Delirium protocol as a part of the ABCDEF Bundle
Delirium protocol as a part of the ABCDEF Bundle Delirium Delirium
«Flowchart»

Perform Delirium Assessment via CAM-ICU

Perform Delirium Assessment via CAM-ICU

Perform Delirium Assessment via CAM-ICU

Perform Delirium Assessment via CAM-ICU

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Consider differential diagnosis (Dr. DRE or THINK)1
Consider differential diagnosis (Dr. DRE or THINK)1
Consider differential diagnosis (Dr. DRE or THINK)1
1 1
Does the patient require deep
sedation or analgosedation?
Does the patient require deep
sedation or analgosedation?
Does the patient require deep
sedation or analgosedation?

Reassess CAM-ICU at least every shift.
Treat pain and anxiety if indicated via
CPOT or RASS
Reassess CAM-ICU at least every shift.
Treat pain and anxiety if indicated via
CPOT or RASS
Reassess CAM-ICU at least every shift.
Treat pain and anxiety if indicated via
CPOT or RASS


Perform SAT8
Perform SAT8
Perform SAT8
8 8
Reassess target sedation
goal every shift
Reassess target sedation
goal every shift
Reassess target sedation
goal every shift

Yes

Yes

Yes

Yes

No

No

No

No
If tolerates SAT, perform SBT9
If tolerates SAT, perform SBT9
If tolerates SAT, perform SBT9
9 9
Remove deliriogenic drugs2
Nonpharmacologic protocol3
Remove deliriogenic drugs2
Nonpharmacologic protocol3
Remove deliriogenic drugs2
Nonpharmacologic protocol3
2 2
3 3
Is the patient in pain?4
Is the patient in pain?4
Is the patient in pain?4
4 4
Reassess target sedation goal and perform SAT8
Reassess target sedation goal and perform SAT8
Reassess target sedation goal and perform SAT8
8 8
Assure adequate pain control4
Consider typical or atypical antipsychotics6
Assure adequate pain control4
Consider typical or atypical antipsychotics6
Assure adequate pain control4
Consider typical or atypical antipsychotics6
4 4
6 6
RASS +2 to +4
RASS +2 to +4
RASS +2 to +4
RASS 0 to +1
RASS 0 to +1
RASS 0 to +1
RASS −1 to −3
RASS −1 to −3
RASS −1 to −3
If tolerates SAT, perform SBT9
If tolerates SAT, perform SBT9
If tolerates SAT, perform SBT9
9 9
Give analgesic5
Give analgesic5
Give analgesic5
5 5
Give adequate sedative for safety and
titrate to goal RASS
Give adequate sedative for safety and
titrate to goal RASS
Give adequate sedative for safety and
titrate to goal RASS

Yes

Yes

Yes

Yes

No

No

No

No
Consider typical or atypical antipsychotics6
Consider typical or atypical antipsychotics6
Consider typical or atypical antipsychotics6
6 6

    Dr. DRE:
Diseases:sepsis,CHF,COPD
Drug Removal: SATs and stopping benzodiazepines/narcotics
Environment:Immobilization,sleep and
day/night orientation,hearing aids,eye
glasses, noise
THINK:
Toxic situation - CHF,shock,dehydration - deliriogenic meds (tight titration) -
New organ failure (liver ,kidney, etc.)
Hypoxemia
Infection/sepsis (nosocomial), immobilization
Nonpharmacologic interventions3
k+ or electrolyte problems

    Dr. DRE:
Diseases:sepsis,CHF,COPD
Drug Removal: SATs and stopping benzodiazepines/narcotics
Environment:Immobilization,sleep and
day/night orientation,hearing aids,eye
glasses, noise
THINK:
Toxic situation - CHF,shock,dehydration - deliriogenic meds (tight titration) -
New organ failure (liver ,kidney, etc.)
Hypoxemia
Infection/sepsis (nosocomial), immobilization
Nonpharmacologic interventions3
k+ or electrolyte problems

    Dr. DRE:
Diseases:sepsis,CHF,COPD
Drug Removal: SATs and stopping benzodiazepines/narcotics
Environment:Immobilization,sleep and
day/night orientation,hearing aids,eye
glasses, noise
THINK:
Toxic situation - CHF,shock,dehydration - deliriogenic meds (tight titration) -
New organ failure (liver ,kidney, etc.)
Hypoxemia
Infection/sepsis (nosocomial), immobilization
Nonpharmacologic interventions3
k+ or electrolyte problems

    Dr. DRE:

Dr. DRE: D
D R
E



T

H
I
N 3
k +

Consider stopping or substituting deliriogenic medication such as benzodipazepines,anticholinergic medications (metoloclopramide,H2 blockers,promethazine,diphenydramine),steroids,etc

Consider stopping or substituting deliriogenic medication such as benzodipazepines,anticholinergic medications (metoloclopramide,H2 blockers,promethazine,diphenydramine),steroids,etc

Consider stopping or substituting deliriogenic medication such as benzodipazepines,anticholinergic medications (metoloclopramide,H2 blockers,promethazine,diphenydramine),steroids,etc

Consider stopping or substituting deliriogenic medication such as benzodipazepines,anticholinergic medications (metoloclopramide,H2 blockers,promethazine,diphenydramine),steroids,etc

2

See nonpharmacologic protocal -see below.

See nonpharmacologic protocal -see below.

See nonpharmacologic protocal -see below.

See nonpharmacologic protocal -see below.

If patient is nonverbal,assess via CPOT, or if patient is verbal assess via visual analog scale.

If patient is nonverbal,assess via CPOT, or if patient is verbal assess via visual analog scale.

If patient is nonverbal,assess via CPOT, or if patient is verbal assess via visual analog scale.

If patient is nonverbal,assess via CPOT, or if patient is verbal assess via visual analog scale.

Typical or athypical antipsychotics.Discontinue if high fever ,QTc prolongation,or druginduced rigidity.

Typical or athypical antipsychotics.Discontinue if high fever ,QTc prolongation,or druginduced rigidity.

Typical or athypical antipsychotics.Discontinue if high fever ,QTc prolongation,or druginduced rigidity.

Typical or athypical antipsychotics.Discontinue if high fever ,QTc prolongation,or druginduced rigidity.

Analgesia - Adequate pain control may decrease delirium. Consider opiates, non-steroidals,acetaminophen,or gabapentin (neuropathic pain).

Analgesia - Adequate pain control may decrease delirium. Consider opiates, non-steroidals,acetaminophen,or gabapentin (neuropathic pain).

Analgesia - Adequate pain control may decrease delirium. Consider opiates, non-steroidals,acetaminophen,or gabapentin (neuropathic pain).

Analgesia - Adequate pain control may decrease delirium. Consider opiates, non-steroidals,acetaminophen,or gabapentin (neuropathic pain).

Spontaneous awakening Trial (SAT) - if meets safety criteria (no active seizures, no alchol withdrawal no agitation, no paralytics, no myocardial ischemia, normal intracrania pressure, FiO2 ≤70%

Spontaneous awakening Trial (SAT) - if meets safety criteria (no active seizures, no alchol withdrawal no agitation, no paralytics, no myocardial ischemia, normal intracrania pressure, FiO2 ≤70%

Spontaneous awakening Trial (SAT) - if meets safety criteria (no active seizures, no alchol withdrawal no agitation, no paralytics, no myocardial ischemia, normal intracrania pressure, FiO2 ≤70%

Spontaneous awakening Trial (SAT) - if meets safety criteria (no active seizures, no alchol withdrawal no agitation, no paralytics, no myocardial ischemia, normal intracrania pressure, FiO2 ≤70%

2 ≤

Spontaneous Breathing Trial (SBT) -if meets safety criteria (no agitation, no myocardial ischemia, Fio2≤50%, adequate inspiratory efforts,O2 saturation

≥88%, no vasopressor use ,PEEP ≤7.5cm

Spontaneous Breathing Trial (SBT) -if meets safety criteria (no agitation, no myocardial ischemia, Fio2≤50%, adequate inspiratory efforts,O2 saturation

≥88%, no vasopressor use ,PEEP ≤7.5cm

Spontaneous Breathing Trial (SBT) -if meets safety criteria (no agitation, no myocardial ischemia, Fio2≤50%, adequate inspiratory efforts,O2 saturation

≥88%, no vasopressor use ,PEEP ≤7.5cm

Spontaneous Breathing Trial (SBT) -if meets safety criteria (no agitation, no myocardial ischemia, Fio2≤50%, adequate inspiratory efforts,O2 saturation

2 ≤ 2

≥88%, no vasopressor use ,PEEP ≤7.5cm

≥ ≤

Consider non-benzodiazepine sedation strategies (propofol or dexmedetomidine)

Consider non-benzodiazepine sedation strategies (propofol or dexmedetomidine)

Consider non-benzodiazepine sedation strategies (propofol or dexmedetomidine)

Consider non-benzodiazepine sedation strategies (propofol or dexmedetomidine)

Non-delirious (CAM-ICU negative)
Non-delirious (CAM-ICU negative)
Non-delirious
Delirious (CAM-ICU positive)
Delirious (CAM-ICU positive)
Delirious
Stupor or coma while on sedative or analgesic drugs7 (RASS −4 or −5)
Stupor or coma while on sedative or analgesic drugs7 (RASS −4 or −5)
7 7 Stupor