ICU Sedation

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I was very surprised to learn how devastating and long-lasting ICU sedation can be on both the cognitive and physical effects are on ICU patients. It never occurred to me that some ventilator patients could and should be ambulated if possible. Even during my ICU rotation, which was only 2 days, I did not realize that sedation with benzodiazepines does not allow the patient to experience a normal sleep cycle. Even though sleep deprivation in critically ill patients has been well documented for more than 30 years (Tembo, Parker, & Higgins, 2013), clinicians still struggle with methods of care that seek to support restful sleep and prevent or alleviate sleep deprivation and nightmares. The study done by Tembo et al. (2013), explored the lived experiences of critically ill patients in ICU with daily sedation interruption. Patients reported “longing for sleep” and ‘being tormented by nightmares”. When the outcomes of patients with daily sedation interruption (DSI) where compared to those with continuous infusion the findings suggested that DIS did not result in psychological harm. Patients in the DSI group fared better for PTSD than those with continuous sedation. It was also found that the DSI group had a shorter length of stay in ICU.

Sleep deprivation is known for causing disorders of the mind, including delirium. The effects of sleep deprivation are both psychological and physiological. In addition to the types of medications used for sedation, the sounds, lighting, and continuous contact with care providers are all factors in poor sleep quality. Participants in the study report having nightmares for months after their ICU experiences. The study’s finding suggested a need for models of care that support restful sleep and prevent or alleviate sleep deprivation and nightmares.

The “Care of the Ventilated Patient – The New Paradigm” was one of the most informative videos about delirium in the ICU that I have seen. It was interesting to see how much of what we do help our patients, is actually harmful. This video that appears to have been created in March 2012, indicates that a study done 10 years previous showed that ICU stays can be reduced and patients benefit from DSI and less sedation. Ten years later and we still haven’t figured it out. I have no experience in the ICU but would be interested to know if there are significant changes in how patients are sedated today.

Tembo, A. C., Parker, V., & Higgins, I. (2013). The experience of sleep deprivation in intensive care patients: Findings from a larger hermeneutic phenomenological study. Intensive and Critical Care Nursing, 29, 310-316.

Nurses Collaborate for Ventilator Weaning

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Situation

              Patients that have serious illnesses often are admitted to the Intensive Care Unit (ICU). A majority of these patients are also on mechanical ventilation to assist with breathing after experiencing acute respiratory distress syndrome (ARDS) as a result of “either direct or indirect pulmonary injury” (Morton & Fontaine, 2013, p.233). Mechanical ventilation is used to  treat a patient that cannot breath on their own. Unfortunately, invasive artificial airways often come with their own complications and high costs.

Background

              Mechanical ventilation is well know to cause ventilator associated pneumonia (VAP) and other nosocomial infections. Studies also show that the longer the length of time on a ventilator, the higher it correlates with hospital re-admissions and a draining of ICU resources (Douglas, Daly, Brennan, Gordon & Uthis, 2011). There is evidence based support for getting patients off of ventilators and sedation, as quickly and safely as possible.

Assessment

              In the article, “Collaborative practice: development, implementation, and evaluation of a weaning protocol for patients receiving mechanical ventilation,” authors write about how patients are typically weaned off of the ventilator and identified a problem with the fact doctors decided subjectively to wean patients and it is not based on protocols (Grap, Strickland, Tormey, Keane, Lubin, Emerson, & … Sessler, 2003). The doctors would use different parameters and those parameters varied from each doctor and each hospital (Grap, 2003).

Resolution

               Grap et al., have focused on using a multidisciplinary approach to wean  patients off of their ventilators sooner; this approach utilizes a standardized protocol for weaning the patients (2003). The article researched the medical respiratory ICU (MRICU) protocol which is composed of several scales, guidelines, and assessment tools to help identify if the patient is ready to be weaned (Grap et al., 2003). The article showed that “[p]atients receiving mechanical ventilation have shorter hospital stays and lower costs when a weaning protocol is used” (Grap et al., 2003, p. 455). The article also supported nurses autonomy and working with the respiratory therapist to individualize the weaning process; this encouraged strong communication within the interdisciplinary team (Grap et al., 2003).

Douglas, S., Daly, B., Brennan, P., Gordon, N., & Uthis, P. (2001). Hospital

readmission among long-term ventilator patients. Chest, 120(4), 1278-1286.

Grap, M., Strickland, D., Tormey, L., Keane, K., Lubin, S., Emerson, J., & … Sessler,

C. (2003). Collaborative practice: development, implementation, and

evaluation of a weaning protocol for patients receiving mechanical

ventilation. American Journal Of Critical Care, 12(5), 454-460.

Morton, P. G., & Fontaine, D. K. (2013). Essentials of Critical Care Nursing; a

               holistic approach. Philadelphia, PA: Wolters Kluwer.

Texting Away Cholesterol

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When it comes to chronic disease, quite often we find the most difficulty not in correcting the pathophysiology of the condition, but in motivating the patient to make real lifestyle changes. Many different forms of education have been tried, some with more success than others, but from what I’ve seen I think that there is a lot to be said for consistency and reaching patients in their daily lives. The article I chose, Text Reminders Help People Lower Blood Pressure, Cholesterol (Shallcross, 2015) demonstrates the power that even simple consistency can have. Today there are hundreds if not thousands of health oriented apps, but most of them require a smartphone and some degree of tech saviness. This article discusses a study recently published in The Journal of the American Medical Association. In this single-blind randomized clinical trial, 710 patients with coronary heart disease were divided into a control (n=358) and intervention group (n=352) (Chow et al., 2015). Each group received the same medical care, but the intervention group also received 4 non-interactive text messages a week focused on education, advice, support, and motivation (Chow et al., 2015). After six months, the intervention group had significant decreases in LDL, SBP, BMI, smoking, and significant increases in activity (Chow et al., 2015).

I find this impressive and exciting. These results are an important reminder that when is comes to patient education, sometimes keeping technology simpler is better. Another important aspect of this model is that text messages are accessible to many people, including those without smartphones. Even in developing countries many people have cell phones that can receive text messages, so this technology could conceivably be applied in such regions. I also appreciate the empowerment aspect of this work. No one was calling these patients to pressure them into changes, they received the messages and independently decided to ignore or take in and apply the content. All in all, I think this study is an important contribution to medicine and hope to see its implications acknowledged.

 

References

Shallcross, L. (2025). Text Reminders Help People Lower Blood Pressure. National Public Radio.

            Retrieved from http://www.npr.org/sections/health-shots/2015/09/22/442518139/text-

           reminders-help-people-lower-their-heart-disease-risk

Chow, C., Redfern, J.,Hillis, G., Thakkar, J., Santo, K., Hackett, M., Jan, S., Graves, N., Keizer, L., Barry,

           T., Bompoint, S., Stepien, S., Whittaker, R., Rodgers, Thiagalingam, A. (2015). Effect of lifestyle-

           focused text messaging on risk factor modification in patients with coronary heart disease

           [Abstract]. The Journal of the American Medical Association 315(12), 1255-1263.

 

 

ICU Delirium

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According to the article Delirium in Critically Ill Patients, ICU delirium affects 16-89% of all ICU patients, with the wide range attributed to ineffective delirium assessment on admission, lack of training for the medical staff, and the implementation of different sedation and analgesia protocols (Zaal & Slooter, 2012).  Those at a higher risk include the elderly, patients with pre-existing cognitive decline, history of alcohol abuse, sepsis, and immobility.

Although the cause of ICU delirium is unclear, Zaal and Slooter (2012) suggest that an alteration in neurotransmitter activity may be at fault, as patients with ICU delirium show a decrease in acetylcholine activity, resulting in disturbed pathways involving attention, concentration, and learning.  Another hypothesis is that delirium is caused by an aberrant stress response, in which the body releases an excess amount of stress hormones that cross the blood-brain barrier, resulting in cognitive impairment (Zaal & Slooter, 2012).

Early screening of ICU patients—with tools such as the intensive care delirium screening checklist (ICDSC) or the confusion assessment method (CAM-ICU)—results in better prognoses for those suffering with delirium.  Zaal and Slooter (2012) report that repeated re-orientation, early mobilization, noise reduction, and less interruptions during sleep are effective measures that reduce delirium by 40%.  Pharmacologically, intravenous low-dose Haloperidol is the drug of choice, as it has shown to decrease delirium in 23% of ICU patients (Zaal & Slooter, 2012).

Prior to researching this topic, I had no idea ICU delirium existed.  However, after reading the articles and watching Anthony Russo’s video, it is clear that more research is needed to not only prevent ICU delirium, but also to effectively treat and provide adequate ongoing psychological help—long after discharge—to those patients in need.

Reference:

Zaal, I. J., Slooter, A. J. C. (2012). Delirium in critically ill patients: Epidemiology, pathophysiology, diagnosis and management. Drugs, 72(11), 1457-1471. Retrieved from http://eds.a.ebscohost.com.summit.csuci.edu:2048/ehost/detail/detail?

Cardiac Website: Cottage Health Heart and Vascular Center

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This is the website of the Cottage Heart and Vascular Center. I found it interesting because it explains (in lay terms) all of the procedures (CABG, PCI, Ablation, etc) performed at our local hospital and what patients should expect. The interactive symptom checker, local cottage heart-hotline, and list of heart attack warning signs are all easy to navigate and seem helpful (also for those of us studying for a test!). While in a clinical rotation I once witnessed a PCI in the cardiac cath lab, and beforehand saw the pt give informed consent after the doctor explained the procedure extremely rapidly. The information on this website would have been extremely helpful to the pt before the emergency procedure– but how many people read up on cottage’s heart services when they’re feeling fine? The website also talks about how the hospital goal for all cardiac events is a 90 min or less timeline from door-to-“definitive treatment” since becoming a Cardiac Receiving Center and Level II Trauma Center for Santa Barbara County.

http://www.cottagehealth.org/services/heart-vascular/services-treatments/

 

 

Adult Cyber Predators

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As I was reading this chapter, I assumed that it was only going to discuss children.  It caught my attention that many adults experience bullying and cyberbullying as well.  I had no idea that 35% of individuals reported being bullied at work by a co-worker.  I wonder if these co-workers that antagonize others were victims of being bullied when they were younger.  As a result, they are taking it out on others as adults.  Also, they may be doing this intentionally to get a promotion.  So they put their fellow employees down in order to get a position many of them are competing for.

 

The Search Begins

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So I have chosen to research the cost of higher education and more focused on textbooks/custom textbook and why they seem to go up every year. So for the beginning I looked at the universal search engines and basic tools that any person with an internet connection can do. After looking at google, yahoo, and duck duck go I found the only differences in duck duck go being the arrangement of the articles that were first given to me.  The first few articles were dated from over a year and a half ago and so I had to modify my search for more recent articles and I found some of the more common websites that produce news articles, being usaToday and the Atlantic.  What I found to be more surprising that there weren’t more recent articles about the issue, I assumed that around August more articles would appear so talk about the new school year.  One of the biggest things I found was in an article written by Erin Thomassen on watchdog.org, that the price of textbooks had risen by 1041% since 1977 and that it was triple the rate of inflation in the country.  This may become my focus for the project that I have in my course but I have only found sources that haven’t been peer reviewed or any other proof of authenticity. From the Ted-talk that we saw for the class I also may most likely use only duck duck go for future searches, because I prefer to sift through the information before it gets to me. Google and Yahoo are geared toward the person’s history and what most likely would want to see and, while I can see the positive of this and being able to arrive to article that are relevant to me, I would lose out on side article that I may be looking for that google or yahoo has deemed unworthy.

Nursing401

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Delirium has been recognized as a serious acute medical condition that’s been called a medical emergency. Every day, 30,000 to 40,000 ICU patient in the United States are suffering from acute brain dysfunction called delirium (Maniou, 2012). Delirium is a manifestation of CNS dysfunction, it is important to recognize and treat life-threatening conditions that may result in delirium such as; sepsis, pneumonia, myocardial infarction, pulmonary embolism and medications. It’s recommended that after nurses’ exclude life-threatening complications that they turn their attention to the patients environment and make attempts to minimize any factors that may exacerbate delirium such as; avoiding prolonged sleep deprivation, minimizing artificial lighting, and being mindful of clustering patient care to avoid additional disruptions.

Patients on mechanical ventilation increase the risk of delirium three-fold. It has been found that the mortality rate with patients experiencing delirium may exceed twice the six-month mortality rate of nondelirious patients, and it is associated with longer hospital stays and with a higher rate of cognitive impairment at discharge (Maniou, 2012). CAM-ICU is a useful tool in diagnosing and monitoring delirium and is recommended to be used frequently in the ICU, it is constructed with yes/no questions for use with nonspeaking, mechanically ventilated ICU patients. To reduce the length of time patients spend heavily sedated and immobilized on a ventilator healthcare providers are awakening patients from sedation earlier, assessing pain, and getting them to breathe on their own as soon as possible to avoid prolonged delirium which can have long lasting effects on cognitive function. Focus is also aimed at getting patients up and moving while still on a ventilator can also help reduce muscle weakness and assist in a speedier recovery.

References:

Landro, L. (2011). Informed patient: changing sedation status quo in the ICU.  Health Blog, Wall Street Journal. Retrieved from http://blogs.wsj.com/health/2011/02/15/changing-the-sedation-status-quo-in-the-icu/

Maniou, M. (2012). Delirium: a distressing and disturbing clinical event in a intensive care unit. Health Science Journal, Vol 6, Issue 4.

 

Reducing the Risk of Heart Disease- Exercise, a Heart Healthy Diet, and the Right Amount of SLEEP

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Article: Too Much, Too Little Sleep May Harm the Heart

We’ve all heard that proper diet and exercise is crucial to lowering our risk for heart disease. This study focused on another major factor that often doesn’t receive as much attention, sleep. With the American mentality of work hard, play hard it often seems that there isn’t much time left for sleep. In fact, it almost seems that individuals pride themselves on their ability to keep up despite minimal amounts of sleep. While these individuals may feel like they’re living life to its fullest, they are missing out on the major benefits of getting a good nights sleep.

With attempting to balance work, school, and some form of a social and healthy lifestyle I often find that sleep gets thrown by the wayside. Recently it’s become a personal goal of mine to try to get better quality sleep and more of it.

I found this article interesting because it discusses not only the importance of sleep as it relates to cardiovascular health, but the importance of the right amount of sleep.

 

According to the article, a study of 47,000 participants showed individuals who:

  • got five or fewer hours of sleep a day had 50 percent more calcium in their arteries than those who slept seven hours a day.
  • slept nine or more hours a day had at least 70 percent more calcium compared to those who slept seven hours.
  • reported poor sleep quality had more than 20 percent more calcium than those who reported good sleep quality.

So, as with most things in life, sleep is good in moderation. It looks as though oversleeping may actually be more harmful to your heart than not getting enough sleep!

 

 

Search Engine Search: Rising Tuition

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A previous post of mine entitled “Social Issues for College Students” detailed a list of issues that I felt were relevant to college students today. In my Digital Citizenship class, we have been assigned to address and explore one issue in depth and the one that I will be examining is the phenomenon of rising tuition costs. For purposes of context, I found this issue to be the most pressing for college students on both daily and long-term bases. If costs continue to rise, we will have students that are avoiding school because they are unable to afford it. The students that do take on the costs and attend school anyway are being saddled with crippling debt that will take several years to pay off. One of the big questions behind this issue are when do the benefits stop outweighing the cost? In other words, how much money is too much?

This week I have done a search engine search on the costs of higher education on the following engines: Google, Yahoo, Bing, and DuckDuckGo. The results varied for each engine, but I was able to find some of the same information on each. I have found that the top results are not necessarily the best sources of information, which I would personally define as being scholarly in nature. The top results are those like The Huffington Post and The New York Times. While those two particular examples are more reliable than most because of more editing and checking of sources, they are still platforms that mostly express opinion. I understand more so than ever why professors are constantly telling students to use scholarly articles and databases for research. The simple fact of the matter is that scholarly resources are evaluated by experts in the field for accuracy, proper information gathering, and facts to back up opinions. I also noticed that DuckDuckGo (an incognito browser that does not track your online presence), presented me with more professional sites such as NPR and US News because it has no idea about the articles that I have previously read on the popular sites listed above.

I look forward to delving more into this topic because I find it to be of the utmost relevancy for college students today and those who love them.

 

Until next time,

MGH. Professor in Training

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