Hyperactive ICU delirium — FFICM MCQ

Correct answer: D — Use non-pharmacological delirium measures and avoid QT-prolonging antipsychotics where possible

The correct answer is D, use non-pharmacological delirium measures and avoid QT-prolonging antipsychotics where possible. This man has hyperactive delirium (fluctuating attention, inattention, visual hallucinations, agitation) precipitated by recent sepsis, an established cause in critical illness recovery. Reversible contributors (hypoxia, hypotension, pain, retention) have already been excluded, so first-line management is non-pharmacological: reorientation, sleep hygiene, correcting sensory deficits, mobilisation, avoiding unnecessary lines or catheters, and involving family. His QTc of 510 ms is markedly prolonged, and haloperidol and other antipsychotics are known to further prolong QTc and risk torsades, so pharmacological sedation is reserved for severe distress or safety risk only, after cardiac review, at the lowest effective dose and shortest duration. Why the other options are wrong: C. Start high-dose haloperidol routinely: haloperidol is not first-line and is contraindicated at high dose in a patient with a QTc over 500 ms because of torsadogenic risk; it should only be considered short-term if de-escalation fails and ECG monitoring allows. B. Deepen sedation with continuous benzodiazepine infusion: benzodiazepines worsen and prolong delirium (except in alcohol withdrawal or seizures) and increase confusion, falls and ventilator/ICU days. E. Apply physical restraint without review: restraint should only be used as a last resort with continuous review and least restrictive practice, never applied unreviewed, as it increases agitation, injury and distress. A. Treat as primary psychosis and transfer to psychiatry: the clinical picture (acute onset, fluctuating course, medical precipitant) is classic delirium, not primary psychiatric illness, and transfer would delay correction of the underlying medical cause. Key point: In delirium with significant QT prolongation, non-pharmacological measures are first-line and antipsychotics are reserved for severe agitation only, used cautiously with ECG monitoring.

Reference: NICE Guideline CG103, Delirium: prevention, diagnosis and management in hospital and long-term care (updated 2023), section on pharmacological management, https://www.nice.org.uk/guidance/cg103