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Delirium in the intensive care unit (ICU) is common and is associated with bad outcomes especially in mechanically ventilated patients with acute lung injury.1-5 While several interventions have shown that goal-directed sedation, use of bolus dosing vs. infusion, use of daily interruption, and the use of the “analgesia alone” approach decreases the duration of mechanical ventilation and ICU length of stay, no study has shown a reduction in ICU delirium. 6-9

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A recently published study10 sought to decrease the use of sedatives and delirium in acute lung injury patients through implementation of the quality improvement (QI) project (n = 82) in comparison with a historical control group (n = 120). Consecutive patients with acute lung injury in the medical ICU were enrolled. The project involved using a “4Es” framework {engage, educate, execute, evaluate}. A new sedation protocol was implemented, which suggests a target Richmond Agitation Sedation Scale (RASS) score of 0 (alert and calm) and requires the initiation of intermittent sedative dosing before switching to continuous infusions. Furthermore, the use of a twice-daily Confusion Assessment Method for the ICU was utilized.

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The authors found that the median proportion of ICU days per patient with narcotic and benzodiazepine infusions was less during the quality improvement project than during the control period (33% vs. 74% and 22% vs. 70%, respectively; both p < 0.001). Also, wakefulness during the QI period increased (median RASS score per patient: −1.5 (lightly sedated) vs. −4.0 (deep sedation), p < 0.001). In terms of delirium, days awake and not delirious increased during the QI period (median proportion of medical ICU days per patient without delirium: 19% vs. 0%, p < 0.001).

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In conclusion, through the use of this structured quality improvement project, the use of sedatives has decreased and days awake without delirium increased, even in patients with acute lung injury.

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 2. Kress JP, Gehlbach B, Lacy M, et al. The long-term psychological effects of daily sedative interruption on critically ill patients. Am J Respir Crit Care Med. 2003;168:1457–1461   [PubMed: 14525802]
 3. Jones C, Bäckman C, Capuzzo M, et al. Precipitants of post-traumatic stress disorder following intensive care: A hypothesis generating study of diversity in care. Intensive Care Med. 2007;33:978–985.   [PubMed: 17384929]
 4. Treggiari MM, Romand JA, Yanez ND, et al. Randomized trial of light versus deep sedation on mental health after critical illness. Crit Care Med. 2009;37:2527–2534.   [PubMed: 19602975]
 5. Milbrandt EB, Angus DC. Bench-to-bedside review: Critical illness-associated cognitive dysfunction mechanisms, markers, and emerging therapeutics. Crit Care 2006;10:238.   [PubMed: 17118217]
 6. Skrobik Y, Ahern S, Leblanc M, et al. Protocolized intensive care unit management of analgesia, sedation, and delirium improves analgesia and subsyndromal delirium rates. Anesth Analg. 2010;111:451–463.   [PubMed: 20375300]
 7. Pandharipande P, Shintani A, Peterson J, et al. Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients. Anesthesiology 2006;104:21–26.   [PubMed: 16394685]
 8. Pandharipande P, Cotton BA, Shintani A, et al. Prevalence and risk factors ...

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