Haloperidol prophylaxis in critically ill patients with a high risk for delirium

Abstract

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 of developing delirium, and evaluated if ourpolicy resulted in quality improvement of relevant delirium outcome measures.
Methods: This study was a before/after evaluation of a delirium prevention project using prophylactic treatment
with haloperidol. Patients with a predicted risk for delirium of ? 50%, or with a history of alcohol abuse or
dementia, were identified. According to the prevention protocol these patients received haloperidol 1 mg/8 h.
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) groups. 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 to 27) vs. median 13 days (3 to 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 to 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.

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Identifiers

ORCID for Lisette Schoonhoven: orcid.org/0000-0002-7129-3766

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