ICU use of haloperidol prior to the 2002 SCCM sedation and analgesia guidelines

Introduction

Delirium occurs in as many as 80% of mechanically ventilated (MV) medical intensive care unit (ICU) patients and is associated with poor outcomes. MV patients spend 43% of all ICU days in delirium, while all patients who become delirious spend about 25% of their ICU days in delirium. The 2002 SCCM sedation and analgesia guidelines call for routine delirium screening and treatment with haloperidol. We sought to understand whether these guidelines represented a change from current practice by examining haloperidol use in the ICUs of a large tertiary care academic medical center.

Hypothesis

We hypothesize that: (1) haloperidol is the most commonly used antipsychotic medication in our ICUs, and (2) use of haloperidol in patients receiving MV > 48 hours is significantly less than 80% (the rate of delirium in MV patients reported in the literature).

Methods

From 1 July 2000 to 30 June 2001 we prospectively collected data for all patients admitted to any ICU at the University of Pittsburgh Medical Center, a tertiary care academic medical center with over 120 ICU beds serving medical, surgical, trauma, neuro, and solid-organ transplant patients. We calculated overall rates of treatment with any antipsychotic and generated mean total and daily dose for those who received haloperidol.

Results

There were 5592 ICU patients incurring 6033 hospitalizations and 6758 ICU admissions during the study period. Of all hospitalizations, 60.4% required mechanical ventilation and 11.9% received an antipsychotic in the ICU. Haloperidol was the most frequently used antipsychotic (79.5% of all administered doses), with risperidone (4.7%) and olanzapine (2.3%) the next most common. Haloperidol was given to 24.9% of MV > 48 hours patients and on 6.9% of all ICU days. MV > 48 hours patients received mean (SD) daily haloperidol dose of 10.2 (9.5) mg for 5.8 (8.0) days, or 24.0% of their ICU days.

Conclusions

Only one in four MV > 48 hours ICU patients received haloperidol. When used, however, the haloperidol dose and duration seemed to be appropriate. Either we do not appropriately treat the majority of delirious patients and the SCCM guidelines represent a significant departure from existing clinical practice, or ICU delirium is not as common as the literature suggests. Further study is needed to define the incidence of ICU delirium in all ICU patient populations and to evaluate the impact of treatment with haloperidol on outcomes of critical care.