Mark van den Boogaard, Lisette Schoonhoven, Theo van Achterberg, Johannes G van der Hoeven, Peter Pickkers Critical Care 2013, 17:R9 (17 January 2013)
Introduction: Delirium is associated with increased morbidity and mortality. We implemented a delirium prevention policy in intensive care unit (ICU) patients with a high risk to develop delirium, and evaluated if our policy resulted in quality improvement of relevant delirium outcome measures.
Methods: A before/after evaluation of a delirium prevention project using prophylactic treatment with haloperidol. Patients with a predicted risk for delirium of [greater than or equal to]50%, or with a history of alcohol abuse or dementia, were identified. According to the prevention protocol these patients received haloperidol 1mg/8hrs. Evaluation was primarily focused on delirium incidence, delirium free days without coma and 28-day mortality. Results of prophylactic treatment were compared with a historical control group and a contemporary group that did not receive haloperidol prophylaxis mainly due to non-compliance to the protocol mostly during the implementation phase.
Results: In 12 months 177 patients received haloperidol prophylaxis. Except for sepsis, patient characteristics were comparable between the prevention and the historical (N=299) group. Predicted chance to develop delirium was 75+/-19% and 73+/-22%, respectively. Haloperidol prophylaxis resulted in a lower delirium incidence (65% vs. 75%, p=0.01), and more delirium-free-days (median 20 days [IQR 8-27] vs. median 13 days [3-27], p=0.003) in the intervention group compared to the control group. Cox-regression analysis adjusted for sepsis showed a hazard rate of 0.80 (95% confidence interval 0.66-0.98) for 28-day mortality. Beneficial effects of haloperidol appeared most pronounced in the patients with the highest risk for delirium. Furthermore, haloperidol prophylaxis resulted in less ICU re-admissions (11% vs. 18%, p=0.03) and unplanned removal of tubes/lines (12% vs. 19%, p=0.02). Haloperidol was stopped in 12 patients because of QTc-time prolongation (n=9), renal failure (n=1) or suspected neurological side-effects (n=2). No other side-effects were reported. Patients who were not treated during the intervention period (N=59) showed similar results compared to the untreated historical control group.
Conclusions: Our evaluation study suggests that prophylactic treatment with low dose haloperidol in critically ill patients with a high risk for delirium probably has beneficial effects. These results warrant confirmation in a randomized controlled trial. Trial registration: clinicaltrial.gov Identifier: NCT01187667.
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