CAM-ICU, ABCDEF bundle, non-pharmacological care — GCC nursing practice
DHA • DOH • SCFHS • MOH GCCDelirium is an acute brain dysfunction characterised by a disturbance in attention, awareness, and cognition that develops over a short period (hours to days) and tends to fluctuate throughout the day. It is not better explained by a pre-existing neurocognitive disorder.
| Feature | Delirium | Dementia | Depression |
|---|---|---|---|
| Onset | Acute (hours–days) | Gradual (months–years) | Weeks–months |
| Fluctuation | Yes — hallmark feature | Less common early on | Variable |
| Attention | Severely impaired | May be intact early | Mildly reduced |
| Consciousness | Altered (RASS ≠ 0) | Usually alert | Usually alert |
| Memory | Impaired (short-term) | Progressive loss | Subjective complaints |
| Reversibility | Often reversible | Not reversible | Treatable |
| Sleep-wake | Severely disrupted | Disturbed late | Early morning waking |
| Hallucinations | Common (visual) | Late stage | Rare (mood-congruent) |
Cholinergic Deficiency
Acetylcholine is key for attention and arousal. Anticholinergic drugs, systemic illness, and surgery reduce ACh activity → cognitive dysfunction. This is why anticholinergics (diphenhydramine, haloperidol at high dose) can precipitate delirium.
Dopamine Excess
Excess dopaminergic activity disrupts cortical circuits. Explains why haloperidol (D2 blocker) has some evidence. Corticosteroids and certain medications increase dopamine release.
Neuroinflammation
Systemic inflammation (sepsis, surgery, trauma) → cytokine release → blood-brain barrier disruption → microglial activation → neuronal dysfunction. IL-1β, TNF-α, IL-6 are key mediators.
Feature 1: Acute Onset & Fluctuating Course
Is there evidence of an acute change in mental status from the patient's baseline? Does the behaviour fluctuate during the day (worse in evenings — "sundowning")?
Feature 2: Inattention (required)
Does the patient have difficulty focusing attention? Ask patient to squeeze hand on letter "A" in: SAVEAHAART. Count errors (>2 = positive). Digit span: can patient repeat 7-2-9?
Feature 3: Disorganised Thinking
Yes/No questions: (1) Will a stone float on water? (2) Are there fish in the sea? (3) Does 1 pound weigh more than 2? (4) Can you use a hammer to pound a nail? Plus: hold up 2 fingers, now same in other hand. ≤1 correct = positive.
Feature 4: Altered Level of Consciousness
RASS other than zero (alert & calm). Includes: vigil/hyperalert (+1 to +4), lethargic/stupor (-1 to -3), or unarousable (-4, -5).
| Item | Assessment | Score |
|---|---|---|
| Alertness | Observe patient. Normal if fully alert throughout the assessment. Mildly sleepy <10s after stimulation is normal. | 0 (normal) or 4 (abnormal) |
| AMT4 | Ask: age, DOB, place (name of hospital), current year. Score the number of errors. | 0 (0 errors), 1 (1 error), 2 (2+ errors) |
| Attention | Say "months of the year backwards from December". Count errors (stopping before May). | 0 (0–1 errors), 1 (2+ errors), 2 (untestable) |
| Acute Change | Evidence of significant change in alertness/cognition in last 2 weeks AND still persisting in last 24h. | 0 (No) or 4 (Yes) |
13-item behavioural observation scale based on DSM-IV criteria. Each shift, nurse observes and scores 0-2. Total ≥3 = probable delirium. Validated for postoperative and surgical patients. Suitable for patients who cannot communicate verbally.
Step 1 — Feature 1: Acute onset or fluctuating course?
Is there an acute change from the patient's mental status baseline? Does it fluctuate during the day?
Step 2 — Feature 2: Inattention present?
Digit Span Test: Ask patient to repeat 7-2-9. Or letter A test: squeeze hand on "A" in CASABLANCA (>2 errors = positive).
Step 3 — Feature 3: Disorganised thinking?
Ask 2 of 4 logic questions (e.g., "Will a stone float on water?" / "Are there fish in the sea?") + follow command (hold up 2 fingers). ≤1 correct = positive.
Step 4 — Feature 4: Altered level of consciousness?
RASS score is anything other than 0 (Alert & Calm). Includes hyperalert (+1 to +4) or sedated (-1 to -3).
Uncontrolled pain is a leading precipitant of ICU delirium. Analgesia-first sedation protocols are now standard.
NRS
Numeric Rating Scale 0–10. Use when patient can self-report. Score ≥4 requires intervention.
BPS
Behavioural Pain Scale. For intubated/sedated patients. Score: facial expression (1–4) + upper limb movements (1–4) + compliance with ventilation (1–4). Score >5 = significant pain.
CPOT
Critical-Care Pain Observation Tool. 4 items: facial expression, body movements, muscle tension, ventilator compliance/vocalisation. Score 0–8. Score ≥3 = significant pain.
SAT (Spontaneous Awakening Trial): Daily sedation interruption — stop continuous sedation, assess patient, restart at 50% dose if needed. Reduces total sedation exposure and duration of mechanical ventilation.
SBT (Spontaneous Breathing Trial): Performed after successful SAT. T-piece or low-pressure support trial to assess readiness for extubation.
SAT Safety Screening: Do NOT perform SAT if: active seizures, alcohol withdrawal, FiO2 >0.5, PEEP >8 cmH2O, continuous infusions for therapeutic purposes, or agitation requiring current sedation for safety.
| Agent | Class | Delirium Effect | Notes |
|---|---|---|---|
| Dexmedetomidine | Alpha-2 agonist | Reduces delirium | MENDS study: ↓ coma & delirium vs midazolam. First choice for sedation in PICS prevention. |
| Propofol | GABA-A agonist | Neutral (short-term) | Preferred for short procedures; less delirium than benzodiazepines. Propofol infusion syndrome risk >48h. |
| Midazolam | Benzodiazepine | Increases delirium | Avoid as first-line ICU sedation. Reserve for seizures, alcohol withdrawal, procedural sedation only. |
| Ketamine | NMDA antagonist | Mixed evidence | Opioid-sparing analgesia benefit; low-dose may be delirium-neutral. Can cause emergence phenomena. |
Use validated tool (CAM-ICU) every shift. Document, escalate, identify and treat underlying causes.
Haloperidol Evidence: HOPE-ICU and MIND trials — haloperidol did NOT significantly reduce delirium duration vs placebo in general ICU populations. However, widely used for symptom management of hyperactive delirium (agitation, hallucinations). Dose: 0.5–1 mg PO/IM; monitor QTc (withhold if QTc >500 ms).
Immobility is a major precipitant of delirium. Early progressive mobility, even in mechanically ventilated patients, is safe and effective.
| ICU Mobility Scale Level | Activity |
|---|---|
| 0 | Nothing — lying in bed passively |
| 1 | Passive exercises in bed (limb movements by nurse/physio) |
| 2 | Active exercises in bed (patient moves limbs) |
| 3 | Passively seated over edge of bed |
| 4 | Actively sitting over edge of bed |
| 5 | Standing at bedside with assistance |
| 6 | Walking with aid/assist (1–2 persons) |
| 7 | Walking independently |
| 8 | Walking stairs |
Family presence is a powerful orientation anchor. In GCC ICUs, family members can serve as language translators, cultural mediators, and emotional anchors for delirious patients.
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| English | Arabic (العربية) | Urdu (اردو) |
|---|---|---|
| You are in the hospital | أنت في المستشفى | آپ ہسپتال میں ہیں |
| Today is [day/date] | اليوم هو [اليوم/التاريخ] | آج [دن/تاریخ] ہے |
| You are safe. I am your nurse. | أنت بأمان. أنا ممرضتك. | آپ محفوظ ہیں۔ میں آپ کی نرس ہوں۔ |
| Your family will visit you. | ستأتي عائلتك لزيارتك. | آپ کا خاندان آپ سے ملنے آئے گا۔ |
| Can you squeeze my hand? | هل يمكنك الضغط على يدي؟ | کیا آپ میرا ہاتھ دبا سکتے ہیں؟ |
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Before prescribing any drug for delirium: review medication list for anticholinergics/polypharmacy, check bloods (FBC, CRP, U&E, glucose, LFT, TFT, B12, ammonia), obtain cultures if infection suspected, review for pain, constipation, urinary retention.
| Parameter | Detail |
|---|---|
| Dose | 0.5–1 mg PO or IM, every 4–8h PRN. Maximum 5 mg/24h in elderly. |
| Route | Oral preferred. IM for acutely agitated patients. IV use associated with QTc prolongation — caution. |
| Monitoring | QTc before starting (baseline), after first 3 doses, then daily. Withhold if QTc >500 ms. Monitor for EPS (rigidity, tremor, oculogyric crisis). |
| Caution | Avoid in: Lewy body dementia (severe sensitivity), Parkinson's disease. Use minimum effective dose in elderly. |
| Evidence | HOPE-ICU (Page, Lancet 2013): No significant reduction in delirium duration. Used for symptom management only. |
| Exception | Agent & Rationale |
|---|---|
| Alcohol withdrawal / Delirium Tremens | Diazepam (long-acting) or lorazepam (renal impairment). CIWA-Ar protocol — see below. |
| Benzodiazepine withdrawal | Taper current benzodiazepine or switch to longer-acting equivalent. |
| Active seizures | Lorazepam IV first-line for status epilepticus. |
| Procedural sedation | Short-term use acceptable — minimise duration. |
MENDS Study (Pandharipande, NEJM 2007): Dexmedetomidine vs lorazepam in mechanically ventilated medical/surgical ICU patients. Dexmedetomidine group: more days alive without delirium/coma, more days breathing without ventilator.
MENDS-2 (2021): Dexmedetomidine vs propofol in sepsis. No significant difference in ventilator-free days but dexmedetomidine patients had less delirium.
Delirium tremens (DT) is life-threatening alcohol withdrawal — peak at 48–96h after last drink. Mortality 5–15% if untreated. Seen in GCC in non-Muslim expat populations.
| CIWA-Ar Score | Severity | Management |
|---|---|---|
| <10 | Mild withdrawal | Supportive care, thiamine 100mg IV/IM, monitor closely |
| 10–15 | Moderate withdrawal | Diazepam 10mg PO/IV OR lorazepam 1–2mg IV (renal impairment). Repeat every 1–2h PRN. |
| >15 | Severe withdrawal / DT risk | Diazepam 10–20mg IV, ICU admission, continuous monitoring. Consider phenobarbital if refractory. |
Q1. A 72-year-old man in the ICU has RASS = -1 and is inattentive. He can answer logic questions correctly but has an acute change from baseline. CAM-ICU result is:
Correct: B
CAM-ICU Positive requires Feature 1 (acute onset/fluctuating) + Feature 2 (inattention) + Feature 3 OR Feature 4. Here: Feature 1 = acute change; Feature 2 = inattentive; Feature 4 = RASS -1 (not alert & calm). CAM-ICU is only inapplicable if RASS = -4 or -5.
Q2. Which sedative agent has the strongest evidence for REDUCING delirium in mechanically ventilated ICU patients compared to benzodiazepines?
Correct: C
The MENDS trial (NEJM 2007) demonstrated dexmedetomidine resulted in significantly more days alive without delirium or coma compared to lorazepam. It is the preferred sedation agent in current PADIS guidelines for ICU delirium prevention.
Q3. A patient with Lewy Body Dementia develops hyperactive delirium post-operatively. Which medication should be AVOIDED?
Correct: C
Haloperidol (a typical antipsychotic with D2 blockade) causes severe and potentially fatal sensitivity reactions in Lewy Body Dementia, including profound extrapyramidal symptoms, neuroleptic malignant syndrome, and acute deterioration. Quetiapine is the preferred atypical antipsychotic for this population.
Q4. According to the ABCDEF bundle, what is the FIRST step before performing a Spontaneous Breathing Trial (SBT)?
Correct: B
The ABCDEF bundle specifies "B = Both SAT and SBT" in a paired protocol. A SAT (daily sedation interruption) should be performed first, and if the patient passes safety screening, an SBT should follow. Girard et al. (Lancet 2008) showed this paired approach reduced mortality by 14%.
Q5. A 67-year-old known alcohol-dependent man is admitted following surgery. He becomes agitated, diaphoretic, and has a tremor 48 hours post-operatively. His CIWA-Ar score is 14. What is the PRIORITY nursing action?
Correct: C
CIWA-Ar 10–15 = moderate withdrawal requiring benzodiazepine treatment. Critically, thiamine MUST be given BEFORE glucose to prevent Wernicke's encephalopathy. Haloperidol is not effective for alcohol withdrawal and lowers seizure threshold. Physical restraints can worsen agitation and are not a primary treatment.