The risk of delirium after sedation with propofol or midazolam in intensive care unit patients.

AIM: Knowledge of risk factors may provide strategies to reduce the high burden of delirium in intensive care unit (ICU) patients. We aimed to compare the risk of delirium after deep sedation with propofol versus midazolam in ICU patients. METHODS: In this prospective cohort study, ICU patients who were in an unarousable state for ≥24 h due to continuous sedation with propofol and/or midazolam were included. Patients admitted ≤24 h, those with an acute neurological disorder and those receiving palliative sedation were excluded. ICU patients were assessed daily for delirium during the 7 days following an unarousable state due to continuous sedation. RESULTS: Among 950 included patients, 605 (64%) subjects were delirious during the 7 days after awaking. The proportion of subsequent delirium was higher after midazolam sedation (152/207 [73%] patients) and after both propofol and midazolam sedation (257/377 [68%] patients), compared to propofol sedation only (196/366 [54%] patients). Midazolam sedation (adjusted cause-specific hazard ratio [adj. cause-specific HR] 1.32, 95% confidence interval [CI] 1.05-1.66) and propofol and midazolam sedation (adj. cause-specific HR 1.29, 95% CI 1.06-1.56) were associated with a higher risk of subsequent delirium compared to propofol sedation only. CONCLUSION: This study among sedated ICU patients suggests that, compared to propofol sedation, midazolam sedation is associated with a higher risk of subsequent delirium. This risk seems more apparent in patients with high cumulative midazolam intravenous doses. Our findings underpin the recommendations of the Society of Critical Care Medicine Pain, Agitation/sedation, Delirium, Immobility (rehabilitation/mobilization), and Sleep (disruption) guidelines to use propofol over benzodiazepines for sedation in ICU patients.

[Prevention of delirium in the Intensive Care Unit]. / Preventie van delier op de intensive care.

Delirium is highly prevalent in the Intensive Care Unit (ICU) and is strongly associated with negative patient outcomes. We aimed to present an overview of the effectiveness of non-pharmacological and pharmacological interventions to prevent delirium in ICU patients. Multicomponent non-pharmacological interventions are proven effective in the prevention of delirium. These interventions are aimed at multiple domains, including re-orientation, providing a safe and healing environment, cognitive stimulation, mobilization and family engagement. A special type of multicomponent intervention is the ''A-F bundle'', comprising both non-pharmacological and pharmacological interventions. Multicomponent non-pharmacological interventions and the ''A-F bundle'' are recommended. There is insufficient evidence for the effectiveness of pharmacological prophylaxis using antipsychotics, dexmedetomidine, melatonin or thiamin, except for delirium due to substance withdrawal. Therefore, pharmacological interventions should be aimed at minimizing delirogenousmedication (especially benzodiazepines and opiates), adequate pain management and the prevention of deep and continuous sedation.