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Discussion #4

Pain management in sedated and mechanically ventilated patients is always something that has interested me. Though we have scales and modalities through which we assess and manage pain in patients that aren’t coherent, it seems impossible that they are all completely foolproof in terms of accuracy and effectiveness.

Additionally, according to a 2013 article, these treatments may also have a negative effect on patient outcomes. I read an article titled Pharmacological Management of Sedation and Delirium in Mechanically Ventilated ICU Patients: Remaining Evidence Gaps and Controversies. This article explored the treatment of pain, anxiety, and delirium (PAD) in ICU patients. The authors assert that, drugs once thought to have a been effective in reducing PAD have been shown to have either little benefit, the potential for significant risk associated with any benefit, or in some cases, the potential to worsen patient outcome (Devlin et al., 2013).

The article provides health care practitioners with background on the most important areas of delirium pharmacotherapy in the ICU,  information on the recent evidence based practice surrounding the treatment of PAD, and discusses areas in relation to this topic that require further investigation or study. The recommendations are all based on the Critical Care Medicine (ACCM) Pain, Agitation, and Delirium Clinical Practice Guidelines.

The guidelines include recommendations such as giving patients daily sedation interruptions while in the ICU; titrating medications to induce a light sleep as opposed to deep sedition, in addition from drug specific recommendations to guide health care practitioners.

The article stresses the importance of closing the gap between evidence-based recommendations and current PAD management practices. In order to achieve these guidelines as well as the many others suggested, the authors suggest a multi-faceted, interdisciplinary approach. They stress the importance of facility specific protocols for PAD management in addition to standardized order sets. The article concludes by saying that in order for the ACCM guidelines to be achieved and patient outcomes to be improved, comprehensive staff accountability and consistent patient education is vital.

Devlin, J. W., Fraser, G. L., Ely, E. W., Kress, J. P., Skrobik, Y., & Dasta, J. F. (2013). Pharmacological management of sedation and delirium in mechanically ventilated ICU patients: remaining evidence gaps and controversies. Semin Respir Crit Care Med, 34(2), 201–215.

To me, it is very scary to take care of a patient on a ventilator. To think that a machine is making the patient breath and keeping them alive is quite intimidating. I am sure it is a scary sight to witness a delirious patient while in an intense environment. Having to monitor critical patients when sedation vacation is happening could be very frightful especially when they start trying to pull out tubes, IVs, and foleys. I am absolutely for the mnemonic THINK solution. Where the components within the pneumonic is looked at when a patient is delirious. Toxic, Hypoxia, Immobility, Non-pharmacological interventions (clustering care, having hearing aids and glasses available) and the Potassium level are the most important factors that could tell you why a patient is delirious. Making sure these factors are not causing the patients delirium is very important. The video of the gentleman who was in the hospital for 22 days was very eye-opening. He stated he can remember these vivid nightmares like it actually happened. He remembers the 15 IVs in the constant worrying that he continues to go with on the daily basis. To be on paralytic and sedatives for so long can cause cognitive impairment. This gentleman is living with post-traumatic stress disorder (PTSD) due to the flashbacks he experiences of the nightmares he endured during his time in the ICU. He also stated that his family wanted to be involved more than they were. This is a scary situation and I am surprised that family members would want to be more involved but I can understand because it could be a scary being in an environment and seeing their loved ones in a situation like this. Study show that early ambulation in the first three days decreases delirium. So the study shows this I think it needs to be done. Evidence-based practice is done because of the best patient outcomes. One hospital decreased the amount of sedatives and paralytics and noticed that 15% of their patients were less likely to die and their length of stay was shortened by four days. Combining the decrease in the amount of drugs given an early ambulation can decrease delirium in the ICU patient. I also agree that follow-up care at home should be done because there’s no way of knowing if the patient had an out of body experience or the constant state of worry and fear while they were under the strides. Being able to identify the psychological stresses and intervene can help them get back to life they were living before the incident.

The use of sedatives in patients within ICU’s has been used to decrease anxiety, reduce pain, and relieve any stress to help in the healing process of patients. It has been found that a long amount of time spent under sedation can have acute delirium effects and in some cases more long term effects. Currently, the use of daily interruptions of sedation, also known as sedation vacation, is being practiced to help in lowering the length of mechanical ventilation, length of ICU stay, and length in hospital stay (Svenningsen et al., 2013). In a study done by Svenningsen et al. (2013), the researchers explored the idea that high fluctuation levels in sedation could lead to delirium in ICU patients. Their study included 640 patients over two years in two hospitals. To assess the patient’s levels of sedation and delirium, the Richmond Agitation and Sedation Scale (RASS) and the Confusion Assessment Method for the ICU (CAM-ICU) tools were used. The researchers found that there was a “significant association between major changes in sedation level and incidence of delirium” (Svenningsen et al., 2013).

I feel that this article does make a good point about how the patient’s levels of sedation are correlated to the effects of delirium. To me, it makes sense. If a patient is heavily sedated, when they wake up, wouldn’t they have some level of delirium? There are some limitations within this study that could potentially make a difference such as assessing the patient’s pain level. But I liked how they utilized two tools to measure the levels of sedation and delirium which helped in determining the different degrees of sedation (ie. hypoactive, hyperactive, and mixed delirium). More studies are needed to determine if a set amount of dosing time, type of medication being used, or the amount of the medication increase the effects of the delirium. After reading this article, I now feel that if we continuously monitor the sedation level that the patient is experiencing throughout the day and are able to adjust the amount of sedatives given based on those levels, the onset of delirium will drop.

Reference

Svenningsen H Egerod I Videbech P Christensen D Frydenberg M Tonnesen E 2013 Fluctuations in sedation levels may contribute to delirium in ICU patients.Svenningsen, H., Egerod, I., Videbech, P., Christensen, D., Frydenberg, M., & Tonnesen, E. (2013). Fluctuations in sedation levels may contribute to delirium in ICU patients. Acta Anaesthesiologica Scandinavica, 57(3), 288-293.  201501281916161677993059