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

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

Maternal Mortality in a Tertiary Care Centre in Nepal

Introduction: Nepal has one of the highest maternal mortality rates. Aims and objective: To identify the maternal deaths and identify the causes and key risk factors. Method: A retrospective (descriptive) study was carried out at BPKIHS by analyzing the case sheets of all maternal deaths of four years (April 1998- March 2002). The cause of death and the factors that may have indirectly contributed to death were noted. Results: The total number of deaths during these four years was forty-four, with 61.4% of patients being multigravid and 96.5% unbooked. More than 85% of patients reported from periphery. The majority (93.18%) of deaths were due to direct causes. The most common cause of maternal death was sepsis (43.18%) of which septic abortion was the leading cause (27.27%). Hypertensive disorders accounted for 29.54% of deaths and out of these, eclampsia was the leading disorder. Haemorrhage accounted for 13.66% of deaths. There were two cases of rupture uterus (4.5%) Anaemia was found in 29.54% of cases and it may have contributed indirectly to maternal mortality. Three deaths (6.8%) were due to medical causes. Conclusion: Preventable causes accounted for majority of deaths. Septic induced abortion and eclampsia together accounted for more than 50 % of deaths. The non-availability of safe abortion services, the mountainous terrain, lack of good primary /district level hospitals and poor transport facility seem to be the most important reasons for most maternal deaths in our study. Key Words: Maternal Mortality, Nepal. [Trop J Obstet Gynaecol, 2004; 21:168-171