Delirium during intensive care unit (ICU) stay is frequent and associated with significant morbidity, mortality and healthcare-related costs. International guidelines suggest its prevention. However, curative treatment remains unclearly established. Despite contradictory and ambiguous academic literature, international guidelines suggest the use of second-generation (atypical)
antipsychotics over
haloperidol. However,
haloperidol remains the most widely used
neuroleptic worldwide as a first-line treatment of agitation and/or
delirium.
Dexmedetomidine, an alpha2-adrenergic receptors agonist, has shown its efficiency in the treatment of
delirium in intubated patients but also in its prevention.
Dexmedetomidine represents a widely used alternative to
haloperidol. Only few studies have compared the efficacy of
dexmedetomidine in non-intubated ICU patients as a first-line curative treatment of
delirium. The main objective of the 4D trial is to demonstrate that
dexmedetomidine decreases
delirium duration compared to placebo.
METHODS/DESIGN: The 4D trial is an investigator-initiated, prospective, multicenter, randomized, double-blinded, two-arm trial, randomizing 300 non-intubated ICU patients with a diagnosis of agitated
delirium to receive
dexmedetomidine or placebo as a cure. In case of agitation (RASS≥ + 2), immediate
haloperidol administration will be allowed, to protect patient and staff in charge, while waiting for study treatment action. The primary outcome measure is a composite of duration of agitation or
delirium or the use of intubation with
deep sedation and
mechanical ventilation. Secondary outcomes include mortalities at 7 and 30 days, ICU
length of stay and occurrence of adverse effects related to
dexmedetomidine use (
bradycardia or
hypotension requesting any treatment; or
haloperidol use (
neuroleptic malignant syndrome, extrapyramidal syndrome, prolonged QTc). The sample size will allow the detection of a 50% decrease of agitation duration (120 min), of an absolute reduction of
delirium duration (1 day) and of a 50% relative decrease of intubation and
mechanical ventilation, with a type 1 error rate of 1.8% (error risk inflation due to components of composite) and power of 90%, assuming a 15% incidence of intubation and
mechanical ventilation requirements, an agitation duration of 240 min and a
delirium duration of 3 days. One hundred and ten patients by group will be needed. An intermediate analysis is scheduled and requires the inclusion of 150 patients.
DISCUSSION: ClinicalTrials.gov , ID: NCT 03317067 . Registered on 23 October 2017.