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CHAPTER 83: ICU-Acquired Weakness 763

these medications for much shorter periods of time. Nevertheless, ICU • Girard TD, Jackson JC, Pandharipande PP, et al. Delirium as a pre-
patients treated with antipsychotics should be monitored closely with dictor of long-term cognitive impairment in survivors of critical
electrocardiography, and the medications should be avoided for patients illness. Crit Care Med. July 2010;38(7):1513-1520.
with a baseline QTc >450 to 500 ms or a prolongation of 25% or greater
from baseline. • Hatta K, Kishi Y, Wada K, Takeuchi T, Odawara T, Usui C,
The role of novel agents, such as dexmedetomidine and rivastigmine, et al. Preventive effects of ramelteon on delirium: a randomized
in delirium treatment has recently been investigated. As described in the placebo-controlled trial. JAMA Psychiatry. 2014;71:397-403.
delirium prevention section above, use of the α -agonist dexmedetomi- • Pandharipande P, Shintani A, Peterson J, et al. Lorazepam is an
2
dine as a sedative for mechanically ventilated ICU patients is associated independent risk factor for transitioning to delirium in intensive
with lower rates of ICU delirium when compared with benzodiazepines. care unit patients. Anesthesiology. Jan, 2006;104(1):21-26.
Dexmedetomidine has also been compared with haloperidol as a • Pandharipande PP, Pun BT, Herr DL, et al. Effect of sedation with
https://kat.cr/user/tahir99/
treatment for agitated delirium in a small pilot study of mechanically dexmedetomidine vs lorazepam on acute brain dysfunction in
ventilated patients. Patients treated with dexmedetomidine were mechanically ventilated patients: the MENDS randomized con-
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more quickly extubated than those patients whose agitation was treated trolled trial. JAMA. December 12, 2007;298(22):2644-2653.
with haloperidol. Though delirium prevalence at baseline was similar • Patel SB, Poston JT, Pohlman A, Hall JB, Kress JP. Rapidly revers-
between the two groups, patients treated with dexmedetomidine may ible, sedation-related delirium versus persistent delirium in the
have had more rapid resolution of delirium though these results were intensive care unit. Am J Respir Crit Care Med 2014; 189:658-65.
not significantly different between groups. Although further study is
required, this pilot study suggests dexmedetomidine may have a role not • Pisani MA, Kong SY, Kasl SV, Murphy TE, Araujo KL, Van Ness
only in preventing delirium among mechanically ventilated patients but PH. Days of delirium are associated with 1-year mortality in an
also treating delirium in this population. older intensive care unit population. Am J Respir Crit Care Med.
van Eijk explored the use of a cholinesterase inhibitor, rivastigmine, December 1, 2009;180(11):1092-1097.
as an adjuvant treatment for ICU delirium in a population of ICU • Reade MC, O’Sullivan K, Bates S, Goldsmith D, Ainslie WR, Bellomo
patients. The trial was stopped prematurely after differences in the R. Dexmedetomidine vs. haloperidol in delirious, agitated, intubated
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mortality rate between the rivastigmine group (22%) and placebo (8%) patients: a randomised open-label trial. Crit Care. 2009;13(3):R75.
met the predefined stopping criteria. Further, the rivastigmine group • Riker RR, Shehabi Y, Bokesch PM, et al. Dexmedetomidine vs
also demonstrated a trend toward longer duration of delirium compared midazolam for sedation of critically ill patients: a randomized trial.
with placebo. These results do not support the use of cholinesterase JAMA. February 4, 2009;301(5):489-499.
inhibitors for the treatment of delirium in the ICU. • Skrobik YK, Bergeron N, Dumont M, Gottfried SB. Olanzapine vs
haloperidol: treating delirium in a critical care setting. Intensive
SUMMARY OF KEY POINTS ON ICU DELIRIUM Care Med. March 2004;30(3):444-449.
Critically ill patients are at great risk for the development of delirium • van Eijk MM, Roes KC, Honing ML, et al. Effect of rivastigmine as
in the ICU. However, this form of brain dysfunction is grossly under- an adjunct to usual care with haloperidol on duration of delirium
recognized and undertreated. Delirium is mistakenly thought to be a and mortality in critically ill patients: a multicentre, double-
transient and expected outcome in the ICU and of little consequence blind, placebo-controlled randomised trial. Lancet. November 27,
(ie, part of the “ICU psychosis”). It is now recognized that delirium is 2010;376(9755):1829-1837.
one of the most frequent complications experienced in the ICU; even • van Eijk MM, van den Boogaard M, van Marum RJ, et al. Routine
after adjusting for covariates such as age, sex, race, and severity of illness, use of the confusion assessment method for the intensive care
delirium is an independent risk factor for prolonged length of stay unit: a multicenter study. Am J Respir Crit Care Med. August 1,
and higher 6-month mortality rates. In addition, many ICU survivors 2011;184(3):340-344.
demonstrate persistent cognitive deficits at follow-up testing months to
years later. It is essential for health care professionals to be able to recog-
nize delirium readily at the bedside. The CAM-ICU is a valid, reliable, REFERENCES
quick, and easy-to-use serial assessment tool for monitoring delirium in
ventilated and nonventilated ICU patients. Delirium is a multifactorial Complete references available online at www.mhprofessional.com/hall
problem for ICU patients that demands an interdisciplinary approach
for assessment, management, and treatment. Critical care nurses and
physicians should assume a position of leadership in the ICU with
regard to delirium monitoring because they are the best-suited members CHAPTER ICU-Acquired Weakness
of the ICU team to successfully implement this essential component of
practice guidelines. Although ongoing trials may elucidate the optimal 83 William Schweickert
patient management, which is recommended by the SCCM clinical
John P. Kress
ways to treat delirium, standard pharmacologic and nonpharmacologic
management strategies have been reviewed.

KEY POINTS
KEY REFERENCES • ICU-acquired weakness designates clinically detected weakness in
• Bergeron N, Dubois MJ, Dumont M, Dial S, Skrobik Y. Intensive critically ill patients in whom there is no plausible etiology other
Care Delirium Screening Checklist: evaluation of a new screening than critical illness. Patients can be labeled with this diagnosis with
tool. Intensive Care Med. May 2001;27(5):859-864. a suggestive history and when they can participate in a compre-
• Ely EW, Shintani A, Truman B, et al. Delirium as a predictor of hensive bedside neuromuscular examination.
mortality in mechanically ventilated patients in the intensive care • Electrophysiology testing, direct muscle stimulation, and biopsy may
unit. JAMA. April 14, 2004;291(14):1753-1762. be necessary to characterize neuromuscular injury in the patient who

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