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A 75-year-old woman with a history of chronic obstructive pulmonary disease is evaluated in the intensive care unit for delirium. She had a median sternotomy and repair of an aortic dissection and was extubated uneventfully on postoperative day 4. Two days later she developed fluctuations in her mental status and inattention. While still in the intensive care unit, she became agitated, pulling at her lines, attempting to climb out of bed, and asking to leave the hospital. Her arterial blood gas values are normal. The patient has no history of alcohol abuse. The use of frequent orientation cues, calm reassurance, and presence of family members has done little to reduce the patient’s agitated behavior.
Which of the following is the most appropriate therapy for this patient’s delirium?
A-Diphenhydramine
B-Haloperidol
C-Lorazepam
D-Propofol
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Ans-B--when supportive care is insufficient for prevention or treatment of delirium, symptom control with medication is occasionally necessary to prevent harm or to allow evaluation and treatment in the intensive care unit. The appropriate treatment for this patient is haloperidol. The recommended therapy for delirium is antipsychotic agents, although no drugs are U.S. Food and Drug Administration–approved for this indication. Ongoing randomized, placebo-controlled trials are investigating different management strategies for intensive care unit delirium.
Diphenhydramine and other antihistamines are a major risk factor for delirium, especially in older patients. Lorazepam is actually deliriogenic, and its use in a delirious patient should be carefully re-evaluated, other than perhaps in patients experiencing benzodiazepine withdrawal or delirium tremens. There is no evidence that propofol has any role in treating delirium.
