Baseline Vulnerabilities May Play a Larger Role than Depth of Anesthesia or Sedation in Postoperative Delirium

Studies in mechanically ventilated patients have brought to the forefront the iatrogenic harm of deep sedation, particularly with continuous benzodiazepine infusions.^1,2  Interventional trials modifying sedation paradigms (e.g., with nonbenzodiazepine medications)³  and delivery patterns (e.g., daily awakening trials, targeted light sedation),⁴  as well as large-scale implementation trials of bundled supportive care (ABCDEF Bundle⁵ ; http://www.iculiberation.com, accessed August 1, 2021), have shown a decrease in sedative medication burden associated with clinically meaningful outcome benefits, including delirium, time on mechanical ventilation, and even mortality. The Society of Critical Care Medicine’s Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption,⁶  therefore, recommend targeting light sedation when needed, minimizing overall sedative medication exposure, and avoiding benzodiazepine infusions. With the high incidence and associated morbidity of postoperative brain dysfunction, there has been interest in utilizing similar techniques in the...