Delirium & Agitation
General Session
Robert Weinrieb, MD, FACLP
Chief Psychiatric Consultant, Program Director Consultation-Liaison Fellowship
Penn Transplant Institute
Philadelphia, PA
Lisa Rosenthal, MD, FACLP
Associate Professor
Northwestern University, Feinberg School of Medicine
Chicago, IL
Catherine Crone, MD, FACLP
Vice Chair of Education
Inova Fairfax Hospital
Falls Church, VA
James Levenson, MD, DFAPA, FACLP
Professor of Psychiatry
Virginia Commonwealth University
Richmond, VA
Background:
Antipsychotics have been used to treat agitation, delusions, and hallucinations in hospitalized patients for decades, despite limited data. A recently published study in the New England Journal of Medicine by Girard et al. asserted that haloperidol or ziprasidone are no better for the treatment of delirium than placebo in the Intensive Care Unit (ICU) setting (1). Although antipsychotics are not typically indicated for comatose or hypoactive patients, they comprised almost 90% of Girard et al.’s study patients, and opioids were given to almost 90% of study patients, as were benzodiazepines and propofol, which worsen delirium. Dexmedetomidine, also administered, could have obfuscated haloperidol or ziprasidone’s benefits. The editorial response to Girard et al.’s findings suggested the trial showed no benefit because the concept of delirium may be flawed, yet did not mention important design flaws (2). Subsequent to Girard et al., publications and news releases conveyed the ineffectiveness of haloperidol and some critical care practice guidelines no longer recommended haloperidol to manage delirium in the ICU (3).
Workshop:
Following Girard et al.’s conclusions, we hypothesized that the use of haloperidol or other neuroleptics to manage delirium in the ICU will diminish, whilst the use of deliriogenic medications to control agitation will increase, as will Dexmedetomidine, a non-deliriogenic sedative. Hence we initiated a retrospective, non-randomized review comparing prescribing practices in the ICUs of our respective institutions before and after publication of Girard et al.
The purpose of this symposium is to explore the rationale underlying the different approaches to delirium management by Psychiatry and Critical Care Medicine, with the goal of developing a unified best practice model.
Structure
- Dr. Weinrieb will introduce speakers and symposium objectives, and present a critical review of Girard et al. (15 min)
- Dr. Crone will review evidence for using neuroleptics to manage delirium in the ICU setting (15 min)
- Dr. Rosenthal will present our study, which seeks to identify changes in delirium management and adverse clinical outcomes associated with publication of Girard et al. (15 min)
- Dr. Levenson will summarize the symposium and propose a best practice model of delirium care (20 min)
- Conclusion: Discussion, Q and A (20 min).