What are your go-to options for managing ICU delirium in patients with contraindications to antipsychotics?

Evidence for Ramelteon (Yu et al., PMID 36726202)

Delirium with behavioral disturbances

• Depakote
• Clonidine
• Propranolol, especially with TBI

Non pharmacological

• Make sure they're closer to the nursing station.
• Constant re-orientation.
• Shades open during the day and close at night.
• Bring anything they ...

I think that the question really should be—what are we trying to treat? If the patient is delirious, as noted, the most important task is to identify this as delirium and then treat the underlying cause. If the patient is aggressive/agitated (hyperactive delirium), then the above medication choices ...

Precedex unless bradycardic or hypotensive. Depakote may also be helpful if LFTs are okay. Of course, if delirium is due to alcohol withdrawal, then the CIWA protocol with benzodiazepines.

There are no medications that can predictably shorten the duration of delirium. The drugs that are listed should only be used, in my opinion, for severe agitation, including antipsychotic medication.

When approaching management of ICU delirium in patients unable to take antipsychotics, a few areas of intervention should be considered:

1.) Treatment of the underlying etiology

2.) Removal or decrease in contributing factors such as other deliriogenic medications and environmental factors such as res...

I assume the question is directed toward pharmacologic options. In that regard, dexmedetomidine is very helpful and should be considered first-line in the absence of bradycardia or hypotension.

Assuming that we are not dealing with delirium secondary to withdrawal, such as alcohol withdrawal, in whi...

I’m not the one who got freaked out with a call to the bedside to manage psychosis, so these answers and treatment plans are very useful to me if I’m ever recalled into such a situation. I certainly agree with Precedex.