In this episode, I’ll discuss whether using haloperidol for ICU delirium reduces mortality.
While many pharmacologic therapies have been studied to treat ICU delirium, the recommendations from the latest SCCM PADIS guidelines is:
We suggest not routinely using haloperidol, an atypical antipsychotic, or a HMG-CoA reductase inhibitor (i.e., a statin) to treat delirium (conditional recommendation, low quality of evidence).
The search for effective pharmacologic treatments for delirium continues, and researchers recently published a post-hoc cohort analysis of a randomized, double-blind, placebo-controlled, delirium prevention trial in Critical Care Medicine.
Nearly 1500 patients were analyzed, about one-third of which developed delirium. 88% of those patients who developed delirium were treated with haloperidol for a mean daily dose of 2.1 mg.
The authors found:
Each milligram of treatment haloperidol administered daily was associated with decreased mortality at 28 days (hazard ratio, 0.93; 95% CI, 0.91–0.95) and 90 days (hazard ratio, 0.97; 95% CI, 0.96–0.98). Treatment haloperidol administered later in the ICU course was less protective of death. Results were stable by prevention study-arm, predelirium haloperidol exposure, and haloperidol treatment protocol adherence.
This post hoc analysis of the REDUCE study cohort demonstrates that use of haloperidol to treat incident delirium, and where the haloperidol dose is titrated to resolve both delirium and its symptoms, may be associated with lower 28-day mortality in a dose-dependent, time-dependent manner.
The authors believe the key difference of their study and others that do not show benefits with pharmacologic treatment is that they focused on incident delirium treatment only. This means only patients that developed delirium during the ICU stay were analyzed – not patients with prevalent delirium that occurs before or at ICU admission.
While this key difference may explain the apparent beneficial effect, the fact that it was a post-hoc analysis should limit adoption of this strategy until a prospective trial can prove a benefit in this specific patient population.
Members of my Hospital Pharmacy Academy have access to practical training from a pharmacist’s point of view on the ABCDEF Delirium Prevention Bundle and ICU Sedation. This is in addition to hundreds of other trainings and resources to help in your practice. To get immediate access, go to pharmacyjoe.com/academy.
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