Critical Illness: Modifying the Impact of ICU-Associated Neurological Dysfunction–USA (Mind-USA)

Question 1

MIND-USA Clinical Q

Answer 1

Among critically ill patients with hypoactive or hyperactive delirium, does administration of the antipsychotic medications haloperidol or ziprasidone improve the number of days alive without delirium or coma when compared to placebo?

Question 2

MIND-USA Bottom Line

Answer 2

Among critically ill patients with hypoactive or hyperactive delirium, administration of the antipsychotic medications haloperidol or ziprasidone did not improve the number of days alive without delirium or coma when compared to placebo.

Question 3

MIND-USA Primary Outcome

Answer 3

Days alive without delirium or coma

Question 4

MIND-USA Inclusion Criteria

Answer 4

Age >18 years Medical/surgical ICU admission Requiring either NIPPV/Mechanical ventilation, vasopressors, or intra-aortic balloon pump Objectively confirmed delirium using the CAM-ICU

Question 5

MIND-USA Interventions

Answer 5

• Haloperidol: Haloperidol 1.25mg (>70 years old) or 2.5mg (<70 years old) IV q12h prn for 14 days or until discharged from ICU. Uptitrated if persistent delirium up to 20mg per day, downtitrated if no delirium.
• Ziprasidone: Ziprasidone 2.5mg (>70 years old) or 5mg (<70 years old) IV q12h prn for 14 days or until discharged from ICU. Uptitrated if persistent delirium up to 40mg per day, downtitrated if no delirium.
• Placebo :Patients were assessed every 12 hours for delirium using CAM-ICU and Richmond Agitation-Sedation Scale.

***If no delirium for 2 assessments, then half dose of antipsychotic. If no delirium for 4 assessments, then hold antipsychotic therapy. Stop if the patient develops torsades, NMS, DRESS, or new structural brain disease resulting in decreased level of consciousness

Question 6

MIND-USA Criticisms

Answer 6

-The high proportion with hypoactive delirium (90%) may have been less likely to benefit from antipsychotic medications compared to hyperactive delirium patients. -The use of ziprasidone in the ICU population is not as widespread compared to the atypical antipsychotic, quetiapine.