Interactive Cardiovascular and Thoracic Surgery 3:233-236(2004)
© 2004 European Association of Cardio-Thoracic Surgery
Best evidence topic - Cardiac general |
Is haloperidol or a benzodiazepine the safest treatment for acute psychosis in the critically ill patient?
Noman Khasatia,
Jacqueline Thompsonb and
Joel Dunningb,*
a Department of Cardiothoracic Surgery, Wythenshawe Hospital, South Moor Road, Manchester M23 9LT, UK
b Department of Cardiothoracic Surgery, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
* Corresponding author. Address: Department of Emergency Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK. Tel.: +44-780-154-8122; fax: +44-161-276-8538
joeldunning{at}doctors.org.uk
Received November 19, 2003;
accepted November 24, 2003
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Abstract
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A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether haloperidol or a benzodiazepine is the safest treatment for acute psychosis in the critically ill patient. Altogether 294 papers were found using the reported search, of which nine presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that haloperidol should be considered the first line drug for agitated patients post cardiac surgery, however lorazepam either alone or in conjunction with haloperidol is an acceptable alternative.
Key Words: Evidence-based medicine; Thoracic surgery; Haloperidol; Lorazepam; Diazepam
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1. Introduction
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A Best Evidence Topic was constructed according to a structured protocol. This protocol is fully described in the ICVTS [1].
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2. Clinical scenario
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It is 1 a.m. and you are the registrar on call. You are asked to see a 70 year old lady 3 days post aortic valve replacement. She is confused and agitated and is trying to pull out her central line. She has already removed her arterial line and is on the side of the bed demanding to see her husband and wanting to get her clothes to go home. Her pulse is 160 and she is in AF, her BP is 100/55 and her oxygen saturation is 92%. She has no past psychiatric history and the nurses are very keen to see her sedated as it is currently taking three people to keep her under control. You want to control her agitation but you are anxious that you may oversedate her or cause cardiac side effects as a result of additional drug administration. You wonder what is the optimal policy for sedation of this agitated lady.
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3. Three-part question
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In (patients in a high dependency setting) is (haloperidol or benzodiazepines) the safest treatment in (treating acute psychosis).
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4. Search strategy
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Medline 1966–Nov 2003 using the OVID interface
(exp haloperidol OR haloperidol.mp OR benzodiazepine.mp OR exp lorazepam OR lorazepam.mp or exp diazepam OR diazepam.mp) and (exp critical care OR exp critical illness/OR critically ill patient.mp. OR exp intensive care units/OR coronary care unit.mp OR cardiac surg$ unit.mp OR high dependency.mp).
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5. Search outcome
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Two hundred and ninety-four papers were found of which five papers were clinically relevant one of these papers summarised several case reports that were also found. In addition four more papers were found on checking reference lists [2–10]. These papers are presented in Table 1.
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6. Comment(s)
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The American College of Critical Care Medicine [5] has provided the highest quality review in this area. They conclude that the first line drug for acute agitation in the critical care environment is haloperidol and that cardiovascular side effects are rare. In addition they state that benzodiazepines may in fact exacerbate symptoms, although lorazepam is a safer second line drug than other benzodiazepines such as diazepam. However this guideline is mainly based on expert consensus in conjunction with case reports. Rao et al. [10] demonstrate the unacceptable cardiovascular side-effects with diazepam with an average 14% drop in cardiac output. Breitbart et al. [4] in a well conducted randomized controlled trial compared lorazepam and haloperidol in medically unwell AIDS patients. They found that haloperidol produced significantly better resolution of delirium and lorazepam invariably produced treatment limiting side-effects including increased confusion, disinhibition and ataxia. We could find no other papers that documented a poorer performance of lorazepam compared to haloperidol either in terms of side effects or resolution of delirium, and in fact Adams et al. [8] described the safe use of a combined policy of both drugs given together. This utilises the fact that lorazepam's onset of action is faster and allows a lower dose of haloperidol to be used. Tesar et al. [7,9] reported the safe use of haloperidol in doses of 100 mg per day or more in agitated patients post cardiac surgery and presents a protocol for its safe use, but the complication of Torsades de pointes is well documented. Hassaballa [2] reported 19 cases of Torsades after haloperidol and Huyse [6] reported a case of cardiac arrest after 7.5 mg of haloperidol. Tisdale [3] performed an interesting study that demonstrated that haloperidol always causes a prolonged QT interval and advocates cardiac monitoring and extra caution with a QT interval over 521 ms.
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7. Clinical bottom line
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Haloperidol should be considered the first line drug for agitated patients post cardiac surgery, however lorazepam either alone or in conjunction with haloperidol is an acceptable alternative.
doi:10.1016/j.icvts.2003.11.005
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References
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- Dunning J, Prendergast B, Mackway-Jones K. Towards evidence-based medicine in cardiothoracic surgery: best BETS. Interac Cardiovasc Thorac Surg. 2003;2:405–409[Abstract/Free Full Text]
- Hassaballa HA, Balk RA. Torsade de pointes associated with the administration of intravenous haloperidol [Review] [29 refs]. Am J Ther. 2003;10:58–60[CrossRef][Medline]
- Tisdale JE, Rasty S, Padhi ID, Sharma ND, Rosman H. The effect of intravenous haloperidol on QT interval dispersion in critically ill patients: comparison with QT interval prolongation for assessment of risk of Torsades de Pointes [erratum appears in J Clin Pharmacol 42(5):577–9]. J Clin Pharmacol. 2002;41:1310–1318
- Breitbart W, Platt MM, Deverenco M, Grau C, Corbera K, Raymond S, Lund S, Jacobson P. A double-blind trial of haloperidol, chlorpromazine, and lorazepam in the treatment of delirium in hospitalized AIDS patients. Am J Psychiat. 1996;153:231–237[Abstract/Free Full Text]
- Shapiro BA, Warren J, Egol AB, Greenbaum DM, Jacobi J, Nasraway SA, Schein RM, Spevetz A, Stone JR. Practice parameters for intravenous analgesia and sedation for adult patients in the intensive care unit: an executive summary. Soc Crit Care Med [comment]. Crit Care Med. 1995;23:1596–1600
- Huyse F, van Schijndel RS. Haloperidol and cardiac arrest. Lancet. 1988;2:568–569[Medline]
- Tesar GE, Stern TA. Rapid tranquilization of the agitated intensive care unit patient. J Intensive Care Med. 1988;3:195–201[Abstract/Free Full Text]
- Adams F. Emergency intravenous sedation of the delirious, medically ill patient. J Clin Psychiat. 1988;49(Suppl 7):
- Tesar GE, Murray GB, Cassem NH. Use of high-dose intravenous haloperidol in the treatment of agitated cardiac patients. J Clin Psychopharmacol. 1985;5:344–347[Medline]
- Rao S, Sherbaniuk RW, Prasad K, Lee SJ, Sproule BJ. Cardiopulmonary effects of diazepam. Clin Pharmacol Ther. 1973;14:182–189[Medline]
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Abstract
1. Introduction