Tackling agitated delirium--the tip of the iceberg.

Reade et al. studied 20 agitated intubated patients in a pilot open-label trial comparing the efficacy of dexmedetomidine versus haloperidol in facilitating extubation. While the study design had limitations, which are outlined by the authors themselves in the paper published in this issue of Critical Care, the study demonstrated an impressive reduction in time to extubation and length of stay. Dexmedetomidine is a promising sedative agent that acts via alpha2-receptors and has been shown to decrease prevalence and duration of delirium in mechanically ventilated patients. Haloperidol is the recommended and standard drug to treat delirium, largely based on large case series and reports. Delirium is a common, underdiagnosed and serious problem in intensive care unit patients. Agitated delirious patients are at risk of immediate adverse events as well as prolonged respiratory support. All delirious patients are at risk of poor cognitive outcomes. Further research is needed into the pharmacological management of delirium, including the use of dexmedetomidine in the management of agitation and the clinical efficacy of haloperidol.