What is the recommended dose of haloperidol (antipsychotic) for Intensive Care Unit (ICU) psychosis and Post-Traumatic Stress Disorder (PTSD)?

Haloperidol Dosing for ICU Delirium

Despite widespread use in clinical practice, there is no published evidence that haloperidol reduces the duration of delirium in ICU patients, and current guidelines do not recommend routine use of haloperidol for either prevention or treatment of ICU delirium. 1

Evidence-Based Recommendations

For ICU Delirium Treatment

When haloperidol is used off-label for ICU delirium (despite lack of evidence), the typical dosing range is IV haloperidol 1-10 mg every 2 hours as needed. 1

• This dosing was documented in a small trial where patients received IV haloperidol 1-10 mg every 2 hours PRN for delirium unrelated to alcohol or benzodiazepine withdrawal 1
• No high-quality studies demonstrate that haloperidol actually reduces delirium duration or improves mortality/morbidity in ICU patients 1
• Most critical care specialists continue to use antipsychotics for delirious patients despite the lack of robust evidence 1

Important Safety Considerations

Haloperidol should be withheld in patients at significant risk for torsades de pointes, including those with baseline QT prolongation, concurrent QT-prolonging medications, or history of this arrhythmia. 1

Alternative Approach: Atypical Antipsychotics

Quetiapine may be superior to haloperidol for reducing delirium duration, starting at 50 mg every 12 hours and increasing by 50 mg increments as needed. 1

• In one small randomized trial (n=36), quetiapine added to haloperidol reduced delirium duration compared to placebo 1
• Quetiapine was initiated at 50 mg every 12 hours and increased by 50 mg if more than one dose of haloperidol was required in the previous 24 hours 1

Haloperidol is NOT Indicated for PTSD

Haloperidol has no established role in treating PTSD and should not be used for this indication. The question appears to conflate ICU delirium (sometimes called "ICU psychosis") with PTSD, which are distinct conditions requiring different management approaches.

First-Line Non-Pharmacologic Approach

Early mobilization should be implemented as the primary intervention to reduce ICU delirium incidence and duration, rather than relying on antipsychotics. 1

• Multicenter trials demonstrate that early mobilization reduces delirium incidence, depth of sedation, and ICU/hospital length of stay while increasing ventilator-free days 1
• This approach is unlikely to cause harm and may reduce hospital costs 1

Critical Pitfalls

• Do not use haloperidol or atypical antipsychotics prophylactically to prevent delirium in ICU patients, as no benefit has been demonstrated 1
• Do not use rivastigmine for ICU delirium, as a multicenter trial was stopped early due to longer/more severe delirium and trend toward higher mortality 1
• Monitor QT interval if haloperidol is used, particularly with concurrent medications that prolong QT 1

Context from Emergency/Acute Psychosis Settings

For reference, in acute psychotic emergencies (not ICU delirium), parenteral haloperidol dosing ranges from 5-10 mg IM, with the 5 mg dose showing superior efficacy to lower doses 1, 2, 3, 4. However, these doses are for acute psychosis management, not ICU delirium, which lacks evidence for haloperidol efficacy entirely. 1