In This Edition
Literature At A Glance
A guide to this month’s studies
- Intravenous haloperidol does not prevent ICU delirium
- Predicting delirium risk in hospitalized adults
- Oral PPIs as effective as IV PPIs in peptic ulcer bleeding
- Probiotic benefit questioned in the elderly
- Colchicine and NSAID better than NSAID alone for acute pericarditis
- Improvement needed in patient understanding at hospital discharge
- Effectiveness of a multihospital effort to reduce rehospitalization
- Hospitals profit from preventing surgical site infections
- Prothrombin complex concentrate safer than fresh frozen plasma in rapidly reversing INR
- Hospital-acquired anemia associated with higher mortality, increased LOS
- Thrombolytics and stroke: the faster the better
Intravenous Haloperidol Does Not Prevent ICU Delirium
Clinical question: Can haloperidol reduce delirium in critically ill patients if initiated early in ICU stay?
Background: Prior studies suggest antipsychotics reduce intensity and duration of delirium in hospitalized patients. Evidence is mixed for preventing delirium. A trial of risperidone demonstrated delirium rate reduction in coronary artery bypass grafting (CABG) patients, but another trial of haloperidol in hip surgery patients failed to prevent onset of delirium. There is little evidence on antipsychotics in ICU delirium.
Study design: Randomized, double-blinded, placebo-controlled trial.
Setting: Single, adult ICU in England.
Synopsis: The study randomized 142 critically ill patients to receive 2.5 mg of intravenous haloperidol versus placebo every eight hours for up to 14 days. There was no significant difference between groups in the total time spent free of delirium or coma. Limitations include the use of open-label haloperidol in 21% of the placebo group patients. More sedation but less agitation was seen with the use of haloperidol, which also prolonged QTc. No severe adverse effects were observed.
This study supports the idea that scheduled antipsychotics should not be used to reduce ICU delirium. Addressing modifiable risk factors and using dexmedetomidine rather than lorazepam for sedation in the ICU continue to be first-line strategies to lower delirium rates.
Bottom line: Prophylactic haloperidol should not be used to prevent ICU delirium.
Citation: Page VJ, Ely EW, Gates S, et al. Effect of intravenous haloperidol on the duration of delirium and coma in critically ill patients (Hope-ICU): a randomized, double-blind, placebo-controlled trial. Lancet Respir Med. 2013;1(7):515-523.
Predicting Delirium Risk in Hospitalized Adults
Clinical question: Can a simple tool be developed and used for predicting delirium in hospitalized adults?
Background: Delirium is a common condition that results in higher mortality, longer length of stays, and higher probability of discharge to nursing home. Current delirium prediction tools are complicated, or restricted to surgical or critically ill patients.
Study design: Prospective cohort study, with separate derivation and validation cohorts.
Setting: Two academic hospitals and a VA hospital in San Francisco.
Synopsis: Investigators enrolled 374 hospitalized patients who were more than 50 years of age and not delirious at time of admission (209 patients in the derivation and 165 in the validation). The authors identified four predictors of delirium: Age >80; failure to spell “World” backwards; disOrientation to place; and higher nurse-rated iLlness severity (AWOL). The authors found that rates of delirium increased with increasing number of predictors (with zero predictors, 2% developed delirium; one predictor, 4%; two predictors, 14%; three predictors, 20%; four predictors, 64%).
These predictors are similar to other previously identified risk factors, as well as to prediction tools that are in use for surgical patients. However, this tool is quick and can be completed by nursing staff, so it may have a role to play in helping triage patients to units more specialized in preventing delirium.