Pharmacologic Management of Intensive Care Unit Delirium: Clinical Prescribing Practices and Outcomes in More Than 8500 Patient Encounters.
Pharmacologic Management of Intensive Care Unit Delirium: Clinical Prescribing Practices and Outcomes in More Than 8500 Patient Encounters.
复制标题
重症监护病房谵妄的药理学管理：8500多名患者的临床处方实践和结果。
DOI：
10.1213/ane.0000000000005365
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发表时间：
2021-09-01
影响因子：
5.7
通讯作者：
Hughes CG
中科院分区：
文献类型：
--
作者：
Boncyk CS;Farrin E;Stollings JL;Rumbaugh K;Wilson JE;Marshall M;Feng X;Shotwell MS;Pandharipande PP;Hughes CG
药物常用于重症监护室（ICU）谵妄的管理，但处方模式和药物选择对患者结局的影响描述不多。我们试图描述ICU谵妄管理的处方实践，并调查药物选择与关键院内结局的独立相关性，包括谵妄消退、院内死亡率、存活天数和脱离ICU或医院的天数。一项对三级学术医疗中心成人ICU谵妄患者的回顾性研究。通过电子健康记录获得关于日常精神状态（正常、谵妄、昏迷）、药物治疗、住院过程和存活率的数据。在调整预先指定的协变量后，构建每日转换模型以评估前一天精神状态和药物给药对第二天精神状态和住院死亡率的独立关联。线性回归模型研究了在ICU入院后的前30天内，存活和离开ICU或医院的天数与药物给药的相关性。我们确定了8591次ICU谵妄。一半（45.6%）的患者接受药物治疗谵妄，包括45.4%接受抗精神病药，2.2%胍法辛和0.84%丙戊酸。开始接受药物治疗的患者的中位最高里士满躁动-镇静量表（RASS）评分为1 [0，1]，未接受药物治疗的患者为0 [-1，0]。氟哌啶醇、奥氮平和奎替卡松占使用的抗精神病药物的97%以上，48%接受两种或两种以上，20.6%在出院时继续服用抗精神病药物。氟哌啶醇和奥氮平与持续性谵妄的几率更大相关（OR分别为1.48，95% CI [1.30，1.65]，p<0.001和OR 1.37，95% CI [1.20，1.56]，p=0.003）和院内死亡风险增加（分别为HR 1.46，95%CI [1.10，1.93]，p=0.01和HR 1.67，95%CI [1.14，2.45]，p=0.01），而奎硫平显示院内死亡率风险降低（HR 0.58，95%CI [0.40，0.84]，p=0.01）。氟哌啶醇、奥氮平和奎替利与存活天数和无住院相关（均p<0.001）。任何抗精神病药物与存活和脱离ICU的天数均无显著相关性。胍法辛和丙戊酸均与住院结果无关。药物干预治疗ICU谵妄是常见的，最常见的是抗精神病药物，并经常在出院时继续。这些药物可能不会带来益处，可能会带来额外的伤害，因此应谨慎用于谵妄管理。在住院和出院期间继续使用这些药物会引起对其安全性和在患者康复中的作用的质疑。不适用
Pharmacologic agents are frequently utilized for management of intensive care unit (ICU) delirium, yet prescribing patterns and impact of medication choices on patient outcomes are poorly described. We sought to describe prescribing practices for management of ICU delirium and investigate the independent association of medication choice on key in-hospital outcomes including delirium resolution, in-hospital mortality, and days alive and free of the ICU or hospital. A retrospective study of delirious adult ICU patients at a tertiary academic medical center. Data was obtained regarding daily mental status (normal, delirious, comatose), pharmacologic treatment, hospital course, and survival via electronic health record. Daily transition models were constructed to assess the independent association of prior day mental status and medication administration on mental status the following day and in-hospital mortality, after adjusting for pre-specified covariates. Linear regression models investigated the association of medication administration on days alive and free of the ICU or the hospital over the first 30-days following ICU admission. We identified 8591 encounters of ICU delirium. Half (45.6%) of patients received pharmacologic treatment for delirium, including 45.4% receiving antipsychotics, 2.2% guanfacine, and 0.84% valproic acid. Median highest Richmond Agitation-Sedation Scale (RASS) score was 1 [0, 1] in patients initiated on medications and 0 [−1, 0] for non-recipients. Haloperidol, olanzapine, and quetiapine comprised > 97% of antipsychotics utilized with 48% receiving two or more and 20.6% continued on antipsychotic medications at hospital discharge. Haloperidol and olanzapine were associated with greater odds of continued delirium (OR 1.48, 95% CI [1.30, 1.65], p<0.001 and OR 1.37, 95% CI [1.20, 1.56], p=0.003, respectively) and increased hazard of in-hospital mortality (HR 1.46, 95% CI [1.10, 1.93], p=0.01 and HR 1.67, 95% CI [1.14, 2.45], p=0.01, respectively) while quetiapine showed a decreased hazard of in-hospital mortality (HR 0.58, 95% CI [0.40, 0.84], p=0.01). Haloperidol, olanzapine, and quetiapine were associated with fewer days alive and free of hospitalization (all p<0.001). There was no significant association of any antipsychotic medication with days alive and free of the ICU. Neither guanfacine nor valproic acid were associated with in-hospital outcomes examined. Pharmacologic interventions for management of ICU delirium are common, most often with antipsychotics, and frequently continued at hospital discharge. These medications may not portend benefit, may introduce additional harm, and should be used with caution for delirium management. Continuation of these medications through hospitalization and discharge draws into question their safety and role in patient recovery. Not applicable