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ICU Delirium Prevention and Management

ICU Delirium Prevention and Management: ICU adult: delirium screening and care → Screen with CAM-ICU or ICDSC → Delirium present? → Delirium present: no...

Pathway Overview

19 steps

Algorithm Steps

19 total

  1. 01Start

    ICU adult: delirium screening and care

    Adults in ICU. Screen every patient with a validated tool. Not for children.

  2. 02Action

    Screen with CAM-ICU or ICDSC

    Adults only. Screen regularly, for example each shift. Assess sedation (RASS) first.

    • CAM-ICU positive: acute change or fluctuating course + inattention + (altered LOC or disorganised thinking)
    • ICDSC score 4 or more (of 8) = delirium
    • RASS -4 or -5: unable to assess; reassess when less sedated
    • Record the result
  3. 03Decision

    Delirium present?

    CAM-ICU positive or ICDSC 4 or more

  4. If Yes
    1. 04Action

      Delirium present: note the subtype

      Hypoactive delirium is common and easy to miss.

      • Hyperactive: RASS +1 to +4, restless or agitated
      • Hypoactive: RASS 0 to -3, quiet, withdrawn or drowsy
      • Mixed: changes between the two
    2. 05Decision

      Withdrawal, Wernicke's risk or drug toxidrome?

      Check before you stop sedatives or give an antipsychotic. Alcohol or benzodiazepine dependence, malnutrition, new serotonergic, anticholinergic or antipsychotic drugs, fever, rigidity or clonus.

    3. If Yes
      1. 06Warning

        Withdrawal or toxidrome: treat the specific cause first

        If unsure, get toxicology advice (Poisons Information Centre 13 11 26).

        • Alcohol or benzodiazepine withdrawal: benzodiazepine per withdrawal protocol; not an antipsychotic alone
        • Alcohol use or malnutrition: IV thiamine before glucose if feasible; never delay glucose for hypoglycaemia
        • NMS, serotonin syndrome or anticholinergic toxicity: stop the cause; no antipsychotic
      2. 07Action

        Find and treat the causes (THINK)

        Delirium is often a sign of acute illness. Check blood glucose early.

        • T: Toxic: shock, heart failure, new organ failure, deliriogenic drugs
        • H: Hypoxaemia (and hypercapnia)
        • I: Infection or sepsis; Immobilisation
        • N: Non-drug needs: sleep, glasses, hearing aids, reorientation
        • K: K+ and other electrolytes (Na+, Ca2+), glucose
        • Also: pain, urinary retention, constipation, non-convulsive seizures (EEG), stroke
      3. 08Action

        Review drugs: reduce deliriogenic drugs

        Dependent on benzodiazepines or alcohol: do not stop benzodiazepines abruptly.

        • Ventilated: light sedation; dexmedetomidine suggested over propofol (PADIS 2025); caution in bradycardia, heart block or hypotension
        • Dexmedetomidine infusion: AU PI limit 24 h; longer use linked to higher mortality at age 65 or younger
        • Reduce benzodiazepines; avoid them for sedation where possible
        • Stop or reduce anticholinergic drugs
        • Opioids: treat pain; avoid excess
        • Review steroids and other deliriogenic drugs
      4. 09Action

        Non-drug measures for every patient

        Multicomponent non-drug strategy is first line (PADIS 2018).

        • Reorientation: clock, calendar, family
        • Sleep: reduce night noise, light and care interruptions
        • Early, enhanced mobilisation and rehabilitation (PADIS 2025)
        • Glasses and hearing aids
        • Family presence and familiar objects
      5. 10Action

        Consider melatonin at night

        PADIS 2025: suggested for adults in ICU (conditional, low certainty).

        • Low risk; aims to improve sleep
        • Effect on delirium uncertain: an Australian ICU RCT (Pro-MEDIC, 2022) found no reduction
        • Dose: see local ICU protocol (PADIS gives no dose)
      6. 11Decision

        Distress or agitation that puts the patient or staff at risk?

        Drugs do not treat delirium. Use them only for distress or safety.

      7. If Yes
        1. 12Warning

          Before an antipsychotic: check contraindications

          If any apply, do not give it; get senior advice.

          • Do not use: Parkinson's disease, Lewy body dementia, previous or suspected NMS
          • QTc prolongation, uncorrected low K+, bradycardia, heart block, other QT drugs or significant heart disease: no haloperidol; quetiapine also prolongs QTc
          • Withdrawal or toxidrome: treat that cause instead
        2. 13Action

          Distress or danger: short-term antipsychotic or dexmedetomidine

          PADIS 2025: no recommendation for or against antipsychotics. Lowest dose, shortest time.

          • Adult: haloperidol 0.5-2 mg IM; IV only with continuous ECG monitoring; max 20 mg/day (PI)
          • Older or frail: start 0.5 mg; titrate slowly; use the smallest total dose (PI gives no fixed lower maximum)
          • Baseline ECG; correct K+ and Mg2+; stop if QTc over 500 ms or up 60 ms or more from baseline
          • NMS signs (fever, rigidity, high CK): stop the antipsychotic
          • Or quetiapine 50 mg enterally every 12 h (off-label; ICU trial dose)
          • Ventilated and agitation stops weaning or extubation: dexmedetomidine (PADIS 2018)
          • Stop when symptoms settle
        3. 14Action

          Reassess every day

          Screen each shift. Look again for causes.

          • Track delirium-free days
          • Keep non-drug measures
          • Stop antipsychotics when symptoms settle; do not continue after ICU without a reason
        4. 15Decision

          Delirium resolved?

          CAM-ICU negative or ICDSC below 4

        5. If Yes
          1. 16Outcome

            Delirium resolved: continue prevention and screening

            Keep the ABCDEF bundle. Delirium can come back.

          If No
          1. 17Outcome

            Persistent delirium: repeat the cause search

            Continue management. Consider senior, psychiatry or neurology review.

        If No
        1. Path rejoins step 14Shared downstream outcome
      If No
      1. Path rejoins step 07Shared downstream outcome
    If No
    1. 18Action

      No delirium (or RASS -4/-5, unable to assess): continue ABCDEF bundle

      Keep screening regularly. RASS -4 or -5: reassess delirium when less sedated. Dexmedetomidine: caution in bradycardia, heart block or hypotension; AU PI limit 24 h.

      • A: Assess, prevent and manage pain
      • B: Both spontaneous awakening and breathing trials (SAT and SBT)
      • C: Choice of sedation: light sedation; avoid benzodiazepines; ventilated: dexmedetomidine suggested over propofol (PADIS 2025)
      • D: Delirium: assess, prevent and manage
      • E: Early mobility and exercise
      • F: Family engagement
      • Consider melatonin at night (PADIS 2025; dose per local ICU protocol)
    2. 19Outcome

      No delirium or not assessable: continue prevention and screening

      Screen again at the next assessment.

Guideline Source

A Focused Update to the Clinical Practice Guidelines for the Prevention and Management of Pain, Anxiety, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

DOI: 10.1097/CCM.0000000000006574View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Alcohol withdrawal, NMS, serotonin syndrome and anticholinergic toxicity need their own treatment; this pathway only routes them out
  • Antipsychotics do not shorten delirium or improve survival; drug doses are adult only and need local ICU protocol review
  • Adults only; does not cover delirium in children
  • Requires trained staff for CAM-ICU or ICDSC assessment
  • Hypoactive delirium is often missed

Contraindicated Populations

pediatric

Applicable Regions

AUUSEUGlobal

AU: Haloperidol injection (Serenace 5 mg/mL): PI recommends IM; IV only with continuous ECG monitoring. Quetiapine for delirium is off-label.

Global: SCCM PADIS 2018 guideline with the 2025 focused update

Version 2Next review: 2027-09-30

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Frequently Asked Questions

What is the ICU Delirium Prevention and Management?

The ICU Delirium Prevention and Management is a management clinical algorithm for Critical Care. It provides a structured decision tree to guide clinical decision-making, based on A Focused Update to the Clinical Practice Guidelines for the Prevention and Management of Pain, Anxiety, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU.

What guideline is the ICU Delirium Prevention and Management based on?

This algorithm is based on A Focused Update to the Clinical Practice Guidelines for the Prevention and Management of Pain, Anxiety, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (DOI: 10.1097/CCM.0000000000006574).

What are the limitations of the ICU Delirium Prevention and Management?

Known limitations include: Alcohol withdrawal, NMS, serotonin syndrome and anticholinergic toxicity need their own treatment; this pathway only routes them out; Antipsychotics do not shorten delirium or improve survival; drug doses are adult only and need local ICU protocol review; Adults only; does not cover delirium in children; Requires trained staff for CAM-ICU or ICDSC assessment; Hypoactive delirium is often missed. Individual patient factors may require deviation from these recommendations.

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