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

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.

Figure 1

Flow of Participants (N= 351) Through Study

Figure 2

Primary Outcomes of PMD: Coma/Delirium Free Days at Day 8 and Day 30 (A) and Change in Delirium Severity Scores at Day 8 and Discharge according to Delirium Rating Scale-Revised-1998 and the Confusion Assessment Method for the Intensive Care Unit-7 (B).