ICU Acute Agitation & Hyperactive Delirium

STEP 1 – FIND THE CAUSE (P‑I‑N‑C‑H)

Pain – assess & treat Infection – fever / new cough New drug started? Withdrawal (alcohol/opioids/sedatives) Cardiac/Cerebral – hypoxia/hypercarbia Metabolic – acidosis/hypoglycemia/hyponatremia Uremia / Hepatic encephalopathy Hazardous – bladder/bowel, lines/tubes pulling

Vitals/Labs quick entry (optional)

SpO₂ (%)

EtCO₂ / PaCO₂ (mmHg)

Glucose (mg/dL)

Na⁺ (mmol/L)

Urea/Cr (mg/dL)

NH₃ (µmol/L)

STEP 2 – SEDATION (if Step 1 fails)

Use soft restraints only if danger to self/staff. Document reason & time.

Dexmedetomidine infusion (NO loading dose)

Patient weight (kg)

Target rate (µg/kg/hr) 0.2–1.5

Infusion strength (µg/mL) (e.g., 200 µg in 50 mL → 4 µg/mL)

Avoid in severe bradycardia/AV block/profound hypotension.

STEP 3 – TREAT THE DELIRIUM

Delirium assessment

CAM‑ICU result RASS target

Olanzapine (off‑label in ICU)

ECG done in last 24–48 h QTc < 500 ms

Dose at 21:00 hrs (OD)

Max per SmPC: 20 mg/24 h total (all routes). Avoid giving IM olanzapine and parenteral benzodiazepines within 1 hour of each other (cardiorespiratory depression risk).

Safety Warnings

Do not exceed 20 mg/24 h of olanzapine (oral + IM combined).
Do not co‑administer IM olanzapine and parenteral benzodiazepines within 1 hour.
Monitor for oversedation, hypotension, bradycardia.
Reassess need for restraints frequently and document.

Label basis: EU SmPC for olanzapine tablets & short‑acting IM injection.

Notes & Print

Free‑text notes (saved locally)

Tip: Printing captures the live timestamp and current plan.

Non‑pharmacological measures (recap)

Calm, clear verbal re‑orientation; reduce noise at night.
Normalize day–night lighting; allow glasses/hearing aids.
Involve family briefly for reassurance if unit policy permits.
Remove unnecessary lines/tubes if safe.

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