Skip to main content
Erschienen in: ProCare 5/2016

01.06.2016 | intensivpflege

Delir und Delirmanagement bei kritisch kranken Patienten

Nichtpharmakologische Maßnahmen bestimmen Prävention und Therapie

verfasst von: Dr. Alexander Kersten, Priv.-Doz. Dr. Sebastian Reith

Erschienen in: PRO CARE | Ausgabe 5/2016

Einloggen, um Zugang zu erhalten

Zusammenfassung

Das Delir bei kritisch kranken Patienten ist als Ausdruck einer zerebralen Organdysfunktion eine häufige Entität auf der Intensivstation. Kennzeichnend ist eine Störung des Bewusstseins und der Kognition, verbunden mit Aufmerksamkeitsschwierigkeiten und Veränderungen der Wahrnehmung, die sich in einem zeitlichen Intervall von Stunden bis Tagen manifestieren können. Das Auftreten eines Delirs hat nachgewiesene negative Effekte auf kurz- und langfristige Outcomeparameter des Patienten und erhöht die Morbidität und Mortalität. Trotz seiner Signifikanz wird das Delir in der Routineversorgung vom intensivmedizinischen Team in vielen Fällen nicht adäquat diagnostiziert. Als Instrumente zur standardisierten Erkennung des Delirs haben sich die gut validierten Skalen der Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) und der Intensive Care Delirium Screening Checklist (ICDSC) etabliert. Diese sind sowohl für ärztliches als auch nichtärztliches Personal einfach anwendbar. Die Therapie des Delirs ist bestimmt durch nichtpharmakologische Maßnahmen. Ziele sind die frühe Identifikation, Reorientierung und Mobilisierung des Patienten, darüber hinaus die Förderung der geistigen Aktivität und die Etablierung eines adäquaten Tag-Nacht-Rhythmus. Die Evidenz bezüglich der pharmakologischen Therapie ist gering, wobei die Wahl der sedierenden Medikation einen nachgewiesenen Einfluss auf Entstehung und Dauer eines Delirs auf der Intensivstation hat.
Literatur
1.
Zurück zum Zitat Baron R, Binder A, Biniek R et al.; DASTaskforce 2015 (2015) Evidence and consensus based guideline for the management of delirium, analgesia, and sedation in intensive care medicine. (DAS-Guideline 2015). Ger Med Sci 13:Doc19PubMedPubMedCentral Baron R, Binder A, Biniek R et al.; DASTaskforce 2015 (2015) Evidence and consensus based guideline for the management of delirium, analgesia, and sedation in intensive care medicine. (DAS-Guideline 2015). Ger Med Sci 13:Doc19PubMedPubMedCentral
2.
4.
Zurück zum Zitat Ely EW, Shintani A, Truman B et al. (2004) Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 291:1753–1762CrossRefPubMed Ely EW, Shintani A, Truman B et al. (2004) Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 291:1753–1762CrossRefPubMed
5.
Zurück zum Zitat Pisani MA, Kong SY, Kasl SV et al. (2009) Days of delirium are associated with 1-year mortality in an older intensive care unit population. Am J Respir Crit Care Med 180:1092–1097CrossRefPubMedPubMedCentral Pisani MA, Kong SY, Kasl SV et al. (2009) Days of delirium are associated with 1-year mortality in an older intensive care unit population. Am J Respir Crit Care Med 180:1092–1097CrossRefPubMedPubMedCentral
6.
7.
Zurück zum Zitat Pauley E, Lishmanov A, Schumann S et al. (2015) Delirium is a robust predictor of morbidity and mortality among critically ill patients treated in the cardiac intensive care unit. Am Heart J 170:79–86CrossRefPubMed Pauley E, Lishmanov A, Schumann S et al. (2015) Delirium is a robust predictor of morbidity and mortality among critically ill patients treated in the cardiac intensive care unit. Am Heart J 170:79–86CrossRefPubMed
8.
Zurück zum Zitat Spronk PE, Riekerk B, Hofhuis J et al. (2009) Occurrence of delirium is severely underestimated in the ICU during daily care. Intensive Care Med 35:1276–1280CrossRefPubMedPubMedCentral Spronk PE, Riekerk B, Hofhuis J et al. (2009) Occurrence of delirium is severely underestimated in the ICU during daily care. Intensive Care Med 35:1276–1280CrossRefPubMedPubMedCentral
9.
Zurück zum Zitat Vasilevskis EE, Ely EW, Speroff T et al. (2010) Reducing iatrogenic risks: ICU-acquired delirium and weakness — crossing the quality chasm. Chest 38:375–381 Vasilevskis EE, Ely EW, Speroff T et al. (2010) Reducing iatrogenic risks: ICU-acquired delirium and weakness — crossing the quality chasm. Chest 38:375–381
10.
11.
Zurück zum Zitat Peterson JF, Pun BT, Dittus RS et al. (2006) Delirium and its motoric subtypes: a study of 614 critically ill patients. J Am Geriatr Soc 54:479–484CrossRefPubMed Peterson JF, Pun BT, Dittus RS et al. (2006) Delirium and its motoric subtypes: a study of 614 critically ill patients. J Am Geriatr Soc 54:479–484CrossRefPubMed
12.
Zurück zum Zitat Ouimet S, Kavanagh BP, Gottfried SB et al. (2007) Incidence, risk factors, and consequences of ICU delirium. Intensive Care Med 33:66–73CrossRefPubMed Ouimet S, Kavanagh BP, Gottfried SB et al. (2007) Incidence, risk factors, and consequences of ICU delirium. Intensive Care Med 33:66–73CrossRefPubMed
13.
Zurück zum Zitat Salluh JI, Soares M, Teles JM et al.; Epidemiology in Critical Care Study Group (2010) Delirium epidemiology in critical care (DECCA): an international study. Crit Care 14(6):R210CrossRefPubMedPubMedCentral Salluh JI, Soares M, Teles JM et al.; Epidemiology in Critical Care Study Group (2010) Delirium epidemiology in critical care (DECCA): an international study. Crit Care 14(6):R210CrossRefPubMedPubMedCentral
14.
Zurück zum Zitat van den Boogaard M, Schoonhoven L, Evers AW et al. (2012) Delirium in critically ill patients: impact on long-term health related quality of life and cognitive functioning. Crit Care Med 40(1):112–118CrossRefPubMed van den Boogaard M, Schoonhoven L, Evers AW et al. (2012) Delirium in critically ill patients: impact on long-term health related quality of life and cognitive functioning. Crit Care Med 40(1):112–118CrossRefPubMed
15.
Zurück zum Zitat Shehabi Y, Rikker RR, Bokesch PM et al. (2010) Delirium duration and mortality in lightly sedated, mechanically ventilated intensive care unit patients. Crit Care Med 38:2311–2318CrossRefPubMed Shehabi Y, Rikker RR, Bokesch PM et al. (2010) Delirium duration and mortality in lightly sedated, mechanically ventilated intensive care unit patients. Crit Care Med 38:2311–2318CrossRefPubMed
16.
Zurück zum Zitat Girard TD, Shintani AK, Jackson JC et al. (2007) Risk factors for posttraumatic stress disorder symptoms following critical illness requiring mechanical ventilation: a prospective cohort study. Crit Care 11:R28CrossRefPubMedPubMedCentral Girard TD, Shintani AK, Jackson JC et al. (2007) Risk factors for posttraumatic stress disorder symptoms following critical illness requiring mechanical ventilation: a prospective cohort study. Crit Care 11:R28CrossRefPubMedPubMedCentral
17.
Zurück zum Zitat van Eijk MM, van Marum RJ, Klijn IA, de Wit N, Kesecioglu J, Slooter AJ (2009) Comparison of delirium assessment tools in a mixed intensive care unit. Crit Care Med 37:1881–1885CrossRefPubMed van Eijk MM, van Marum RJ, Klijn IA, de Wit N, Kesecioglu J, Slooter AJ (2009) Comparison of delirium assessment tools in a mixed intensive care unit. Crit Care Med 37:1881–1885CrossRefPubMed
18.
Zurück zum Zitat Ely EW, Inouye SK, Bernard GR et al. (2001) Delirium in mechanically ventilated patients: validity and reliability of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). JAMA 286:2703–2710CrossRefPubMed Ely EW, Inouye SK, Bernard GR et al. (2001) Delirium in mechanically ventilated patients: validity and reliability of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). JAMA 286:2703–2710CrossRefPubMed
19.
Zurück zum Zitat Bergeron N, Dubois MJ, Dumont M, Dial S, Skrobik Y (2001) Intensive Care Delirium Screening Checklist: evaluation of a new screening tool. Intensive Care Med 27:859–864CrossRefPubMed Bergeron N, Dubois MJ, Dumont M, Dial S, Skrobik Y (2001) Intensive Care Delirium Screening Checklist: evaluation of a new screening tool. Intensive Care Med 27:859–864CrossRefPubMed
20.
Zurück zum Zitat Vasilevskis EE, Morandi A, Boehm L et al. (2011) Delirium and sedation recognition using validated instruments: reliability of bedside intensive care unit nursing assessments from 2007 to 2010. J Am Geriatr Soc 59:(Suppl 2):S249–S255CrossRefPubMedPubMedCentral Vasilevskis EE, Morandi A, Boehm L et al. (2011) Delirium and sedation recognition using validated instruments: reliability of bedside intensive care unit nursing assessments from 2007 to 2010. J Am Geriatr Soc 59:(Suppl 2):S249–S255CrossRefPubMedPubMedCentral
21.
Zurück zum Zitat Reade MC, Eastwood GM, Peck L, Bellomo R, Baldwin I (2011) Routine use of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) by bedside nurses may underdiagnose delirium. Crit Care Resusc 13:217–224PubMed Reade MC, Eastwood GM, Peck L, Bellomo R, Baldwin I (2011) Routine use of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) by bedside nurses may underdiagnose delirium. Crit Care Resusc 13:217–224PubMed
22.
Zurück zum Zitat Pun BT, Dunn J (2007) The sedation of critically ill adults — part 1: assessment: the first in a two-part series focuses on assessing sedated patients in the ICU. Am J Nurs 107:40–48 Pun BT, Dunn J (2007) The sedation of critically ill adults — part 1: assessment: the first in a two-part series focuses on assessing sedated patients in the ICU. Am J Nurs 107:40–48
23.
Zurück zum Zitat Barr J, Fraser GL, Puntillo K et al. (2013) Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 41:263–306CrossRefPubMed Barr J, Fraser GL, Puntillo K et al. (2013) Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 41:263–306CrossRefPubMed
24.
Zurück zum Zitat Inouye SK, Bogardus ST Jr, Charpentier PA et al. (1999) A multicomponent intervention to prevent delirium in hospitalized older adults. N Engl J Med 340(9):669–676CrossRefPubMed Inouye SK, Bogardus ST Jr, Charpentier PA et al. (1999) A multicomponent intervention to prevent delirium in hospitalized older adults. N Engl J Med 340(9):669–676CrossRefPubMed
25.
Zurück zum Zitat Vidan MT, Sanchez E, Alonso M, Montero B, Ortiz J, Serra JA (2009) An intervention integrated into daily clinical practice reduces the incidence of delirium during hospitalization in elderly patients. J Am Geriatr Soc 57(11): 2029–2036CrossRefPubMed Vidan MT, Sanchez E, Alonso M, Montero B, Ortiz J, Serra JA (2009) An intervention integrated into daily clinical practice reduces the incidence of delirium during hospitalization in elderly patients. J Am Geriatr Soc 57(11): 2029–2036CrossRefPubMed
26.
Zurück zum Zitat Rivosecchi RM, Smithburger PL, Svec S et al. (2015) Non-pharmacological interventions to prevent delirium: an evidence based systematic review. Crit Care Nurse 35(1):39–51CrossRefPubMed Rivosecchi RM, Smithburger PL, Svec S et al. (2015) Non-pharmacological interventions to prevent delirium: an evidence based systematic review. Crit Care Nurse 35(1):39–51CrossRefPubMed
27.
Zurück zum Zitat Inouye SK, Baker DI, Fugal P et al. (2006) Dissemination of the hospital elder life program: implementation, adaptation, and successes. J Am Geriatr Soc 54:1492–1499CrossRefPubMed Inouye SK, Baker DI, Fugal P et al. (2006) Dissemination of the hospital elder life program: implementation, adaptation, and successes. J Am Geriatr Soc 54:1492–1499CrossRefPubMed
28.
Zurück zum Zitat van den Boogaard M, Pickkers P, Slooter AJ et al. (2012) Development and validation of PREDELIRIC (PREdiction of DELIRium in ICU patients) delirium prediction model for intensive care patients: observational multicentre study. BMJ 344:e420CrossRefPubMedPubMedCentral van den Boogaard M, Pickkers P, Slooter AJ et al. (2012) Development and validation of PREDELIRIC (PREdiction of DELIRium in ICU patients) delirium prediction model for intensive care patients: observational multicentre study. BMJ 344:e420CrossRefPubMedPubMedCentral
29.
Zurück zum Zitat Tabet N, Hudson S, Sweeney V et al. (2005) An educational intervention can prevent delirium Tabet N, Hudson S, Sweeney V et al. (2005) An educational intervention can prevent delirium
30.
Zurück zum Zitat Inouye SK, Bogardus ST, Charpentier PA et al. (1999) A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 340:669–676CrossRefPubMed Inouye SK, Bogardus ST, Charpentier PA et al. (1999) A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 340:669–676CrossRefPubMed
31.
Zurück zum Zitat Schweickert WD, Pohlman MC, Pohlman AS et al. (2009) Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 373(9678):1874–1882CrossRefPubMed Schweickert WD, Pohlman MC, Pohlman AS et al. (2009) Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 373(9678):1874–1882CrossRefPubMed
32.
Zurück zum Zitat Inouye SK, Bogardus ST, Williams CS et al. (2003) The role of adherence on the effectiveness of nonpharmacologic interventions. Arch Intern Med 163:958–964CrossRefPubMed Inouye SK, Bogardus ST, Williams CS et al. (2003) The role of adherence on the effectiveness of nonpharmacologic interventions. Arch Intern Med 163:958–964CrossRefPubMed
33.
Zurück zum Zitat Hu RF, Jiang XY, Hegadoren KM et al. (2015) Effects of earplugs and eye masks combined with relaxing music on sleep, melatonin and cortisol levels in ICU patients: a randomized controlled trial. Crit Care Med 19:115 Hu RF, Jiang XY, Hegadoren KM et al. (2015) Effects of earplugs and eye masks combined with relaxing music on sleep, melatonin and cortisol levels in ICU patients: a randomized controlled trial. Crit Care Med 19:115
34.
Zurück zum Zitat Kress P, Pohlman AS, O’Connor MF et al. (2000) Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 342:1471–1477CrossRefPubMed Kress P, Pohlman AS, O’Connor MF et al. (2000) Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 342:1471–1477CrossRefPubMed
35.
Zurück zum Zitat Girard TD, Kress JP, Fuchs BD et al. (2008) Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomized controlled trial. Lancet 371:126–134CrossRefPubMed Girard TD, Kress JP, Fuchs BD et al. (2008) Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomized controlled trial. Lancet 371:126–134CrossRefPubMed
36.
Zurück zum Zitat Kalisvaart KJ, de Jonghe JF, Bogaards MJ et al. (2005) Haloperidol prophylaxis for elderly hipsurgery patients at risk for delirium: a randomized placebo-controlled study. J Am Geriatr Soc 53:1658–1666CrossRefPubMed Kalisvaart KJ, de Jonghe JF, Bogaards MJ et al. (2005) Haloperidol prophylaxis for elderly hipsurgery patients at risk for delirium: a randomized placebo-controlled study. J Am Geriatr Soc 53:1658–1666CrossRefPubMed
37.
Zurück zum Zitat Wang W, Li HL, Wang DX et al. (2012) Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery: a randomized controlled trial. Crit Care Med 40:731–739CrossRefPubMed Wang W, Li HL, Wang DX et al. (2012) Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery: a randomized controlled trial. Crit Care Med 40:731–739CrossRefPubMed
38.
Zurück zum Zitat Prakanrattana U, Prapaitrakool S (2007) Efficacy of risperidone for prevention of postoperative delirium in cardiac surgery. Anaesth Intensive Care 35:714–719PubMed Prakanrattana U, Prapaitrakool S (2007) Efficacy of risperidone for prevention of postoperative delirium in cardiac surgery. Anaesth Intensive Care 35:714–719PubMed
39.
Zurück zum Zitat Riker RR, Shehabi Y, Bokesch PM et al. (2009) Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial. JAMA 301:489–499CrossRefPubMed Riker RR, Shehabi Y, Bokesch PM et al. (2009) Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial. JAMA 301:489–499CrossRefPubMed
40.
Zurück zum Zitat Pandharipande PP, Pun BT, Herr DL et al. (2007) Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial. JAMA 298:2644–2653CrossRefPubMed Pandharipande PP, Pun BT, Herr DL et al. (2007) Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial. JAMA 298:2644–2653CrossRefPubMed
41.
Zurück zum Zitat Jakob SM, Ruokonen E, Grounds RM et al. (2012) Dexmedetomidine vs midazolam or propofol for sedation during prolonged mechanical ventilation: two randomized controlled trials. JAMA 307:1151–1160CrossRefPubMed Jakob SM, Ruokonen E, Grounds RM et al. (2012) Dexmedetomidine vs midazolam or propofol for sedation during prolonged mechanical ventilation: two randomized controlled trials. JAMA 307:1151–1160CrossRefPubMed
42.
Zurück zum Zitat Devlin JW, Roberts RJ, Fong JJ et al. (2010) Efficacy and safety of quetiapine in critically ill patients with delirium: a prospective, multicenter, randomized, doubleblind, placebocontrolled pilot study. Crit Care Med 38:419–427CrossRefPubMed Devlin JW, Roberts RJ, Fong JJ et al. (2010) Efficacy and safety of quetiapine in critically ill patients with delirium: a prospective, multicenter, randomized, doubleblind, placebocontrolled pilot study. Crit Care Med 38:419–427CrossRefPubMed
43.
Zurück zum Zitat Girard TD, Pandharipande PP, Carson SS et al. (2010) Feasibility, efficacy, and safety of antipsychotics for intensive care unit delirium: the MIND randomized, placebo-controlled trial. Crit Care Med 38:428–437CrossRefPubMedPubMedCentral Girard TD, Pandharipande PP, Carson SS et al. (2010) Feasibility, efficacy, and safety of antipsychotics for intensive care unit delirium: the MIND randomized, placebo-controlled trial. Crit Care Med 38:428–437CrossRefPubMedPubMedCentral
44.
Zurück zum Zitat Reade MC, O’Sullivan K, Bates S, Goldsmith D, Ainslie WR, Bellomo R (2009) Dexmedetomidine vs. haloperidol in delirious, agitated, intubated patients: a randomised open-label trial. Crit Care 13:R75CrossRefPubMedPubMedCentral Reade MC, O’Sullivan K, Bates S, Goldsmith D, Ainslie WR, Bellomo R (2009) Dexmedetomidine vs. haloperidol in delirious, agitated, intubated patients: a randomised open-label trial. Crit Care 13:R75CrossRefPubMedPubMedCentral
Metadaten
Titel
Delir und Delirmanagement bei kritisch kranken Patienten
Nichtpharmakologische Maßnahmen bestimmen Prävention und Therapie
verfasst von
Dr. Alexander Kersten
Priv.-Doz. Dr. Sebastian Reith
Publikationsdatum
01.06.2016
Verlag
Springer Vienna
Erschienen in
PRO CARE / Ausgabe 5/2016
Print ISSN: 0949-7323
Elektronische ISSN: 1613-7574
DOI
https://doi.org/10.1007/s00735-016-0644-5

Weitere Artikel der Ausgabe 5/2016

ProCare 5/2016 Zur Ausgabe

freizeit & leben

freizeit & leben

PflegeKolleg

Männersache