In this episode of PRISM Rounds, we examine a new randomized clinical trial comparing olanzapine with low-dose dexmedetomidine for established delirium in critically ill adults.
The primary outcome was neutral: patients in both groups had a median of 3 days alive without delirium or coma. But the study also found more adverse events with dexmedetomidine and a provocative difference in 90-day mortality that demands careful interpretation.
We place these findings in the context of MIND-USA, AID-ICU, SPICE III, nocturnal dexmedetomidine studies, and the 2025 PADIS guideline update. The key issue is not simply which drug performed better, but whether ICU clinicians are asking medications to do different jobs: prevent delirium, control agitation, or actually treat established delirium.
We discuss what this trial adds, its major limitations, why the mortality signal should remain hypothesis-generating, and what the results should—and should not—change at the bedside.
Primary article:
https://doi.org/10.1093/ajrccm/aamag235
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PRISM Rounds, critical care, ICU, delirium, ICU delirium, dexmedetomidine, olanzapine, antipsychotics, sedation, agitation, PADIS, MIND-USA, AID-ICU, SPICE III, mechanical ventilation, intensive care medicine, pulmonary critical care, evidence based medicine, journal club, randomized controlled trial, FOAMcc, FOAMed
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