Quetiapine in prolonged ICU delirium

Cardiopulmonary Arrest Following a Single 25 Mg Dose of Quetiapine: A Case Report

Introduction

Quetiapine is commonly used in intensive care units (ICU) to treat delirium. Cardiopulmonary arrest caused by low dose quetiapine is unreported. Only two cases in the literature have reported acute respiratory failure after single doses of 50mg and 100mg respectively. We report a case of cardiopulmonary arrest in a patient after the administration of a single 25mg dose of quetiapine.

Case presentation

A 72-year-old Chinese female with multiple cardiovascular co-morbidities was admitted to the ICU intubated, following complications from an elective endovascular repair of an infrarenal abdominal aortic aneurysm. She was alert and extubated the following day. She subsequently showed signs of delirium and was administered a single 25mg dose of oral quetiapine. Seven hours after ingestion, she developed type 2 respiratory failure and eventually cardiopulmonary arrest. She was successfully resuscitated and other causes for cardiopulmonary arrest were excluded. Twenty-four hours following her cardiopulmonary arrest, her respiratory failure had completely reversed and she was extubated uneventfully.

Conclusion

This case report demonstrates that a single dose of oral quetiapine 25mg is sufficient to cause respiratory failure and cardiopulmonary arrest. Caution is advised when prescribing quetiapine in the elderly, especially in those with impaired drug clearance.

Quetiapine in refractory hyperactive and mixed intensive care delirium: a case series

Introduction

Delirium affects up to 80% of patients admitted to intensive care units (ICUs) and contributes to increased morbidity and mortality. Haloperidol is the gold standard for treatment, although quetiapine has been successfully used in the management of delirium.

Methods

We conducted a retrospective study of patients admitted to the ICU between February 2008 and May 2010 who were prescribed quetiapine by the attending clinician. Data collected included demographics, history of drug and/or alcohol dependence, ICU and hospital length of stay, length of mechanical ventilation and the duration of treatment with sedatives and medications for delirium. The daily dose of quetiapine was recorded. Hyperactive or mixed delirium was identified by a validated chart review and a Richmond Agitation Sedation Scale (RASS) score persistently greater than 1 for 48 hours despite therapy.

Results

Seventeen patients were included. Delirium onset occurred after a median of five days. Patients were being given at least four agents for delirium prior to the introduction of quetiapine, and they had a median RASS score of 3. Quetiapine was initiated at a 25 mg daily dose and titrated to a median daily dose of 50 mg. The median duration of delirium prior to quetiapine therapy was 15 days. Quetiapine commencement was associated with a reduction in the need for other medications (within 0 to 6 days) and resolution of delirium within a median of four days. Adverse events included somnolence and transient hypotension.

Conclusions

This case series provides an initial effort to explore a possible role for quetiapine in the management of refractory hyperactive and mixed ICU delirium.