From the Journals

Haloperidol does not prevent delirium in ICU patients

 

Key clinical point: Prophylactic haloperidol did not prevent delirium or improve survival in a large, placebo-controlled trial at 21 ICUs in the Netherlands.

Major finding: Delirium was diagnosed in 33.3% of haloperidol subjects versus 33.0% of placebo patients.

Study details: The trial enrolled 1,789 critically ill adults.

Disclosures: This work was supported by ZonMw, the Netherlands Organization for Health Research and Development. The lead investigator had no disclosures.

Source: van den Boogaard M et al. JAMA. 2018 Feb 20;319(7):680-90.

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Nondrug options may be the key

The study has demonstrated that in critically ill patients currently receiving best-practice nonpharmacological interventions to prevent delirium, the addition of haloperidol does not improve survival nor reduce the incidence of delirium or the harms associated with delirium. The findings challenge the current model that the addition of psychoactive medication to patients who are already receiving multiple interventions may be beneficial. Prophylactic haloperidol is not the solution for the complex problem of delirium in critically ill patients. It may be that no single pharmacological intervention can provide a solution.

Future research is warranted into nonpharmacological interventions. They generally involve either doing less for patients (avoiding excessive sedation, benzodiazepines, nocturnal noise, and stimulation) or ensuring the continued provision of relatively simple therapies (mobilization, maintaining a day-night schedule, and noise reduction). Although some of these interventions may require planning and cooperation of a multidisciplinary team, a strength of ICU care in general, other interventions may be as simple as providing earplugs and eye patches to improve sleep.

Anthony Delaney, MD, PhD, is associate professor of intensive care medicine at the University of Sydney. Naomi Hammond, PhD, is a research fellow and senior lecturer at the University of New South Wales, Sydney. Edward Litton, MD, PhD, is an intensive care specialist in Perth, Australia. They made their comments in a JAMA editorial, and had no disclosures ( JAMA. 2018 Feb 20;319[7]:659-60 ).


 

FROM JAMA


Prophylactic haloperidol had no effect on reducing the incidence of delirium, which was diagnosed in 33.3% of haloperidol subjects and 33.0% of placebo patients. Likewise, there were no significant differences between the groups in the number of delirium-free and coma-free days, duration of mechanical ventilation, and ICU and hospital length of stay. The number of reported adverse events with treatment also did not differ significantly between the groups: 0.3% in the 2-mg haloperidol group versus 0.1% in the placebo arm.

The duration of prophylactic therapy was a median of 2 days, but a subgroup analysis in patients treated for more than 2 days also did not show any benefits with haloperidol.

“The study population included severely ill ICU adults whose brains may have been too seriously affected for haloperidol to exert a prophylactic effect, since in non-ICU adults, prophylactic haloperidol may have beneficial effects. But the subgroup of patients with a low severity of illness score also demonstrated no beneficial effects,” the investigators said.

Subjects were a mean of 66.6 years old; 61.4% were men. Most of the ICU admissions were urgent and for medical or surgical reasons.

This study was supported by ZonMw, the Netherlands Organization for Health Research and Development. Dr. van den Boogaard had no disclosures. One author reported grants and consultant and speaker fees from Pfizer, Merck, Astellas, and Gilead, among others.

SOURCE: van den Boogaard M, et al. JAMA. 2018 Feb 20;319(7):680-90.

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