Impact of Early Reinitiation of Neuropsychiatric Medications on Agitation and Delirium in the Intensive Care Unit: A Retrospective Study

Abstract

Background: Approximately 17% of intensive care unit (ICU) patients are prescribed at least 1 home neuropsychiatric medication (NPM). When abruptly discontinued, withdrawal symptoms may occur manifesting as agitation or delirium in the ICU setting. Objective: To evaluate the impact of early reinitiation of NPMs. Methods: This was a retrospective, observational cohort of adult ICU patients in a tertiary care hospital. Patients were included if admitted to the ICU and prescribed a NPM prior to arrival. Study groups were based on the timing of reinitiation of at least 50% of NPMs: ≤72 hours (early group) versus >72 hours (late group). Results: The primary outcome was the proportion of patients with at least 1 agitation or delirium episode in the first 72 hours. Agitation and delirium were defined as at least 1 RASS assessment between +2 to +4 and a positive CAM-ICU assessment, respectively. A total of 300 patients were included, with 187 (62%) and 113 (38%) in the early and late groups, respectively. There was no difference in agitation or delirium (late 54 [48%] vs early 62 [33%]; adjusted odds ratio [aOR] = 1.5; 95% CI = 0.8-2.8; P = 0.193). Independent risk factors found to be associated with the primary outcome were restraints (aOR = 12.9; 95% CI = 6.9-24.0; P < 0.001) and benzodiazepines (BZDs; aOR = 2.0; 95% CI = 1.0-3.7; P = 0.038). Conclusions: After adjustment for baseline differences, there was no difference in agitation or delirium. Independent risk factors were restraint use and newly initiated BZDs.

Prevenção primária de delirium em idosos sob terapia intensiva: uma revisão integrativa

“…A amostragem desse estudo consistiu em 1.789 pacientes com média de idade de 66,6 anos, e apresentou que o haloperidol teve desempenho semelhante ao placebo para esse objetivo. Também, uma coorte retrospectiva (Cucci et al, 2021) com 300 pessoas de média de idade 65,3 anos, objetivou avaliar se o período de tempo após admissão em UTI em que se reiniciava o uso de medicações neuropsiquiátricas teria influência sobre a incidência de delirium. Encontrou-se que a administração desses fármacos antes ou após três dias de internação não apresentaram diferença quanto ao aparecimento de novos casos de delirium.…”

Concise Definitive Review for Reinitiation of Antidepressants, Antipsychotics, and Gabapentinoids in ICU Patients

“…Other considerations include the product formulation, enteral access for administration, and presence of additional NPMs. Additionally, considerations for potential drug interactions, organ dysfunction, and adverse drug reactions should be assessed (13, 22).…”

“…Early reinitiation (within 24 hr) of NPM was not associated with a difference in new-start antipsychotics, the use of restraints, or ICU length of stay; however, early initiation of NPMs was associated with a shorter hospital length of stay (6.5 vs 8.6 d; p = 0.048) (24). Only 10–15% of patients included in other studies of NPM reinitiation were taking preexisting antipsychotics (13, 17).…”

“…There was also a lower occurrence of delirium with early NPM reinitiation (17% vs 43%; p = 0.02). Cucci et al (13) performed a retrospective cohort study in ICU patients on a variety of NPMs, including SSRIs, SNRIs, and serotonin modulators. Although early reinitiation within 72 hours was associated with a lower composite outcome of agitation or delirium by an unadjusted analysis (33% vs 48%; unadjusted odds ratio [OR], 1.8; 95% CI, 1.1–3; p = 0.012), there was no difference after adjustment for baseline differences (adjusted OR, 1.5; 95% CI, 0.8–2.8; p = 0.193) (13).…”

“…Weaning sedation and analgesia prior to extubation can be equally challenging in this patient population (12). How preexisting conditions and NPMs interplay with ICU analgosedation strategies, delirium, and recovery from critical illness is largely unknown (13). Emerging studies are beginning to provide some insights on this clinical dilemma.…”