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Abstract

Introduction: Delirium in the intensive care unit (ICU) is associated with increased mortality and long term cognitive dysfunction. Recent guidelines provide recommendations for nonpharmacologic, but not pharmacologic prevention due to variable outcomes when antipsychotics are used for prevention. Importantly, the majority of this research was conducted in non-ICU patients. The purpose of this retrospective study is to evaluate the incidence of delirium in ICU patients who received antipsychotics. Methods: This was a single center retrospective cohort study. Patients admitted to medical, surgical, and cardiothoracic surgery ICUs who received either haloperidol or quetiapine and were Confusion Assessment Method for the ICU (CAM-ICU) negative upon initiation of either medication were included. Patients were divided into four groups: scheduled haloperidol, prn haloperidol, scheduled quetiapine, and prn quetiapine. The primary outcome measure was to compare the incidence and duration of delirium. Secondary outcome measures included: 1) characterization of adverse effects and 2) description of risk factors associated with delirium. Results:: Eighty patients were included in the study. The majority received either scheduled quetiapine (35%) or as needed haloperidol (55%) while 10% received prn quetiapine and no patients received scheduled haloperidol. APACHE II score was higher in the prn haloperidol group (17.1 vs 11.5 vs 14.0; p = 0.02). Incidence of delirium was 39% in the scheduled quetiapine group compared with 50% in the prn quetiapine group and 36% in the prn haloperidol group (p = 0.79). There was no difference in delirium-free days between groups (11.6 vs 8.7 vs 7.2; p = 0.15). The scheduled quetiapine group had a slightly longer time to first episode of delirium, but this was not statistically significant (11 days vs 4.8 days vs 5.6 days; p = 0.20). Hospital length of stay (LOS) was longer in the scheduled quetiapine group (27 days vs 15.1 days vs 15.5 days; p = 0.02). There was no difference in 30-day mortality (7.1% vs 12.5% vs 18.2%; p = 0.39) and incidence of QTc prolongation (34.8% vs 0% vs 22.2%; p = 0.22). In the multivariate analysis, ICU LOS was identified as a risk factor for delirium. Conclusions: There was no difference in overall incidence or duration of ICU delirium between scheduled quetiapine, prn quetiapine, or prn haloperidol. Safety outcomes, including mortality and QTc prolongation, were similar between groups. ICU LOS was associated with increased incidence of delirium. Additionally, longer hospital length of stay was observed with the use of scheduled quetiapine.