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J Am Geriatr Soc. 2019 May;67(5):1057-1065. doi: 10.1111/jgs.15781. Epub 2019 Jan 25.

Pharmacological Management of Delirium in the Intensive Care Unit: A Randomized Pragmatic Clinical Trial.

Author information

1
Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana.
2
Indiana University Center for Aging Research, Indianapolis, Indiana.
3
Regenstrief Institute, Inc, Indianapolis, Indiana.
4
Sandra Eskenazi Center for Brain Care Innovation at Eskenazi Health, Indianapolis, Indiana.
5
Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafayette, Indiana.
6
Department of Psychiatry, Indiana University School of Medicine, Indianapolis, Indiana.
7
Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana.

Abstract

BACKGROUND/OBJECTIVE:

Delirium in the intensive care units (ICUs) is prevalent, with both delirium duration and delirium severity associated with adverse outcomes. We designed a pragmatic trial to test the efficacy of a pharmacological management of delirium (PMD) bundle in improving delirium/coma-free days and reducing delirium severity among ICU patients.

DESIGN:

A randomized pragmatic clinical trial.

SETTING:

Medical, surgical, and progressive ICUs of three tertiary care hospitals.

PARTICIPANTS:

A total of 351 critically ill patients.

INTERVENTION:

A multicomponent PMD bundle consisting of reducing the exposure to 20 definite anticholinergic medications and benzodiazepines and prescribing low-dose haloperidol.

MEASUREMENTS:

The primary outcomes were delirium/coma-free days, measured through the Richmond Agitation-Sedation Scale and the Confusion Assessment Method for the ICU (CAM-ICU), and delirium severity, measured through Delirium Rating Scale-Revised-98 and the CAM-ICU-7. Secondary outcomes were in-hospital and posthospital discharge 30-day mortality, ICU and hospital lengths of stay, and delirium-related hospital complications.

RESULTS:

We randomized 351 critically ill delirious patients (mean age = 59.3 years [SD = 16.9 years]; 52% female, 42% African Americans) to receive the PMD bundle or usual care. There were no significant differences in median delirium/coma-free days at day 8 (PMD vs usual care = 4 [interquartile range {IQR} = 2-7] days vs 5 [IQR = 1-7] days; P = .888) or at day 30 (PMD vs usual care = 26 [IQR 19-29] days vs 26 [IQR, 14-29] days; P = .991). There were no significant differences for decrease in delirium severity at day 8, but at hospital discharge, the intervention group showed a greater reduction in delirium severity (mean decrease in CAM-ICU-7 score for PMD vs usual care = 3.2 [SD = 3.3] vs 2.5 [SD = 3.2]; P = .046). No differences were observed between groups for ICU and hospital lengths of stay, mortality, and delirium-related hospital complications. Similar results were observed when analyses were limited to patients 65 years or older and 75 years or older.

CONCLUSION AND RELEVANCE:

Implementing the PMD bundle in the ICU did not reduce delirium duration or severity among critically ill patients.

TRIAL REGISTRATION:

clinicaltrials.gov Identifier: NCT00842608. J Am Geriatr Soc 67:1057-1065, 2019.

KEYWORDS:

benzodiazepine; delirium; haloperidol; randomized trial

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