & Wilkins DOI: 10.1097/CCM.0b013e31825ae0f8
tion–Sedation Scale +1 to +4 during all and communicate effectively. Frightening Box 1. A psychiatric emergency in the intensive care unit
A 50-yr-old man with a history of bipolar disorder, viral hepatitis, and suicide attempts via overdose was brought to his local emergency room by his wife because he was confused (unable to remember his wife’s name), febrile, perspiring excessively, and “stiff.” The day prior he had been tremulous and anxious. Upon arrival, he was febrile with increased white blood cell count, transaminases, ammonia, and creatine phosphokinase. No source of infection was identified, and a toxicology screen for common illicit drugs was negative.
The patient was admitted to the intensive care unit (ICU), hydrated vigorously, intubated, and sedated with propofol and haloperidol. His home psychiatric medications (olanzapine, bupropion, and fluoxetine) were held. Brain imaging and cerebrospinal fluid findings were unremarkable. Given clinical worsening, with increased muscle tone, his physicians wondered whether the patient may have neuroleptic malignant syndrome. They administered a single dose of dantrolene, which appeared helpful. The patient was extubated and discharged home after several days. However, he was readmitted to the ICU a week later with a recurrence of his symptoms, and he was transferred to a tertiary medical center.
Upon transfer, he was hyperactive, tremulous, diaphoretic, febrile, and unable to communicate. He exhibited both hyperreflexia and myoclonus. Upon detailed review of his medical records, it became evident that the patient’s fluoxetine dose had been doubled shortly before his initial ICU admission (the patient had had worsening depressive symptoms). In between admissions, he had resumed taking fluoxetine. Given his history and acute symp-toms, the patient’s acute neuropsychiatric state was reformulated as serotonin syndrome. His physicians administered cyproheptadine, and most of his symptoms resolved within 24 hrs. After resolution of his delirium and urinary retention on a general medical ward, he was transferred to the inpatient psychiatric service for treatment of recurrent depression.
delirium involves deficient cholinergic patients with delirium (including various neurotransmission and excess dopamine motoric subtypes), atypical antipsychotics tion of catecholamines, which may cross neurotransmission (41, 42), and some may be as effective as enteral haloperi- the blood-brain barrier in sepsis and acti- studies support the use of dopamine dol (48–52). To our knowledge, only two vate the amygdala to produce traumatic blockers (antipsychotics) to prevent delir- studies of antipsychotics for delirium in Treat Agitated Delirium and Psychosis. group (50, 51). First, in a three-arm ran- survivors have substantial symptoms of Note that no medications are approved by domized, blinded feasibility study, nei- posttraumatic stress (27–30, 38, 39) and/ the Food and Drug Administration to treat ther low-dose haloperidol nor ziprasidone or depression (27, 31, 40), sometimes delirium. Nevertheless, existing guidelines (both administered enterally) significantly lasting for years. Patients who recalled recommend haloperidol as the medica- frightening psychotic experiences in tion of choice, based on evidence from time patients spent delirious or comatose the ICU had substantially more of these case series (44). Advantages of haloperi- (50); however, a larger trial with these dol include various routes of administra- same medications is evaluating this ques- tion (including the intravenous route for tion more definitively (ClinicalTrials.
Treatment and Prevention
rapid action) and its favorable side-effect gov identifier NCT01211522). Second, profile compared with other antipsychotic in a placebo-controlled trial, quetiapine The management of acute hyperactive drugs commonly used in the ICU setting 50–200 mg every 12 hrs reduced the dura- delirium involves treating agitation and (44). Although haloperidol can cause dose- tions of both delirium and agitation (51); psychosis and removing/minimizing risk dependent electrocardiogram QT interval in the trial, intravenous haloperidol was prolongation, it appears to cause less QT administered, as needed, to patients in prevent delirium beyond standard critical prolongation than other antipsychot- care practice (treating infection, ensur- ing adequate oxygenation, and managing toms are less common with intravenous haloperidol. Beyond the management of haloperidol administration than with agitation, antipsychotics may be used to oral or intramuscular administration (46, reduce frightening psychotic symptoms esis regarding the pathophysiology of 47). Based on small trials in critically ill in delirious patients (including those with hypoactive delirium); in order to detect Table 1. Risk factors for delirium (“I WATCH DEATH”) (3, 4, 14)
these symptoms, clinicians should have a high index of suspicion and question the Electrolyte or acid-base imbalance, liver or kidney failure Brain injury, surgery, severe burns, heat stroke, hypothermia role in the treatment of agitation. Exist- Central nervous system Tumor, hematoma, epileptic seizure, hydrocephalus, vasculitis, meningeal on agitation in the setting of ventilator Respiratory failure, left heart failure, hypotension, anemia, carbon monoxide weaning. In one open-label pilot study, Cortisol or glucose dysregulation, hypothyroidism, hyperparathyroidism fully weaned because of agitated delirium Cerebrovascular accident, shock, arrhythmia, hypertensive encephalopathy Pesticides, solvents, vitamin intoxication, alcohol or illicit drugs, medications (including γ-aminobutyric acid-ergic agents and with a significantly shorter median time to extubation (20 vs. 42 hrs, p = .016), as is important not to use excessive doses of (e.g., diaphoresis, incontinence, decreased well as a significantly shorter ICU length opioids. Some opioids may be relatively level of consciousness, mutism, elevated of stay after study drug commencement less deliriogenic (e.g., morphine) (57, 81), or labile blood pressure, elevated creatine (1.5 vs. 6.5 days, p = .004) (53). In another whereas others appear particularly delir- phosphokinase) developing in association open-label, uncontrolled study of 28 iogenic (e.g., meperidine and tramadol) with the use of neuroleptic (i.e., antipsy- patients with agitation during weaning, (81–86).
chotic) medication (10). Box 2 lists com- Promote a More Normal Sleep-Wake mon antipsychotic medications, as well Cycle. Disrupted sleep can be both a risk as other dopamine-blocking drugs (e.g., tion of agitation (within 6 hrs of infusion factor for delirium and a manifestation antinausea medications) that can contrib- of delirium. Several interventions may ute to NMS. Other adverse drug reactions tion after a median of 70 (interquartile be helpful (87). First, promote a quiet associated with hyperthermia that should range 28–96) hrs (54). Unfortunately, environment at night by reducing loud be considered in the differential diagnosis dexmedetomidine is substantially more conversations, televisions, unnecessary of NMS and SS include adrenergic or anti- expensive than haloperidol, though alarms, and overhead pages (88–90). ICU cholinergic toxicity, or uncoupling of oxi- higher drug costs may be offset by shorter noise levels often exceed 80 decibels, the dative phosphorylation—none of which threshold associated with sleep disruption should be associated with rigidity; malig- (91–94). Second, group together disrup- tions is not the only intervention that can tive, but necessary, patient care activi- help agitated delirium. Calm verbal reas- ties, like clinical assessments, medication (106).
surance and reorientation by staff and/or administration, wound care, bathing, ICU physicians, given the frequent admin- Manage Sedation Carefully. Medica- graphs (90, 93, 95, 96). Third, minimize istration of antipsychotics to critically ill tions that increase γ-amino butyric acid sedative agents known to disrupt sleep patients for agitated delirium (44, 107). neurotransmission (i.e., benzodiazepines (e.g., benzodiazepines), and consider Importantly, several NMS risk factors and propofol) are common and important alternate methods to address insomnia are common in ICU patients: agitation modifiable risk factors for delirium (55– (i.e., including nondrug measures) (97). and use of typical antipsychotics (e.g., 58) and coma (59–62). As needed, bolus Fourth, keep patient rooms dark at night haloperidol), often in parenteral form, in dosing and interruption of continuous and bright (with daylight) during the day- higher doses (e.g., 20 mg of haloperidol infusions of sedatives reduce delirium and time (4).
daily), and in patients who are neurolep- Early Physical Rehabilitation. Pro- (59, 63–66) without increasing post-ICU viding early physical and occupational psychological distress (67, 68). Continu- therapy in the ICU reduced the duration Treatment
ous infusions of dexmedetomidine, a of delirium and improved physical func- non-γ-amino butyric acid-ergic sedative, tion in a randomized trial (98). Similarly, an ICU quality improvement project that ticular, the dopamine agonist bromocrip- epine infusions (56, 58). Morphine-only reduced sedation and facilitated rehabili- sedation also appears to reduce ICU tation was associated with an increased or worsen SS. Also, antipsychotics for length of stay (69). Note that, if alcohol proportion of ICU days without delirium hyperactive delirium or presumed SS or other γ-amino butyric acid-ergic seda- or coma (99). Conversely, immobility and can worsen/prolong NMS (112, 113). No tive withdrawal is suspected, patients are physical restraints may increase the risk medications are approved by the Food and generally given benzodiazepines more of delirium (100).
Drug Administration for the treatment of Reduce Sensory Deprivation and NMS; recommendations for treatment Minimize Anticholinergics. Anticholin- Orient Patients. Poor visual acuity and have been drawn from case series (113). ergic drugs are highly deliriogenic (70–73) hearing impairment are risk factors for Note that consultation with local poison and should be withheld, when possible, in delirium (101, 102). Providing eyeglasses control centers can be helpful in the man- ICU patients. Of >100 medications com- and/or hearing aids were part of a multi- monly prescribed in the elderly (74), those faceted strategy that reduced delirium in http://www.aapcc.org/dnn/default.aspx).
with the most potent anticholinergic prop- older hospitalized patients (103). Clocks Discontinue All Dopamine Blockers. It and calendars in patients’ rooms (104) is important to note that antipsychotics mine, tolterodine, doxepin, amitriptyline, and verbal orientation by staff and/or fam- thioridazine, and clozapine. Those with the ily members (4) may also be helpful.
next most potent anticholinergic properties included diphenhydramine, oxybutynin, NEUROLEPTIC MALIGNANT
nortriptyline, paroxetine, olanzapine, and SYNDROME
chlorpromazine (74). Currently, cholines- terase inhibitors are not indicated for the ive care is the mainstay of treatment for prevention or treatment of delirium, given drome (SS), and other toxidromes overlap NMS (112, 113). This includes vigorous negative clinical trial results and potential substantially (105, 106). Table 2 illus- hydration, attention to electrolyte abnor- trates shared and unique features of NMS malities, external cooling for extreme Manage Pain. Inadequately treated and SS. The DSM-IV criteria for NMS hyperthermia, and managing complica- pain disrupts sleep and is a risk factor for include severe muscle rigidity, elevated tions (cardiorespiratory and renal failure, delirium (79, 80). On the other hand, it temperature, and other related findings aspiration, and coagulopathies) (112, 113).
Table 2. Characteristics of neuroleptic malignant syndrome and serotonin syndrome (105, 106)
Variable, Hypertension, Sialorrhea Pallor, diapho- Variable: Increased tone, Hyperreflexia, Dilated Hyperactive Consider Benzodiazepines for Milder can be administered 1.0–2.5 mg/kg of medications and illicit drugs associ- Cases. Benzodiazepines (e.g., lorazepam intravenously, then 1 mg/kg every 6 hrs ated with SS, including several drugs 1–2 mg intravenously every 4–6 hrs) may if hyperthermia and/or rigidity reduces that are monoamine oxidase inhibi- ameliorate symptoms in milder cases of after the first dose. Side effects can tors and have indications other than NMS, particularly catatonic symptoms include respiratory and hepatic impair- like mutism and immobility (113, 114).
ment. If the patient has a good response, 118–120).
Consider Dopaminergic Agents. Bro- mocriptine (starting at 2.5 mg bid-tid, to an oral preparation after the first few Recognition
up to 45 mg/day), amantadine (200–400 days. Dantrolene should be continued mg/day in divided doses), and other for 10 days after resolution of NMS, as enterally administered dopaminergic patients can have a recurrence if it is tion, diaphoresis, increased muscle tone, elevated temperature, hyperreflexia, and toms (e.g., rigidity) (113), speed recov- Consider Electroconvulsive Therapy. toms  can include confusion, shivering, dilated pupils, hyperactive bowel sounds, tachycardia, and hypertension (105, 118). therapy are ineffective after 2 days (113, 117). Electroconvulsive therapy has been the  Hunter Serotonin Toxicity Criteria a recurrence if it is discontinued prema- SEROTONIN SYNDROME
diagnosis is often delayed (122). Thus, it Consider Dantrolene. The skeletal Though overdoses of serotonergic is important for clinicians to be aware of muscle relaxant dantrolene appears to drugs and the use of serotonergic drug the signs and consider the diagnosis in reduce symptoms, speed recovery, and combinations often precede SS (also patients who have been treated with sero- reduce mortality in patients with NMS known as serotonin toxicity), this syn- who have extreme hyperthermia and drome can develop in patients taking rigidity (113, 115, 116). Note that benzo- usual therapeutic doses of serotonergic Treatment
diazepines or dopamine agonists can be medications. Combinations of mono- administered with dantrolene, but not amine oxidase inhibitors with other Some patients’ symptoms will resolve calcium channel blockers given the risk serotonergic drugs are strongly associ- of cardiovascular collapse (113). Patients ated with SS (118). Box 3 provides a list gic medications with supportive therapy. Box 2. Drugs associated with neuroleptic malignant syndrome (113)
fluoxetine and its active metabolite have Typical antipsychotics: pimozide, droperidol, haloperidol, fluphenazine, trifluoperazine, thiothixene, perphenazine, loxapine, molindone, mesoridazine, thioridazine, chlorpromazine Provide Supportive Therapy. Support- Atypical antipsychotics: clozapine, olanzapine, risperidone, quetiapine, ziprasidone, aripiprazole Other dopamine blockers: metoclopramide, prochlorperazine, promethazine tion of vital signs. Avoid longer-acting Box 3. Drugs associated with serotonin syndrome (105, 106, 118–120)
Monoamine oxidase inhibitorsa: tranylcypromine, phenelzine, isocarboxazid, moclobemide, nialamide, iproniazid, clorgiline, and toloxatone (antidepressants); pargyline and selegiline (antiparkinsonian agents); procarbazine (antineoplastic); linezolid and furazolidone (antibiotics); Syrian rue (harmine and harmaline—various uses) Selective serotonin reuptake inhibitors: fluoxetine, sertraline, paroxetine, fluovoxamine, citalopram, escitalopram Serotonin–norepinephrine reuptake inhibitors: venlafaxine, duloxetine, milnacipran Tricyclic and other antidepressants: clomipramine, imipramine, trazodone “Mood stabilizers”: lithium, valproate Opiates: meperidine, fentanyl, methadone, tramadol, dextromethorphan, dextropropoxyphene, pentazocine Antiemetics: ondansetron, granisetron, metoclopramide Antihistamines: chorphenamine, brompheniramine Antimigraine drugs: “triptans” (controversial) (120) Supplements/herbal products: L-tryptophan, 5-hydroxytryptophan, Hypericum perforatum (St. John’s wort), ginseng Stimulants: amphetamine, 3,4-methylenedioxymethamphetamine (“Ecstasy”) Psychedelics: lysergic acid diethylamide, 5-methoxy-diisopropyltryptamine aNote that the listed monoamine oxidase inhibitors have various uses within and outside of medicine. Thus, we specify their usual indications here.
potent blocker of this receptor at higher epinephrine; dopamine should be avoided sion in patients with autonomic instabil- doses (12–32 mg in a 24-hr period) (105, because of the risk of an exaggerated 119, 125). A starting dose of 12 mg can hemodynamic response (105). In patients Control Agitation. Agitation in SS be crushed and administered via a naso- can be fairly severe, and sedation with gastric tube, followed by 2 mg every 2 dia, short-acting agents such as nitroprus-benzodiazepines may be necessary. Ben- hrs if symptoms continue, and 4–8 mg side or esmolol are preferred (105).
zodiazepines improve survival in animal q6 hrs for maintenance dosing. In cases Control Hyperthermia. Temperature models of SS, perhaps through a blunting in which NMS has been ruled out clini- cally, the antipsychotic chlorpromazine be severe (>41°C). Antipyretics are not tion is required with the use of physical (e.g., 50–100 mg intramuscular) and helpful. Patients with high temperatures restraints because persistent struggling atypical antipsychotics may also be con- should be intubated for airway protection against restraints could contribute to sidered as alternative serotonin antag- worsening lactic acidosis, hyperthermia, onists. If activated charcoal has been lar blockade with a nondepolarizing agent and mortality (105, 124).
(105), and active cooling measures should Consider Serotonin Antagonists. promazine may be necessary, as cypro- Although no medication is approved by heptadine is not available in parenteral Avoid Bromocriptine and Dantrolene. the Food and Drug Administration for the form (120).
treatment of SS, results from case series Control Autonomic Instability. Patients a patient treated with bromocriptine and dase inhibitor interactions with other improve survival in an animal model of sion, and hyperthermia) should receive serotonergic drugs can be treated with low SS (123).
serotonin receptor antagonists (105). doses of direct-acting sympathetic amines Cyproheptadine, an antihistamine, is a like norepinephrine, phenylephrine, or MEDICATION OVERDOSE
Box 4. The Hunter Serotonin Toxicity Criteriaa
In the presence of a serotonergic agent, serotonin toxicity is diagnosed: overdoses (128, 129), and ICU physicians ric medications, ideally in collaboration Or if induciblec or oculard clonus and agitation or diaphoresis are present with psychiatric consultants. In this sec- Or if inducible or ocular clonus and increased muscle tone and temperature >38°C are present tion, we outline two principles for patient Or if tremor and hyperreflexia are present First, it is often unnecessary to restart asensitivity 84% and specificity 97% when compared with the “gold standard”—diagnosis by a medical toxicologist (121); balternate involuntary muscular contraction and relaxation in rapid care setting, i.e., they can be held pend- succession; ce.g., with rapid dorsiflexion of the ankle; dslow continuous lateral eye movements.
ing a psychiatric consultation. However, holding certain psychiatric medications 2. Rizos DV, Peritogiannis V, Gkogkos C: Cata- of ICU delirium. Intensive Care Med 2007; could result in withdrawal. For example, tonia in the intensive care unit. Gen Hosp if a patient has been taking a regular dose 18. Pisani MA, Kong SY, Kasl SV, et al: Days of of a benzodiazepine, it may be necessary 3. Irani SR, Vincent A: Autoimmune encephali- delirium are associated with 1-year mortality tis – new awareness, challenging questions. in an older intensive care unit population. Am J Respir Crit Care Med 2009; 180:1092–1097 4. Neufeld K, Huberman A, Needham D: Delir- 19. Shehabi Y, Riker RR, Bokesch PM, et al; need to be adjusted based on the clinical ium. In: Principles and Practice of Hospital SEDCOM (Safety and Efficacy of Dexmedeto- state of the patient (e.g., a lower dose if Medicine. McKean S, Brotman D, Dressler D, et al (Eds). Illinois, Burr Ridge, McGraw-Hill, in lightly sedated, mechanically ventilated Similarly, abruptly stopping serotonin 5. Morandi A, Jackson JC, Ely EW: Delirium in intensive care patients. Crit Care Med 2010; reuptake inhibitors can lead to a distress- the intensive care unit. Int Rev Psychiatry 20. Thomason JW, Shintani A, Peterson JF, et 6. Bergeron N, Dubois MJ, Dumont M, et al: al: Intensive care unit delirium is an inde- Intensive Care Delirium Screening Checklist: pendent predictor of longer hospital stay: A prospective analysis of 261 non-ventilated Evaluation of a new screening tool. Intensive patients. Crit Care 2005; 9:R375–R381 21. Jackson JC, Gordon SM, Hart RP, et al: The the medication on which the patient 7. Ely EW, Inouye SK, Bernard GR, et al: Delir- ium in mechanically ventilated patients: association between delirium and cognitive Validity and reliability of the confusion decline: A review of the empirical literature. assessment method for the intensive care pressant, a psychiatrist may discontinue unit (CAM-ICU). JAMA 2001; 286:2703–2710 22. Girard TD, Jackson JC, Pandharipande PP, et 8. Ely EW, Margolin R, Francis J, et al: Evalua- al: Delirium as a predictor of long-term cog- tion of delirium in critically ill patients: Vali- nitive impairment in survivors of critical ill- dation of the Confusion Assessment Method ness. Crit Care Med 2010; 38:1513–1520 for the Intensive Care Unit (CAM-ICU). Crit 23. van den Boogaard M, Schoonhoven L, Evers AWM, et al: Delirium in critically ill patients: CONCLUSIONS
9. Salluh JI, Soares M, Teles JM, et al; Delirium Impact on long-term quality of life and cog- Epidemiology in Critical Care Study Group: nitive functioning. Crit Care Med 2012; 40:112–118 24. Dubois MJ, Bergeron N, Dumont M, et al: (DECCA): An international study. Crit Care Delirium in an intensive care unit: A study of risk factors. Intensive Care Med 2001; midine, as well as measures to minimize 10. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. 25. Ely EW, Siegel MD, Inouye SK: Delirium in Fourth Edition. Washington, DC, American the intensive care unit: An under-recognized syndrome of organ dysfunction. Semin Respir 11. Ely EW, Truman B, Shintani A, et al: Monitor- ing sedation status over time in ICU patients: 26. Milbrandt EB, Deppen S, Harrison PL, et al: Reliability and validity of the Richmond Costs associated with delirium in mechani- Agitation-Sedation Scale (RASS). JAMA 2003; cally ventilated patients. Crit Care Med 2004; gic agents, controlling agitation with 12. Peterson JF, Pun BT, Dittus RS, et al: Delir- 27. Davydow DS, Desai SV, Needham DM, et ium and its motoric subtypes: A study of 614 al: Psychiatric morbidity in survivors of critically ill patients. J Am Geriatr Soc 2006; the acute respiratory distress syndrome: A often unnecessary to restart psychiatric systematic review. Psychosom Med 2008; medications upon which a patient has 13. Pandharipande P, Cotton BA, Shintani A, et al: Motoric subtypes of delirium in mechani- 28. Davydow DS, Gifford JM, Desai SV, et al: Post- cally ventilated surgical and trauma intensive traumatic stress disorder in general intensive care unit patients. Intensive Care Med 2007; care unit survivors: A systematic review. Gen Hosp Psychiatry 2008; 30:421–434 14. Wise MG: Delirium. In: Clinical Manual 29. Bienvenu OJ, Gould NF, Mason ST, et al: Anxi- ety disorders prevention: Overview and focus ACKNOWLEDGMENT
Consultation-Liason Psychiatry. Arlington, on post-traumatic stress disorder. Minerva VA, American Psychiatric Publishing, 2005, 30. Bienvenu OJ, Neufeld KJ: Post-traumatic 15. Ely EW, Shintani A, Truman B, et al: Delirium stress disorder in medical settings: Focus on ing brief case report (Box 1), based on a as a predictor of mortality in mechanically the critically ill. Curr Psychiatry Rep 2011; ventilated patients in the intensive care unit. 31. Davydow DS, Gifford JM, Desai SV, et al: REFERENCES
16. Lin SM, Liu CY, Wang CH, et al: The impact Depression in general intensive care unit of delirium on the survival of mechanically survivors: A systematic review. Intensive Care 1. Krauseneck T, Graz C, Krähenmann O, et al: ventilated patients. Crit Care Med 2004; Psychiatric emergencies on ICU. Anasthesiol 32. Skirrow P, Jones C, Griffiths RD, et al: Inten- Intensivmed Notfallmed Schmerzther 2007; 17. Ouimet S, Kavanagh BP, Gottfried SB, et al: sive care: Easing the trauma. Psychologist Incidence, risk factors and consequences 33. Sharshar T, Hopkinson NS, Orlikowski D, et in a critical care setting. Intensive Care Med 62. Arroliga AC, Thompson BT, Ancukiewicz M, al: Science review: The brain in sepsis–culprit et al; Acute Respiratory Distress Syndrome and victim. Crit Care 2005; 9:37–44 49. Han CS, Kim YK: A double-blind trial of ris- Network: Use of sedatives, opioids, and neu- 34. Ebersoldt M, Sharshar T, Annane D: Sepsis- peridone and haloperidol for the treatment of associated delirium. Intensive Care Med delirium. Psychosomatics 2004; 45:297–301 with acute lung injury and acute respira- 50. Girard TD, Pandharipande PP, Carson SS, et tory distress syndrome. Crit Care Med 2008; 35. Siami S, Annane D, Sharshar T: The encepha- al; MIND Trial Investigators: Feasibility, effi- lopathy in sepsis. Crit Care Clin 2008; 24:67– cacy, and safety of antipsychotics for intensive 63. Brook AD, Ahrens TS, Schaiff R, et al: Effect care unit delirium: The MIND randomized, of a nursing-implemented sedation protocol 36. Ekström-Jodal B, Häggendal J, Larsson LE, placebo-controlled trial. Crit Care Med 2010; on the duration of mechanical ventilation. et al: Cerebral hemodynamics, oxygen uptake Crit Care Med 1999; 27:2609–2615 and cerebral arteriovenous differences of 51. Devlin JW, Roberts RJ, Fong JJ, et al: Effi- 64. Kress JP, Pohlman AS, O’Connor MF, et catecholamines following E. coli endotoxin cacy and safety of quetiapine in critically ill in dogs. Acta Anaesthesiol Scand 1982; patients with delirium: A prospective, mul- sions in critically ill patients undergoing ticenter, randomized, double-blind, placebo- mechanical ventilation. N Engl J Med 2000; 37. Ekström-Jodal B, Larsson LE: Effects of controlled pilot study. Crit Care Med 2010; dopamine of cerebral circulation and oxygen 65. Girard TD, Kress JP, Fuchs BD, et al: Efficacy metabolism in endotoxic shock: An experi- 52. Wan RY, Kasliwal M, McKenzie CA, et al: Que- and safety of a paired sedation and ventilator mental study in dogs. Crit Care Med 1982; tiapine in refractory hyperactive and mixed weaning protocol for mechanically ventilated intensive care delirium: A case series. Crit patients in intensive care (Awakening and 38. Jackson JC, Hart RP, Gordon SM, et al: Post- Breathing Controlled trial): A randomised traumatic stress disorder and post-traumatic 53. Reade MC, O’Sullivan K, Bates S, et al: Dex- controlled trial. Lancet 2008; 371:126–134 stress symptoms following critical illness in medetomidine vs. haloperidol in delirious, 66. Needham DM, Korupolu R, Zanni JM, et al: medical intensive care unit patients: Assess- agitated, intubated patients: A randomised Early physical medicine and rehabilitation ing the magnitude of the problem. Crit Care open-label trial. Crit Care 2009; 13:R75 for patients with acute respiratory failure: A 54. Shehabi Y, Nakae H, Hammond N, et al: The quality improvement project. Arch Phys Med 39. Griffiths J, Fortune G, Barber V, et al: The effect of dexmedetomidine on agitation dur- prevalence of post traumatic stress disor- ing weaning of mechanical ventilation in 67. Kress JP, Gehlbach B, Lacy M, et al: The long- der in survivors of ICU treatment: A sys- critically ill patients. Anaesth Intensive Care term psychological effects of daily sedative tematic review. Intensive Care Med 2007; interruption on critically ill patients. Am J 55. Pandharipande P, Shintani A, Peterson J, et Respir Crit Care Med 2003; 168:1457–1461 40. Bienvenu OJ, Colantuoni E, Mendez-Tellez al: Lorazepam is an independent risk factor 68. Jackson JC, Girard TD, Gordon SM, et al: PA, et al: Depressive symptoms and impaired for transitioning to delirium in intensive Long-term cognitive and psychological out- physical function after acute lung injury: A care unit patients. Anesthesiology 2006; comes in the awakening and breathing con- 2-year longitudinal study. Am J Respir Crit trolled trial. Am J Respir Crit Care Med 2010; 41. Flacker JM, Lipsitz LA: Neural mechanisms 56. Pandharipande PP, Pun BT, Herr DL, et al: of delirium: Current hypotheses and evolving 69. Strøm T, Martinussen T, Toft P: A protocol of concepts. J Gerontol A Biol Sci Med Sci 1999; no sedation for critically ill patients receiving in mechanically ventilated patients: The mechanical ventilation: A randomised trial. 42. Steiner LA: Postoperative delirium. Part MENDS randomized controlled trial. JAMA 1: Pathophysiology and risk factors. Eur J 70. Tune LE, Damlouji NF, Holland A, et al: Asso- 57. Pandharipande P, Cotton BA, Shintani A, et ciation of postoperative delirium with raised 43. Steiner LA: Postoperative delirium. part 2: al: Prevalence and risk factors for develop- serum levels of anticholinergic drugs. Lancet Detection, prevention and treatment. Eur J intensive care unit patients. J Trauma 2008; 71. Han L, McCusker J, Cole M, et al: Use of 44. Jacobi J, Fraser GL, Coursin DB, et al; Task medications with anticholinergic effect pre- Force of the American College of Critical 58. Riker RR, Shehabi Y, Bokesch PM, et al; dicts clinical severity of delirium symptoms Care Medicine (ACCM) of the Society of Criti- SEDCOM (Safety and Efficacy of Dexmedeto- in older medical inpatients. Arch Intern Med ety of Health-System Pharmacists (ASHP), 72. Flacker JM, Cummings V, Mach JR Jr, et American College of Chest Physicians: Clini- sedation of critically ill patients: A random- al: The association of serum anticholiner- cal practice guidelines for the sustained use ized trial. JAMA 2009; 301:489–499 gic activity with delirium in elderly medi- of sedatives and analgesics in the critically ill 59. Kollef MH, Levy NT, Ahrens TS, et al: The cal patients. Am J Geriatr Psychiatry 1998; adult. Crit Care Med 2002; 30:119–141 use of continuous i.v. sedation is associated 45. Glassman AH, Bigger JT Jr: Antipsychotic with prolongation of mechanical ventilation. 73. Gerretsen P, Pollock BG: Drugs with anticho- drugs: Prolonged QTc interval, torsade de linergic properties: A current perspective on pointes, and sudden death. Am J Psychiatry 60. Weinert CR, Calvin AD: Epidemiology of use and safety. Expert Opin Drug Saf 2011; sedation and sedation adequacy for mechani- 46. Ayd FJ Jr: Haloperidol update: 1975. Proc R cally ventilated patients in a medical and sur- 74. Chew ML, Mulsant BH, Pollock BG, et al: gical intensive care unit. Crit Care Med 2007; Anticholinergic activity of 107 medications 47. Altamura AC, Sassella F, Santini A, et al: commonly used by older adults. J Am Geriatr Intramuscular preparations of antipsychot- 61. Payen JF, Chanques G, Mantz J, et al: Cur- ics: Uses and relevance in clinical practice. rent practices in sedation and analgesia for 75. Liptzin B, Laki A, Garb JL, et al: Donepezil in mechanically ventilated critically ill patients: the prevention and treatment of post-surgi- 48. Skrobik YK, Bergeron N, Dumont M, et al: cal delirium. Am J Geriatr Psychiatry 2005; Olanzapine vs haloperidol: Treating delirium study. Anesthesiology 2007; 106:687–695 76. Sampson EL, Raven PR, Ndhlovu PN, et al: A 91. Topf M, Davis JE: Critical care unit noise 107. Seitz DP, Gill SS: Neuroleptic malignant randomized, double-blind, placebo-controlled and rapid eye movement (REM) sleep. Heart syndrome complicating antipsychotic treat- trial of donepezil hydrochloride (Aricept) for ment of delirium or agitation in medical and reducing the incidence of postoperative delir- 92. Freedman NS, Gazendam J, Levan L, et al: surgical patients: Case reports and a review ium after elective total hip replacement. Int J Abnormal sleep/wake cycles and the effect of the literature. Psychosomatics 2009; Geriatr Psychiatry 2007; 22:343–349 of environmental noise on sleep disruption 77. Gamberini M, Bolliger D, Lurati Buse GA, in the intensive care unit. Am J Respir Crit 108. Keck PEJr, Pope HGJr, Cohen BM, et al: Risk et al: Rivastigmine for the prevention of factors for neuroleptic malignant syndrome. postoperative delirium in elderly patients 93. Gabor JY, Cooper AB, Crombach SA, et al: A case-control study. Arch Gen Psychiatry undergoing elective cardiac surgery–a ran- Contribution of the intensive care unit envi- domized controlled trial. Crit Care Med 2009; ronment to sleep disruption in mechanically 109. Berardi D, Amore M, Keck PEJr, et al: Clini- ventilated patients and healthy subjects. Am cal and pharmacologic risk factors for neu- 78. van Eijk MM, Roes KC, Honing ML, et al: J Respir Crit Care Med 2003; 167:708–715 roleptic malignant syndrome: A case-control Effect of rivastigmine as an adjunct to usual 94. Elliott RM, McKinley SM, Eager D: A pilot study. Biol Psychiatry 1998; 44:748–754 care with haloperidol on duration of delirium study of sound levels in an Australian adult 110. Sachdev P, Mason C, Hadzi-Pavlovic D: and mortality in critically ill patients: A multi- general intensive care unit. Noise Health centre, double-blind, placebo-controlled ran- nant syndrome. Am J Psychiatry 1997; domised trial. Lancet 2010; 376:1829–1837 95. Olson DM, Borel CO, Laskowitz DT, et al: 79. Novaes MA, Aronovich A, Ferraz MB, et al: Quiet time: A nursing intervention to pro- 111. Viejo LF, Morales V, Puñal P, et al: Risk fac- Stressors in ICU: Patients’ evaluation. Inten- mote sleep in neurocritical care units. Am J tors in neuroleptic malignant syndrome. A sive Care Med 1997; 23:1282–1285 case-control study. Acta Psychiatr Scand 80. Nelson JE, Meier DE, Oei EJ, et al: Self- 96. Tamburri LM, DiBrienza R, Zozula R, et al: reported symptom experience of critically ill Nocturnal care interactions with patients 112. Bhanushali MJ, Tuite PJ: The evaluation and cancer patients receiving intensive care. Crit in critical care units. Am J Crit Care 2004; malignant syndrome. Neurol Clin 2004; 81. Morrison RS, Magaziner J, Gilbert M, et al: 97. Bourne RS, Mills GH: Sleep disruption in Relationship between pain and opioid analge- critically ill patients–pharmacological con- 113. Strawn JR, Keck PE Jr, Caroff SN: Neurolep- sics on the development of delirium following siderations. Anaesthesia 2004; 59:374–384 tic malignant syndrome. Am J Psychiatry hip fracture. J Gerontol A Biol Sci Med Sci 98. Schweickert WD, Pohlman MC, Pohlman AS, et al: Early physical and occupational 114. Francis A, Chandragiri S, Rizvi S, et al: Is 82. Eisendrath SJ, Goldman B, Douglas J, et al: therapy in mechanically ventilated, criti- Meperidine-induced delirium. Am J Psychia- cally ill patients: A randomised controlled malignant syndrome? CNS Spectr 2000; trial. Lancet 2009; 373:1874–1882 83. Marcantonio ER, Juarez G, Goldman L, et al: 99. Needham DM, Korupolu R: Rehabilitation 115. Rosenberg MR, Green M: Neuroleptic The relationship of postoperative delirium quality improvement in an intensive care with psychoactive medications. JAMA 1994; unit setting: Implementation of a quality improvement model. Top Stroke Rehabil to therapy. Arch Intern Med 1989; 84. Adunsky A, Levy R, Heim M, et al: Meperi- dine analgesia and delirium in aged hip frac- 100. Inouye SK, Charpentier PA: Precipitating 116. Sakkas P, Davis JM, Janicak PG, et al: Drug ture patients. Arch Gerontol Geriatr 2002; factors for delirium in hospitalized elderly persons. Predictive model and interrelation- syndrome. Psychopharmacol Bull 1991; 85. Künig G, Dätwyler S, Eschen A, et al: Unrec- ship with baseline vulnerability. JAMA 1996; ognised long-lasting tramadol-induced delir- 117. Trollor JN, Sachdev PS: Electroconvulsive ium in two elderly patients. A case report. 101. Inouye SK, Viscoli CM, Horwitz RI, et al: Pharmacopsychiatry 2006; 39:194–199 A predictive model for delirium in hospi- drome: A review and report of cases. Aust N 86. Brouquet A, Cudennec T, Benoist S, et al: talized elderly medical patients based on Impaired mobility, ASA status and adminis- admission characteristics. Ann Intern Med 118. Sternbach H: The serotonin syndrome. Am J tration of tramadol are risk factors for post- operative delirium in patients aged 75 years 102. Inouye SK: Predisposing and precipitating 119. Gillman PK: The serotonin syndrome and or more after major abdominal surgery. Ann factors for delirium in hospitalized older its treatment. J Psychopharmacol (Oxford) patients. Dement Geriatr Cogn Disord 1999; 87. Kamdar BB, Needham DM, Collop NA: Sleep 120. Sun-Edelstein C, Tepper SJ, Shapiro deprivation in critical illness: Its role in phys- 103. Inouye SK, Bogardus STJr, Charpentier ical and psychological recovery. J Intensive PA, et al: A multicomponent intervention A review. Expert Opin Drug Saf 2008; to prevent delirium in hospitalized older 88. Helton MC, Gordon SH, Nunnery SL: The patients. N Engl J Med 1999; 340:669–676 121. Dunkley EJ, Isbister GK, Sibbritt D, et al: The correlation between sleep deprivation and the 104. Marcantonio ER, Flacker JM, Wright RJ, et Hunter Serotonin Toxicity Criteria: Simple intensive care unit syndrome. Heart Lung al: Reducing delirium after hip fracture: A and accurate diagnostic decision rules for randomized trial. J Am Geriatr Soc 2001; serotonin toxicity. QJM 2003; 96:635–642 89. Kahn DM, Cook TE, Carlisle CC, et al: Identifi- 122. Attar-Herzberg D, Apel A, Gang N, et al: The cation and modification of environmental noise serotonin syndrome: Initial misdiagnosis. in an ICU setting. Chest 1998; 114:535–540 tonin syndrome. N Engl J Med 2005; Isr Med Assoc J 2009; 11:367–370 90. Freedman NS, Kotzer N, Schwab RJ: Patient 123. Nisijima K, Shioda K, Yoshino T, et al: Diaz- perception of sleep quality and etiology of 106. McAllen KJ, Schwartz DR: Adverse drug sleep disruption in the intensive care unit. reactions resulting in hyperthermia in the development of hyperthermia in an animal Am J Respir Crit Care Med 1999; 159(4 Pt intensive care unit. Crit Care Med 2010; model of the serotonin syndrome. Neuro- 124. Hick JL, Smith SW, Lynch MT: Metabolic 127. Kline SS, Mauro LS, Scala-Barnett DM, et factors for intensive care admission. Eur J acidosis in restraint-associated cardiac al: Serotonin syndrome versus neuroleptic arrest: A case series. Acad Emerg Med 1999; 130. Schatzberg AF, Haddad P, Kaplan EM, et al: Serotonin reuptake inhibitor discontinua- 125. Kapur S, Zipursky RB, Jones C, et al: 128. Henderson A, Wright M, Pond SM: Expe- tion syndrome: A hypothetical definition. Cyproheptadine: A potent in vivo sero- Discontinuation Consensus panel. J Clin tonin antagonist. Am J Psychiatry 1997; admitted to an intensive care unit over six Psychiatry 1997; 58(Suppl 7):5–10 years. Med J Aust 1993; 158:28–30 131. Black K, Shea C, Dursun S, et al: Selective 126. Snider SR, Hutt C, Stein B, et al: Increase in 129. Novack V, Jotkowitz A, Delgado J, et al: Gen- serotonin reuptake inhibitor discontinua- brain serotonin produced by bromocriptine. eral characteristics of hospitalized patients tion syndrome: Proposed diagnostic crite- after deliberate self-poisoning and risk ria. J Psychiatry Neurosci 2000; 25:255–261

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(pdf) after sexual assault: a recovery guide for survivors

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