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Early Pharmacologic Treatment of Delirium May Reduce Physical Restraint Use: a Retrospective Study
Study Question: Does early initiation of pharmacologic delirium treatment vs. no treatment or delayed treatment reduce the number of days in physical restraints?
Study Description: This was a retrospective, single-center study conducted in a medical/surgical ICU of a tertiary community hospital. Patients with at least 1 positive delirium screen and on mechanical ventilation (MV) were eligible for inclusion. Patients who received a dose of a delirium treatment medication within 24 hours of the first positive screen were considered the “treatment” group and those who received a dose > 24 hours after the first positive screen or not at all were considered the “no-treatment” group. Medications considered clinically accepted for delirium treatment included quetiapine, olanzapine, risperidone, ziprasidone, haloperidol, and dexmedetomidine.
The primary outcomes were days spent in physical restraints and time to extubation after first positive delirium screen. Secondary outcomes included ICU and hospital length of stay (LOS), time to first delirium onset, presence of deliriogenic medications prior to a positive screen, survival to discharge, and discharge outcomes scores.
Results: A total of 200 patients were included in the study (treatment group n = 98, no-treatment group n = 102). Just under 18% of patients in the no-treatment group ultimately received treatment at a mean time of 100 (44-170) hours after first positive delirium screen. Duration of time in physical restraints after the first positive delirium score was 3 (1-12) days in the treatment group compared with 6 (1-21) days in the no-treatment group (p < 0.001) and median time to extubation was 3 (1-21) days vs. 6.5 (1-99) days (p < 0.001). ICU and hospital LOS and in-hospital mortality were significantly reduced and outcomes scores were significantly improved in the treatment group as compared to the no-treatment group.
Conclusion(s): Pharmacotherapy within 24 hours of the first positive delirium screen resulted in fewer days in physical restraints and MV compared with delayed or no treatment.
Perspective: This was the first study to assess early pharmacologic treatment for delirium as compared to no intervention or late intervention. Some of the study’s limitations include the lack of information on concomitant, deliriogenic medications, patients’ severity of illness throughout their ICU stay, and nonpharmacologic interventions used to reduce delirium. More patients in the treatment group had a hyperactive component to their delirium, perhaps contributing to the earlier initiation of treatment. Additional considerations for research in this area should better define the specific treatments and dosing strategies employed between groups, assess for treatment-related adverse effects, and include non-MV patients who are also at risk for developing delirium.