Prophylactic Peri-Extubation IV Haloperidol Regimen for Agitation in The MICU In At-Risk Patients: A Feasibility Project

Abstract: Background/Significance: In mechanically ventilated intensive care unit (ICU) patients, the peri-extubation period can be especially precarious due to subjective patient trauma and high resource utilization if complications occur. While D2 antagonists have been employed prophylactically based on delirium risk (1), and alpha-2 agonists have been used in ventilator weaning (2), we could not find any data on peri-extubation antipsychotics other than case reports (3). We sought to employ a prophylactic antipsychotic regimen specifically in the peri-extubation period to bridge patients at risk for agitation. We also emphasize a pragmatic, proactive, team-oriented approach, involving the entire ICU staff in patient identification.


Methods: This is an IRB-approved quality improvement project conducted at the University of Virginia Hospital. Starting in February 2022, all patients admitted to the medical ICU (MICU) who are mechanically ventilated are assessed for the risk of agitation during extubation. Risk is defined by clinician judgment (psychiatry and/or MICU primary team), including past or current history of agitation (peri-extubation or not) or documented hyperactive/mixed delirium. Nurses, pharmacists, and respiratory therapists also participated in identification and reported potentially at-risk patients to the team. Exclusion criteria include a haloperidol allergy or corrected QT interval (QTc) deemed to be inappropriately prolonged on a case by case basis. Once approved by the primary team and ready for extubation, patients were given a standardized haloperidol dosing regimen. The regimen consists of a prophylactic haloperidol 2.5mg IV dose during sedation weaning, followed by 2.5mg IV doses q30 minutes thereafter if agitation is present.



To assess for feasibility, our primary outcomes include usage of the haloperidol regimen (number of patients encounters using the regimen as a proportion of total MICU patient encounters given any antipsychotics) and safety (documented or reported adverse events such as QTc prolongation, hypotension, and extrapyramidal side effects). Secondary outcomes include: rate of re-intubation within 24 hours, Richmond Agitation Sedation Scale (RASS) score peri-extubation, use of physical restraints, and the amount of alternative anti-agitation medications used (dexmedetomidine, benzodiazepines, atypical antipsychotics). Contingent on statistical power, we will conduct a retrospective cohort comparison with patients prior to implementation of regimen.



Results
We anticipate completion by July 2022.



Discussion
We hope to demonstrate the feasibility of a proactive, team-based approach to agitation at a particularly vulnerable juncture in ICU care.



Conclusion
TBD





References
1. van den Boogaard M et al. Haloperidol prophylaxis in critically ill patients with a high risk for delirium. Crit Care.



2. Shehabi Y et al. The effect of dexmedetomidine on agitation during weaning of mechanical ventilation in critically ill patients. Anaesth Intensive Care.


3. Rosenthal LJ et al. Weaning from prolonged mechanical ventilation using an antipsychotic agent in a patient with acute stress disorder. Crit Care Med.