Delirium management in burn patients

Delirium is a form of acute brain organ dysfunction defined as a disturbance of consciousness, accompanied by fluctuation of mental status, inattention and perceptual disturbances. According to the American Burn Association, there are approximately 500,000 burn injuries per year that receive medical treatment, with 40,000 hospitalizations and 25,000 referrals to specialized burn centers. Burn patients often experience longer periods of mechanical ventilation and ICU care, making them at risk for developing delirium and its associated complications. Delirium is an independent predictor of mortality in critically ill patients, also causing impairment of cognitive and functional status, persisting even after ICU and hospital discharge. Early identification of potential risk factors (e.g. older age, pre-existing intellectual deterioration or past substances abuse) and management and correction of precipitating causes (pain management, emotional stress and sleep deprivation) can improve outcomes. Evidence supporting delirium treatment is still inadequate. For this reason, current international guidelines mainly focus on the elimination of potentially contributing factors (e.g. treatable disease states, pain, adverse drug effects and environmental factors) and the early identification of delirium onset. Validated assessment tools, such as Confusion Assessment Method for the ICU (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) are useful and feasible instrument which help early identification of delirium. Despite the increased awareness of specialists regarding delirium and its consequences in ICU patients, the implementation of validated screening tests for the diagnosis of delirium is still weak. Occurrence of delirium is severely underestimated if diagnosed only from the clinical impression, especially in the hypoactive delirium subtype the most frequent motoric subtype of delirium. Conversely, a subjective assessment may provide a diagnosis of delirium in patients uncooperative because of pain, anxiety or distress. Both under- and overestimation of delirium could lead to incorrect management of ICU patients with severe consequences. Current recommendations aim attention at delirium prevention, primarily non-pharmacological strategies (e.g. early mobilization, sleep promotion and environmental improvement measures), highlighting that no clear and strong evidence exists regarding pharmacological agents both preventing or treating delirium. In addition to prevention and non-pharmacological techniques, appropriate drug management is an important adjunct in the management of patients with delirium. Drug treatment should be considered when other non-pharmacological measures have failed or patient has distressing symptoms. Haloperidol and olanzapine are the first line choices in delirium management. Regular drug treatment should be commended for patients who are CAM-ICU positive. When delirium symptoms resolve, antipsychotic medication can be withdrawn over 48 to 72 hours. Only short treatment courses (less than a week) should be used.