Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade

interruption, nurses stopped benzodiazepine and opiate infusions once a day and assessed hourly for

wakefulness (e.g., a light SAS or RASS score, plus ability to follow at least three commands).

Clinical outcomes (published 2012): There was no difference in the primary outcome of time to

successful extubation between the two groups (7 days in both groups). There was a significant

difference in time to extubation in the prespecified surgical/trauma group between sedation

protocol with daily sedation interruption and sedation protocol alone (6 vs. 13 days; hazard ratio

[HR] 2.55; 95% CI, 1.40–5.44). No difference in time to extubation was detected between groups

among medical ICU patients (9 vs. 8 days; HR 0.92; 95% CI, 0.72–1.18). However, significantly

lower daily doses of both benzodiazepines and opiates boluses and continuous infusions were

used in the sedation protocol–alone group than in the sedation protocol plus interruption group.

Although the sedation protocol suggested to target light sedation, the actual mean RASS/SAS was

not reported for either group making it unclear how deeply sedated either group was.

(ICDSC) was diagnosed in 53.8% of patients in the study; there was no difference in delirium

in the sedation protocol–alone group versus the protocol plus daily sedation interruption group.

Patients who had delirium had a longer duration of mechanical ventilation, longer ICU and hospital

stay, longer use of restraints, higher rates of tracheostomy, and higher incidence of unintentional

device removal. Patients with delirium received almost the twice the mean dose of midazolam

equivalents/patient/day (104 mg vs. 57 mg), higher fentanyl equivalents/patient/day (1497 mcg vs.

1150 mcg), more frequent use of anticholinergics (18 vs. 8.6%), and more frequent use of trazadone

or zopiclone (17.7 vs. 9.8%) than did patients who were not delirious. Patients who developed

delirium had a higher incidence of alcohol and cigarette use than did patients who did not develop

delirium.

Recall in ICU survivors (published 2015): The SLEAP investigator study did patient interviews on

days 3, 28, and 90 post-ICU discharge to determine differences in recall between the sedation-alone

protocol group and the protocol plus daily sedation interruption group. There were no differences in

type of recall between the sedation strategies. Delusional memories were common at day 28 (70%

of patients) but were unrelated to the presence of delirium or the total dose of benzodiazepines or

opiates. Patients with no recall had received lower total doses of benzodiazepines than had patients

with recall. Emotional memories such as panic and confusion declined over time.

Score

Term

Description

+4

Combative

Overtly combative or violent; immediate danger to staff

+3

Very agitated

Pulls on or removes tube(s) or has aggressive behavior toward staff

+2

Agitated

Frequently nonpurposeful movement or patient-ventilator dyssynchrony

+1

Restless

Anxious or apprehensive, but movements not aggressive or vigorous

Alert and calm

−1

Drowsy

Not fully alert but has sustained (> 10 s) awakening, with eye contact, to voice

−2

Light sedation

Briefly (< 10 s) awakens with eye contact to voice

−3

Moderate sedation

Any movement (but no eye contact) to voice

−4

Deep sedation

No response to voice, but any movement to physical stimulation

−5

Unarousable

No response to voice or physical stimulation