Long-term outcomes with haloperidol versus placebo in acutely admitted adult ICU patients with delirium.

PURPOSE: We assessed long-term outcomes in acutely admitted adult patients with delirium treated in intensive care unit (ICU) with haloperidol versus placebo. METHODS: We conducted pre-planned analyses of 1-year outcomes in the Agents Intervening against Delirium in the ICU (AID-ICU) trial, including mortality and health-related quality of life (HRQoL) assessed by Euroqol (EQ) 5-dimension 5-level questionnaire (EQ-5D-5L) index values and EQ visual analogue scale (EQ VAS) (deceased patients were assigned the numeric value zero). Outcomes were analysed using logistic and linear regressions with bootstrapping and G-computation, all with adjustment for the stratification variables (site and delirium motor subtype) and multiple imputations for missing HRQoL values. RESULTS: At 1-year follow-up, we obtained vital status for 96.2% and HRQoL data for 83.3% of the 1000 randomised patients. One-year mortality was 224/501 (44.7%) in the haloperidol group versus 251/486 (51.6%) in the placebo group, with an adjusted absolute risk difference of - 6.4%-points (95% confidence interval [CI] - 12.8%-points to - 0.2%-points; P = 0.045). These results were largely consistent across the secondary analyses. For HRQoL, the adjusted mean differences were 0.04 (95% CI - 0.03 to 0.11; P = 0.091) for EQ-5D-5L-5L index values, and 3.3 (95% CI - 9.3 to 17.5; P = 0.142) for EQ VAS. CONCLUSIONS: In acutely admitted adult ICU patients with delirium, haloperidol treatment reduced mortality at 1-year follow-up, but did not statistically significantly improve HRQoL.

Haloperidol vs. placebo for the treatment of delirium in ICU patients: a pre-planned, secondary Bayesian analysis of the AID-ICU trial.

PURPOSE: The AID-ICU trial was a randomised, blinded, placebo-controlled trial investigating effects of haloperidol versus placebo in acutely admitted, adult patients admitted in intensive care unit (ICU) with delirium. This pre-planned Bayesian analysis facilitates probabilistic interpretation of the AID-ICU trial results. METHODS: We used adjusted Bayesian linear and logistic regression models with weakly informative priors to analyse all primary and secondary outcomes reported up to day 90, and with sensitivity analyses using other priors. The probabilities for any benefit/harm, clinically important benefit/harm, and no clinically important differences with haloperidol treatment according to pre-defined thresholds are presented for all outcomes. RESULTS: The mean difference for days alive and out of hospital to day 90 (primary outcome) was 2.9 days (95% credible interval (CrI) - 1.1 to 6.9) with probabilities of 92% for any benefit and 82% for clinically important benefit. The risk difference for mortality was - 6.8 percentage points (95% CrI - 12.8 to - 0.8) with probabilities of 99% for any benefit and 94% for clinically important benefit. The adjusted risk difference for serious adverse reactions was 0.3 percentage points (95% CrI - 1.3 to 1.9) with 98% probability of no clinically important difference. Results were consistent across sensitivity analyses using different priors, with more than 83% probability of benefit and less than 17% probability of harm with haloperidol treatment. CONCLUSIONS: We found high probabilities of benefits and low probabilities of harm with haloperidol treatment compared with placebo in acutely admitted, adult ICU patients with delirium for the primary and most secondary outcomes.

Use of Infrared Thermography in Diagnosing Necrotizing Fasciitis in the Emergency Department: A Case Study.

OBJECTIVE: Necrotizing fasciitis is a difficult diagnosis with a very high mortality. However, thermal imaging has the potential to identify increasing skin temperature and rapid progression. MATERIALS AND METHODS: We used repeat photographs taken with a thermal camera to visualize changes in skin temperature over time. RESULTS: An unstable male patient presented at the emergency department. Thermal imaging showed increased skin temperature of his left foot with a rapid increase and progression in extent within 1 hour. Necrotizing fasciitis was suspected and later confirmed. CONCLUSIONS: We believe thermal imaging could be an important adjunct for the diagnosis of suspected necrotizing fasciitis. LEARNING POINTS: Necrotizing fasciitis is a difficult diagnosis to make.Thermal imaging can visualize skin temperature and thus show increased temperature and extent.Rapid identification of necrotizing fasciitis is vital for patient survival.

Inter-Observer Agreement in Measuring Respiratory Rate.

BACKGROUND: Respiratory rate (RR) is an important vital sign which is strongly correlated with in-hospital mortality. At the same time, RR is the most likely vital sign to be omitted when assessing a patient. We believe that one reason for this could be the difficulty in measure the RR, since it is not read off a monitor, but counted manually. Also there is the possibility of assessment bias and the inter-observer reliability becomes important. We therefore set out to investigate how the nursing staff counting the actual number of respirations per minute would agree with the nursing staff using a predefined ordinal scale. METHODS: For this prospective study, we recorded five videos of a young healthy man breathing approximately 5, 10, 15, 30 and 60 times per minute. The videos were shown in a random order to a suitable sample of the nursing staff. The participants were randomized into two groups; one to count the exact number of breaths per minute, and one to use a predefined ordinal scale. RESULTS: Comparing the exact number of breaths per minute, the Intra Class Coefficient (ICC) was 0.99 (95% CI: 0.97-1.00). Comparing the RR using the predefined scale, the overall Kappa Fleiss Coefficient was 0.75. CONCLUSIONS: The inter-observer agreement was high when comparing the use of the actual number of breaths per minute and substantial when comparing the use of the predefined scale. This is the largest inter-observer study on RR to date. However, further studies on the use of scaled comparisons of RR are needed.

Adverse life events as risk factors for behavioural and emotional problems in a 7-year follow-up of a population-based child cohort.

BACKGROUND AND AIM: The aim of the study was to identify risk factors for significant changes in emotional and behavioural problem load in a community-based cohort of Danish children aged 9-16 years, the risk factors being seven parental and two child-related adverse life events. METHODS: Data on emotional and behavioural problems was obtained from parents filling in the Child Behavior Checklist (CBCL) when the child was 8-9 and again when 15 years old. Data on risk factors was drawn from Danish registers. Analysis used was logistic regression for crude and adjusted change. RESULTS: Parental divorce significantly raised the odds ratio of an increase in emotional and behavioural problems; furthermore, the risk of deterioration in problem behaviour rose significantly with increasing number of adverse life events. By dividing the children into four groups based on the pathway in problem load (increasers, decreasers, high persisters and low persisters), we found that children with a consistently high level of behavioural problems also had the highest number of adverse life events compared with any other group. CONCLUSIONS: Family break-up was found to be a significant risk factor. This supports findings in previous studies. The fact that no other risk factor proved to be of significance might be due to lack of power in the study. Children experiencing high levels of adverse life events are at high risk of chronic problem behaviour. Thus these risk factors should be assessed in daily clinical practice.