Critically ill patients do not benefit from the antipsychotic medications commonly used for four decades to treat delirium in the intensive care unit (ICU), according to a large, multi-site study published in the New England Journal of Medicine.
Rather, using an approach that uses the least amount of sedation while keeping the patient comfortable, involving the family and getting the patient moving around provides the most benefit.
Each year, more than 7 million patients in U.S. hospitals experience delirium, making them disoriented, withdrawn, drowsy or difficult to wake. The MIND USA (Modifying the INcidence of Delirium) study sought to determine whether typical and/or atypical antipsychotics — haloperidol or ziprasidone — affected patient delirium, survival, length of stay or safety.
“We found, after extensive investigation with medical centers all over the country, that the patients who get these potentially dangerous drugs are not experiencing any improvements whatsoever in delirium, coma, length of stay or survival,” said senior author E. Wesley Ely, MD, MPH, professor of Medicine at Vanderbilt University School of Medicine.
Researchers looked at the data of nearly 21,000 patients at 16 U.S. medical centers. Of the 1,183 patients on mechanical ventilation or in shock, 566 had become delirious and were randomly placed into groups to receive either intravenous haloperidol, ziprasidone, or placebo (saline).
The findings showed no significant difference in duration of delirium or coma among patients on haloperidol or ziprasidone compared to placebo. In addition, there were no notable differences among patients on either antipsychotic medication compared to placebo in 30-day and 90-day mortality or time on the ventilator, or in the ICU and hospital.
“Every day, there are many thousands of patients receiving unnecessary antipsychotics in the critical care setting that are bringing risk and cost without benefit with respect to the outcomes measured in this NIA-sponsored MIND-USA study,” said Ely, who is also associate director of Research for the VA Geriatric Research Education Clinical Center, and co-director of the CIBS (Critical Illness, Brain dysfunction, and Survivorship) Center at Vanderbilt University Medical Center.
Rather, the ICU Liberation Collaborative investigation, just released by the Society of Critical Care Medicine, details how to streamline the best care for critically ill patients in the ICU by using the ABCDEF Bundle (a memory tool to help clinicians follow best practices in the ICU. Each letter represents a type of care).
The research tracked 15,000 patients at 70 medical centers across the U.S. and found that higher performance of the ABCDEF bundle saved lives, reduced length of stay, reduced delirium and coma, hospital re-admissions and made patients less likely to be transferred to nursing homes, Ely said.
“In the ICU Liberation Collaborative investigation, we used a safety bundle much like what your airplane pilots use to help you get safely to your destination,” Ely said.
“We try and provide the least amount of sedation to keep people safe and comfortable in the ICU while also managing their delirium, involving their families, getting them mobilized and walking around.”