Survival of intensive care patients at elevated risk of delirium

No benefit of prophylactic haloperidol

Delirium is a serious condition with an elevated risk of mortality in the short and longer term. This also goes for patients who develop delirium during a stay at an intensive care unit. Hence, preventing delirium is highly clinically relevant, as is research into drugs that might achieve this.

  • A recent Dutch study concluded that medical prevention of delirium by means of intravenous haloperidol does not improve the chances of survival of ICU patients within a month. Nor do there appear to be indications that haloperidol could prevent the development of delirium in these patients, as the incidence of delirium remained just as high (approx. 33%).
  • Similar conclusions cannot as yet be drawn for all patients admitted to an ICU, as the study discussed here excluded many patients based on the subjective clinical judgement of the attending staff. Nevertheless, the authors conclude that there is no place for haloperidol as a prophylaxis for delirium.
  • No major adverse effects of the prophylactic use of haloperidol in ICU patients were found in this study.
  • The study discussed here is a good example of research showing that a medical intervention that would appear to be plausible (intravenous haloperidol as a prophylaxis to prevent delirium) does not automatically mean improved care (reducing an elevated risk of future mortality).
  • We therefore recommend to cease this prophylactic medical treatment, as long as no evidence for a relevant effect is found.

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Washington DC: American Psychiatric Association. 2013.
  2. Rood P, Huisman-de Waal G, Vermeulen H, Schoonhoven L, Pickkers P, van den Boogaard M. Effect of organisational factors on the variation in incidence of delirium in intensive care unit patients: A systematic review and meta-regression analysis. Aust Crit Care. 2018 May;31(3):180-7.
  3. Klein Klouwenberg PM, Zaal IJ, Spitoni C, Ong DS, van der Kooi AW, Bonten MJ, et al. The attributable mortality of delirium in critically ill patients: prospective cohort study. BMJ. 2014 Nov 24;349:g6652.
  4. Salluh JI, Wang H, Schneider EB, Nagaraja N, Yenokyan G, Damluji A, et al. Outcome of delirium in critically ill patients: systematic review and meta-analysis. BMJ. 2015 Jun 3;350:h2538.
  5. Israni J, Lesser A, Kent T, Ko K. Delirium as a predictor of mortality in US Medicare beneficiaries discharged from the emergency department: a national claims-level analysis up to 12 months. BMJ Open. 2018 May 5;8(5):e021258.
  6. Nederlandse Vereniging voor Intensive Care Wd. NVIC Richtlijn Delirium op de Intensive Care. 2010.  Via: https://nvic.nl/sites/nvic.nl/files/Richtlijnen%20aanmaken/NVIC-richtlijn-delirium-14-5-2010_0.pdf.
  7. van den Boogaard M, Slooter AJC, Bruggemann RJM, Schoonhoven L, Beishuizen A, Vermeijden JW, et al. Effect of Haloperidol on Survival Among Critically Ill Adults With a High Risk of Delirium: The REDUCE Randomized Clinical Trial. JAMA. 2018 Feb 20;319(7):680-90.

The literature refers to the Dutch text

Authors

  • dr H.J.E.M. Janssens