Archive for year: 2015

Individuals that are admitted to the Intensive Care Unit (ICU) are already critically ill, and now, according to the article by Rattray will be faced with a longer recovery time that could be weeks, months and in some cases years to return to pre-ICU health status. 25-76% of these patient suffer from muscle wasting, weakness, and fatigue from prolonged bed-rest and immobility, and the severity increases with the more critically ill the person is. She further states that these patients suffer psychological problems from their stay in ICU. Due to their perceived experience they suffer from anxiety, depression (28%), PTSD (20%), and cognitive problems including delirium (20-80%), that negatively affect their health status. The characteristics of patients most likely to suffer from delirium are those that are already cognitively impaired, respiratory disease, older age, smokers, and alcohol abuse. Additionally, the illness that this is most prevalent are sepsis, dehydration, prolonged stay in the ICU, and biochemical abnormalities. Environmental precipitants include but are not limited to physical restraints, noise, sleep deprivation, isolation, as well as benzodiazepine and opioid use. Rattray states that rehabilitation should begin while the patient is still in ICU, by daily sedation reductions and early mobilization. This would need to be done with a team of multidisciplinary care providers that begin rehabilitation as soon as the patient is admitted to ICU and continue after discharge.

According to the article Intensive care delirium: the new black by Egerod, it is unclear if ICU delirium is the result of the illness or the medications. However, she does state that these patients suffer from adverse health outcomes from prolonged delirium and stay in ICU. Egerod further promotes the use of interdisciplinary team to manage pain, sleep, circadian rhythm, lighter sedation and early ambulation. Additionally, use of family to participate in care as it gives the patient comfort and familiarity and connects them to the outside world.

Both authors promote reduced sedation, decreased use of benzodiazepines, avoiding sleep disruption and increased physical therapy and activity. Due to the high rate of patients suffering from delirium and other adverse effects from their stay in ICU that have developed standardized tests in which to assess their functioning and delirium. Further research is needed to understand these mechanisms so as to provide better treatment that will provide better health outcomes for the critically ill population.

References:
Egerod, I. (2013). Intensive care delirium: the new black. Nursing in Critical Care, 18(4), 164-165.
Rattray, J. (2014). Life after critical illness: an overview. Journal of Clinical Nursing, 3(5/6), 623-633.

Delirium is defined in the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV as a disturbance of consciousness and cognition that develops over a short period of time (hours to days) and fluctuates over time. It is a common manifestation of acute brain dysfunction in critically ill patients, and occurs in up to 80% of the sickest intensive care unit (ICU) populations. People with delirium are unable to think clearly, have decreased attention, and may have auditory and/or visual hallucinations.

Critically ill patients are subject to numerous risk factors for delirium. Some of these, such as exposure to sedative and analgesic medications, may be modified to reduce risk. Although dysfunction of other organ systems continue to receive more clinical attention, delirium is now recognized to be a significant contributor to morbidity and mortality in the ICU, and it is recommended that all ICU patients be monitored using a validated delirium assessment instrument such as, The CAM-ICU.

The CAM-ICU is modified from the Confusion Assessment Method (CAM) and assesses four features: acute change or fluctuation in mental status from baseline, inattention, altered level of consciousness, and disorganized thinking.

Delirium in the ICU is quite common. The pathophysiology of delirium is poorly understood but it is theorized to be a neurobehavioral manifestation of neurotransmitter imbalance.

Some causes of delirium include: poor oxygen perfusion of the brain, chemical changes in the brain, medications, infections or sepsis, and alcohol withdrawal.

People who are more likely to get delirium are those who have: dementia, depression, poor eyesight and/or hearing, heart failure, infection/sepsis, or take certain high-risk medicines.

Among medical ICU patients, delirium is associated with multiple complications and adverse outcomes, including self-extubation and removal of catheters, failed extubation, prolonged hospital stay, increased health care costs, and increased mortality.

When delirium is diagnosed or suspected, the underlying causes should be sought. Components of delirium management include supportive therapy and pharmacological management. Reorientation techniques or memory cues such as a calendar, clocks, and family photos may also be helpful. The environment should be stable, quiet, and well lit. Physical restraints should be avoided. Delirious patients may pull out intravenous lines, climb out of bed, and may not be compliant. Perceptual problems lead to agitation, fear, combative behavior, and wandering. Severely delirious patients should never be left alone or unattended and may benefit from constant observation to help avoid the use of physical restraints.