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INTRODUCTION
Advances in medical science and technology
have prompted the establishment of many
highly specialized units (ICUs) providing
intensive patient care. ICU psychosis
/Delirium in the intensive care unit is a
serious problem that has recently attracted
much attention. As the number of intensive
care units and the number of people in them
grow, ICU psychosis is perforce increasing
as a problem.
DEFINITION
Eisendrath defined "ICU Syndrome" /"ICU
psychosis" as an acute organic brain
syndrome involving impaired intellectual
functioning and occurring in patients treated
within a critical care unit.

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A disorder in which patients in an
intensive care unit (ICU) or a similar
hospital setting may experience anxiety,
become paranoid, hear voices, see things that
are not there, become severely disoriented in
time and place, become very agitated, even
violent, etc. The condition has been formally
defined as "acute brain syndrome involving
impaired intellectual functioning which
occurs in patients who are being treated
within a critical care unit.
INCIDENCE
It is commonly found in the critically ill
with a reported incidence of15-80% By
some estimates, 80% of elderly intensive-
care patients develop the condition, which
frequently leads to nursing home stays and a
hastened death.

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ETIOLOGY AND PRE DISPOSING
FACTORS
ICU psychosis is believed to be caused by a
person’s underlying medical condition and
perhaps worsened by characteristics of the
ICU, such as sleep deprivation and sensory
overload or monotony.
The main cause of ICU psychosis is believed
to be underlying medical factors. The most
common underlying medical factors that
may lead to ICU psychosis include:
Metabolic disturbances
Electrolyte imbalances
Withdrawal syndromes
Acute infection (intracranial and
systemic)
Seizures
Head trauma
Vascular disorders
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 Intracranial space-occupying lesions
Use of certain medications and
substances, either through
intoxication or withdrawal, such as
anti-anxiety medications and
narcotics
Other possible causes of ICU delirium
include characteristics of the ICU and
psychological factors, though generally none
of these conditions cause delirium on their
own.
ICU environment (not a conclusive cause)
Sleep deprivation
Social isolation
Immobilization
Unfamiliar surroundings
Excessive noise
Sensory monotony
Absence of diurnal light variation
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Psychological factors
 Stress of being in the ICU
Patients are extremely ill and in life-
threatening situations
Patients have multiple or serious
medical problems
They may be unable to communicate
their needs
There is a loss of personal control
Patients are in a new and threatening
environment
Cognitive status prior to ICU admission
A patient’s prior cognitive level and
age may predispose a patient to
delirium.

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PATHOPHYSIOLOGY
The pathophysiologic mechanism is poorly
understood.
Neurotransmitter imbalance
 Imbalances in synthesis, release, and
inactivation of neurotransmitters that
normally control cognitive function,
behavior, and mood. Greatest focus given to
dopamine and acetylcholine. Imbalance in
one or both results in neuronal instability and
unpredictable neurotransmission. Excess of
dopamine or depletion of acetylcholine.
Other neurotransmitters- y- aminobutyric
acid (GABA), serotonin, endorphins,
glutamate
Inflammation: Inflammatory abnormalities
induced by endotoxin and cytokines
probably contributes Tumor necrosis factor-
a, interleukin-1 ,other cytokines and
chemokines initiate cascade of endothelial
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damage, thrombin formation, and
microvascular compromise May incite brain
dysfunction by decreasing cerebral blood
flow via formation of microaggregates of
 fibrin, platelets, neutrophils, and
erythrocytes in cerebral microvasculature.
Constricting cerebral vasculature-activation
of alpha 1 adrenoceptors. Interfering with
neurotransmitter synthesis and
neurotransmission Inflammatory mediators
cross blood-brain barrier, increase vascular
permeability, Blunted anti-inflammatory
response. Higher plasma concentrations
tumor necrosis factor receptor-1, and lower
plasma concentrations of protein C, matrix
metalloproteinase-9 were associated with
increased risk of delirium

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Impaired oxidative metabolism: Delirium
as behavioral manifestation of `widespread
reduction of cerebral oxidative metabolism
resulting in imbalance of neurotransmission'.
Engel and Romano believed diffuse slowing
 on EEG to represent a reduction in brain
metabolism. Oxidative stress responsible for
multi-organ dysfunction in critically ill
patients.
Availability of large neutral amino acids
Neurotransmitter levels and function
affected by changes in plasma concentrations
of various amino acid precursors. Proposed
that altered availability of large neutral
amino acids contributes to development of
delirium. Amino acid entry into brain
regulated by sodium-independent large
neutral amino acid transporter type 1
(LAT1).

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Tryptophan, essential amino acid and
precursor for serotonin, competes with large
neutral amino acids (for eg, tyrosine,
phenylalanine, valine, leucine, and
isoleucine) for transport across BBB via
 LAT1. Phenylalanine competes with large
neutral amino acids Increased cerebral
uptake of tryptophan and phenylalanine,
compared with other large neutral amino
acids, leads to elevated levels of dopamine
and norepinephrine (noradrenaline).
Clinical manifestations
Symptoms of ICU psychosis usually come
on quickly and last 24 to 48 hours, though it
can last as long as two weeks in some cases.

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Symptoms of ICU psychosis are the same as
those of delirium and may include:
 Fluctuating levels of consciousness
 Delusions
 Confusion and disorientation
 Visual hallucinations
 Abnormal behavior such as
 aggression or passivity
 Emotional or personality changes,
with frequent mood changes,
including anger, agitation, anxiety,
apathy, depression, fear, euphoria,
irritability, suspicion
 Slurred speech and language
difficulties
 Saying things that don’t make sense
 Changes in feeling (sensation) and
perception
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 Loss of attention
 Inability to concentrate
 Changes in movement (restlessness
or slow movement)
 Changes in sleep patterns
 Memory loss
 Disorganized thinking
 Incontinence
  Signs of medical illness (such as
fever, chills, pain, etc.) or medication
side effects
Delirium is not the same as dementia, which
develops slowly and progressively worsens.
DIAGNISTIC EVALUATION
Intensive Care Delirium Screening Checklist
(ICDSC) and the Confusion Assessment
Method for the ICU (CAM-ICU). Using
ICDSC, each patient is assigned a score from
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0 to 8; a cut-off score of 4 has sensitivity
99% and specificity 64% for identifying
delirium

ICU Delirium checklist

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 Confusion assessment method
 Mini mental status examination
 Explore other organic causes
 SlOOB protein indicator of glial
activation and/or death. Shown to be
elevated in patients with delirium
 Higher baseline levels of
 procalcitonin or C-reactive protein
were associated with more days with
delirium
 Other biomarkers elevated-brain-
derived neurotrophic factor, neuron-
specific enolase, interleukins, cortisol
MANAGEMENT
ICU delirium is reversible and treatable in
most cases. Treating the underlying medical
condition can often reverse symptoms of
delirium.
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Other treatments for ICU delirium include:
 Adequate fluid and electrolyte
balance
 Adequate nutrition and vitamin
supply
 Weaning patients off breathing
machines sooner
 Providing the patient an environment
 in which they can get better sleep and
allowing patients to preserve their
normal sleep-wake cycles
 Using medications that may be less
likely to trigger delirium
 Providing adequate pain relievers if
needed
 Establishing clear communication
with the patient

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 Reorienting the patient to time and
place frequently
 Involving family members in care
 Continuity of health care personal
 Clear concise communication
 Repeated verbal reminders of time,
place and person.
 Clock, calendar, TV, newspaper,
radio readily accessible as a means of
 orientating in time
 Simplify the environment, single
room when available, reduce noise
levels, remove unnecessary
equipment
 Adjust lighting according to day and
night cycle.
 Keep familiar objects
 Flexible visiting hours
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 Allow maximum periods of
uninterrupted sleep
 Encourage mobilization and increase
activity levels
 Relaxation techniques like music
therapy and massage may also help.
Pharmacological management

 Antipsychotic agents such as

haloperidol is commonly used.
 Olanzapine and respiridone have
 been used as they are less sedating
and have fewer side effects
 Benzodiazepine would be beneficial,
and lorazepam is the drug of choice.
 Haloperidol recommended as drug of
choice for treatment of ICU delirium
by SCCM

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 Blocks D2 dopamine receptors,
resulting in amelioration of
hallucinations, delusions,
unstructured thought patterns
 SCCM guidelines-hyperactive
delirium to be treated with 2 mg
intravenously, followed by repeated
doses (doubling previous dose) every
15 to 20 minutes while agitation
persists
 Once agitation subsides scheduled
 doses (every 4 to 6 hours) may be
continued for few days, followed by
tapered doses for several days.
Common doses for ICU patients
range from 4 to 20 mg/day
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 Atypical antipsychotics (risperidone,
ziprasidone, quetiapine, olanzapine)
may also be helpful in delirium.
 Skrobik et al (2004) compared
olanzapine with haloperidol and
reported that resolution of delirium
symptoms was similar in both but
more side effects were observed in
haloperidol
 Medications should be avoided in
with prolonged QT intervals
 Dexmedetomidine, novel alpha 2-
receptor agonist that does not act on
GABA receptors, may to be
 alternative sedative agent less likely
to cause delirium.
 Pandharipande P. et al (2007)
showed ICU patients sedated with
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 dexmedetomidine spent fewer days
in coma and more days
neurologically normal than
lorazepam.
 Benzodiazepines are not
recommended for management of
delirium
NURSING MANAGEMENT
Maintaining a Safe Environment
Environmental factors, such as social
isolation and sensory deprivation, and being
moved to a new environment contribute
to delirium. Therefore, while in hospital it
should be recognized that patients are at
increased risk of developing delirium by
 being moved to a different unit or clinical
environment, especially critical severe
patients.

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Education
Nurses and doctors need the skills to work
with these patients at risk of or experiencing
delirium. It is likely that, to improve care of
the patient who is at risk or has delirium,
staff
will need more than education and training.
Communicating
Quality communication is essential for
patients at risk of developing delirium, and
nurses need to consider how they
communicate with all patients. To begin
with,
it is useful to assess the level of sensory
 impairment, as this has been implicated in
the development of delirium.
Controlling the situation
Keeping an eye on the patient was important
for nurses because they used the information
gained from observation to determine

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whether they needed to intervene to settle the
patient down. Nurses spoke at length about
how they controlled or managed patients
who were at risk for delirium. Their rationale
for intervening included ensuring the
patients received their therapy, preventing
injury, and controlling a situation in which
behavior might escalate.