Haldol (Haloperidol) in the ICU: One-Minute Journal Club

Haldol is an antipsychotic that we frequently use in the ICU for delirium.
But the truth is that the data behind using it is not as robust as we would like.
Earlier today, there was a paper published in the NEJM that attempted to find its effects on delirium.
Hat tip to the authors. Read these data for yourself. Do not trust me.
This was a multicenter, blinded, placebo-controlled trial.
They enrolled 1000 ICU patients to receive haldol or placebo for delirium.
Both hyperactive and hypoactive delirium were recruited.
CAM-ICU was the primary tool used to diagnose delirium.
The dose was 2.5mg 3 times daily plus 2.5 mg as needed up to a total maximum daily dose of 20 mg.
Delirium is known to increase length of stay.
This is why the primary endpoint is days alive and out of the hospital at 90 days.
Well, there’s no difference.
Even adjusting for the subgroups there was no difference.
No difference was found in the secondary outcomes either.
At least it doesn’t cause harm.
What are we supposed to do now? Not give haldol in the ICU?
For additional studies on delirium CLICK HERE.

Haldol (Haloperidol) in the ICU for...
Haldol (Haloperidol) in the ICU for Delirium: One-Minute Journal Club

Citations

Andersen-Ranberg NC, Poulsen LM, Perner A, Wetterslev J, Estrup S, Hästbacka J, Morgan M, Citerio G, Caballero J, Lange T, Kjær MN, Ebdrup BH, Engstrøm J, Olsen MH, Oxenbøll Collet M, Mortensen CB, Weber SO, Andreasen AS, Bestle MH, Uslu B, Scharling Pedersen H, Gramstrup Nielsen L, Toft Boesen HC, Jensen JV, Nebrich L, La Cour K, Laigaard J, Haurum C, Olesen MW, Overgaard-Steensen C, Westergaard B, Brand BA, Kingo Vesterlund G, Thornberg Kyhnauv P, Mikkelsen VS, Hyttel-Sørensen S, de Haas I, Aagaard SR, Nielsen LO, Eriksen AS, Rasmussen BS, Brix H, Hildebrandt T, Schønemann-Lund M, Fjeldsøe-Nielsen H, Kuivalainen AM, Mathiesen O; AID-ICU Trial Group. Haloperidol for the Treatment of Delirium in ICU Patients. N Engl J Med. 2022 Oct 26. doi: 10.1056/NEJMoa2211868. Epub ahead of print. PMID: 36286254.
Link to NOT FREE Article

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Podcast Script.

Welcome to the Saving Lives Podcast, I’m eddyjoe. For historical context, today is the x of x of 2022 and the article I am going to be discussing today was published on October 26, 2022 in the NEJM. It is free for you to download so check out the link in the show notes. As always, this is not medical advice and you should not care for patients based on this podcast or video. The paper is titled “haloperidol for the treatment of delirium in ICU patients”. I feel the authors did a great job with this trial so a definite hat tip to them. At the end of my review of this article, I will address the comments and concerns shared after I posted my one minute breakdown of this article. There was no shortage of interest and comments which is why I wanted to break this one down a bit further.

In the introduction, the authors define delirium and the role of haloperidol which we all call by the brand name, Haldol. In epic I have a little favorites order set for different therapeutics used for delirium. We cannot forget, however, that the first thing about delirium is avoiding it occurring in the first place. The PADIS guidelines which are also free for one to download provide non-pharmacological strategies to avoid delirium from happening in the first place. That should be our goal. Maintaining sleep wake cycles, avoiding benzodiazepines, providing patients with their eyeglasses and hearing aids are amongst the strategies we can take to avoid delirium. That being said, it will still occur no matter what we do. After all, there’s nothing normal about the ICU and the things we do there.

The methods elaborate to us that this is a multicenter, blinded, parallel-group, placebo-controlled clinical trial. I don’t think the authors could have done any better. The study took place in ICU’s in Denmark, Finland, the United Kingdom, Italy, and Spain. They screened patients for enrollment using mostly the CAM-ICU score but they also used the ICDSC which is the Intensive Care Delirium Screening Checklist. If you don’t have these implemented in your ICU for daily rounding you should. Patients were randomized on a 1 to 1 ratio to either receive haldol or placebo. An important component to keep in mind is that they enrolled both hyperactive and hypoactive delirium.

How much haloperidol was provided?

When I first saw this study I was curious about this component the most. Patients who received placebo received, well, placebo. Those who received haldol received 2.5mg three times daily. If the patient needed a bit more, they could receive additional doses up to a total of 20mg per day. If that didn’t cut it, safety of the staff and patient were preserved with either propofol, benzos, or dexmedetomidine. The staff was not hung out to dry as many were concerned about in the comments section of my IG post.

In total, they recruited 491 patients into the haldol group and 472 in

Outcomes

The primary outcome was a composite outcome. I think I better start getting used to those although I don’t really like them. It was “the number of days alive and out of the hospital within 90 days after randomization.” I’ll go over the results of the primary outcome before moving over to the secondary outcomes. I