Title: Impact of Early Resumption of Neuropsychiatric Medications on Sedation Outcomes in Critically Ill Patients Authors: Jade Gallahair, Victoria Biaggi, Morgan Turney, Joseph Trang
Background: Delirium and agitation are common in critically ill adults and are associated with increased mortality, prolonged ventilation, and longer ICU and hospital stays. Withdrawal from chronic neuropsychiatric medications (NPMs), including SSRIs, SNRIs, benzodiazepines, antipsychotics, and gabapentinoids is a potentially modifiable contributor. Abrupt discontinuation may precipitate withdrawal symptoms such as anxiety, restlessness, insomnia, and psychosis, which can manifest as agitation or delirium in the ICU. Although emerging evidence suggests that early reinitiation of home NPMs may improve sedation and delirium outcomes, existing studies show mixed results, and no standardized guideline informs optimal timing. Additional evaluation is needed to clarify the clinical impact of early NPM resumption. The primary objective of this study is to determine whether early resumption of home neuropsychiatric medications reduces the incidence of agitation within the first 72 hours of ICU admission compared with delayed or no resumption.
Methods: This multicenter retrospective observational cohort study assessed critically ill adults admitted to the ICU who were receiving chronic neuropsychiatric medications prior to hospitalization, focusing on patterns of agitation and timing of medication resumption. Patients were assigned to early initiation (£72 hours) or late initiation (>72 hours or not restarted during ICU stay) groups based on timing of NPM resumption upon ICU admission. The primary endpoint was incidence of agitation, defined as a Richmond Agitation Sedation Scale (RASS) score of +2 to +4 within the first 72 hours of ICU admission. Secondary outcomes included incidence of delirium, duration of mechanical ventilation, new start NPM during ICU admission, hospital length of stay and mortality.
Results: Among the 101 patients initially reviewed, 52 individuals were excluded. A total of 49 patients were included in the final analysis, with 33 patients in the early restart group and 16 patients in the late or no restart group. Differences in baseline home medication classes were also observed, with fewer patients in the early start group prescribed benzodiazepines (21.2% vs 50%; p=0.040). There was no statistically significant difference in the incidence of agitation with 54.5% occurrence in the early start group and 68.8% in the late start (p=0.343). Secondary outcomes were similar between groups for mortality, incidence of delirium, new initiation of neuropsychiatric medications, duration of mechanical ventilation, and hospital length of stay. ICU length of stay was longer in the early start group (14.65 days vs 11.00 days; p=0.023).
Conclusion: In this retrospective cohort study of critically ill adults with preexisting neuropsychiatric medication use, early resumption of home NPMs within 72 hours of ICU admission did not significantly reduce the incidence of agitation compared with delayed or no resumption. Notably, patients in the early restart group experienced a longer ICU length of stay, and baseline differences in home medication classes specifically benzodiazepines were observed between groups.
