Intensive-care units have long kept critically ill patients immobilized, heavily sedated and on a breathing machine. The aim is to keep them free of pain, anxiety and agitation as they heal and undergo invasive procedures and monitoring.
Laura Landro explains why traditional methods used to manage patients in intensive care who are heavy sedated on a mechanical ventilator are now being shown to harm patients, including triggering or exacerbating delirium.
But there is growing evidence that such care can increase patients' risk for other problems after they leave the hospital and in years to come. Studies show that prolonged heavy sedation, for example, can trigger or exacerbate delirium, a temporary state of acute brain injury that has been linked to higher rates of death and dementia. Patients immobilized in the ICU quickly lose muscle and bone strength and become frail, which can significantly slow the pace and degree of recovery. A year after being discharged, as many as half of ICU patients are unable to return to work.
A growing number of hospitals are putting in place new five-step protocols for their ICUs that include sedating patients more lightly when possible and regularly assessing them for pain and signs of delirium. Hospitals also are waking patients at regular intervals to see if they can breathe on their own sooner. And they are getting patients up and moving as soon as possible to help restore their mental and physical equilibrium.
An estimated 40% of U.S. hospitals have adopted at least some of the steps, which were developed by Vanderbilt University's ICU Delirium and Cognitive Impairment Study Group and other institutions with funding from the federal government. The Society of Critical Care Medicine is reviewing the protocols as part of the professional organization's ongoing development of guidelines for patient care in ICUs.
Since ICU patients generally can't monitor their treatment, it's important for friends and family to make sure the critically ill are getting the most attentive care. Vanderbilt provides information on the new protocols and assessment tools used to diagnose delirium and test for pain and sedation at www.ICUdelirium.org.
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Some long-standing practices in intensive-care units can raise the risk of mental and physical impairment down the road.
ABCDE's for the ICU
Here are some steps to ask medical staff if they are taking when a loved one is in intensive care.
Awakening
Action: Patients should be woken from sedation at regular intervals.
Consequence: Prolonged sedation can result in delirium, or severe confusion, which in turn is associated with long-term cognitive impairment.
Breathing
Action: Patients should be assessed daily for their ability to breathe without a mechanical ventilator.
Consequence: The use of a ventilator for long periods can boost the risk of pneumonia and lead to longer hospital stays.
Choice of Sedation
Action: Use milder sedative drugs if feasible.
Consequence: Commonly used drugs, like benzodiazepenes, may contribute to brain injury.
Delirium Monitoring and Management
Action: Hospital staff should evaluate patients for delirium routinely, such as by asking them to identify objects in photographs, and should modify treatment accordingly.
Consequence: Patients with delirium run a greater risk of infections, adverse effects of medications and excessive sedation.
Early Mobility
Action: Conscious patients should be gotten up and moving and started on physical therapy
Consequence: Lack of movement contributes to muscle atrophy, bone loss, blood clots and skin ulcers.
"The whole purpose of an ICU visit is to get well enough to get back to your life," says Barbara Kamholz, a psychiatrist with Duke University and the Veterans Administration Medical Center in Durham, N.C. "If we are disabling people in the process it isn't consistent with the goal of recovery," she says.
About five million U.S. adults spend at least a day in an ICU each year. They are admitted for heart failure, recovery from major surgery, severe infections such as sepsis and pneumonia and a host of other reasons. Between 80% and 90% of patients on average survive an ICU stay, though the sickest patients have higher death rates.
But research conducted in recent years shows that 50% to 80% of people who leave the ICU later suffer from long-term cognitive impairment that appears to be related to how long they were delirious in the hospital, Vanderbilt says. Studies at Johns Hopkins University and other institutions show as many as a third of ICU survivors may suffer from depression after they leave the hospital, and between 15% and 40% of patients experience symptoms of post traumatic stress disorder.
Delirium, a temporary state of acute brain injury that can include frightening hallucinations, is common to many ICU patients but is often missed because patients can't easily communicate. Doctors haven't been overly concerned about delirium because its effects were believed to be temporary and any brain injury reversible.
In recent years, however, studies have shown that prolonged delirium in the ICU is a risk factor for long-term cognitive impairment and death. Patients who survive ICU care may be discharged with memory and thinking problems that cause them to lose their jobs and feel "like their brain is swimming in molasses," says E. Wesley Ely, a critical-care expert at Vanderbilt who helped develop the new protocols.
Elderly patients are at higher risk of cognitive decline. But adults in their 40s and 50s are also vulnerable. At that age, neurons that protect the brain from injury naturally lose some of the potency that protects younger brains, says Malaz Boustani, a researcher at Indiana University Center for Aging Research. In July, the center is opening a post-ICU survivor clinic to focus on cognitive and functional rehabilitation.
Melissa Akers, 51, was hospitalized at Vanderbilt in 2009 for a severe illness known as ARDS, or acute respiratory distress syndrome, after recovering from two years of chemotherapy for leukemia. She says nurses woke her up often to reduce the level of sedation, and assessed her mental state with questions like "does a stone float on water?"
Still, Ms. Akers was in the ICU for six weeks, suffering hallucinations and losing much of her muscle strength. She says she has been unable to return to her job as an administrative assistant and has trouble with daily tasks. "It's a long journey back and I'm not there yet," she says.
Getting Healed
A growing proportion of patients are surviving a stay in hospitals' intensive-care units. But studies show that an ICU stay may result in a poorer quality of life in the future.
- About five million U.S. adults are admitted to an ICU each year.
- The average length of stay is 6.1 days, when care is provided by an intensive-care specialist, or 9.3 days, when there is an attending physician.
- Some of the top reasons for being admitted to ICU include respiratory failure, post-surgical management, heart disorder, gastrointestinal hemorrhage and sepsis (blood poisoning).
- Between 80% and 90% of all patients in an ICU survive, but 25% to 35% of the sickest ICU patients die in the hospital.
- Evidence is growing that ICU patients face increased risk for problems after they leave the hospital and in years to come, including depression and long-term cognitive impairment.
Sources: Society of Critical Care Medicine; Vanderbilt University's ICU Delirium and Cognitive Impairment Study Group
Dr. Ely says some intensive care units have been reluctant to change their practices for fear of harming patients or exposing them to pain they won't be able to express. He says it is also easier to care for patients who are sedated rather than waking them, walking them around the halls and quizzing them on their level of pain and confusion. He stresses pain control is "always the top priority."
Dale Needham, a critical-illness specialist at Johns Hopkins University, says it took several years to convince doctors and nurses to take the new approach. "We were taught in medical and nursing school that we were helping them and giving them amnesia about their ICU experience but what we are really giving them is delusional memories and hallucinations and long term impairment," he says.
Rees Mitchell, 55, was hospitalized in the ICU at Vanderbilt under Dr. Ely's care four years ago. He had fever and severe sepsis after a stem cell transplant for lymphoma, and was initially heavily sedated because he couldn't tolerate the ventilator. With Mr. Mitchell's pregnant wife, Jessica, standing by, Dr. Ely reduced his sedation each day as much as possible, and frequently assessed his pain and mental state.
Ms. Mitchell recalls being worried about the strategy, afraid he was still too sick. But she became more confident as she saw her husband begin to heal and try to communicate.
Mr. Mitchell was able to leave the hospital after nine days, in time to be at his wife's bedside for the birth of their son, who they named Wes, after Dr. Ely.
Mr. Mitchell says he had no trouble going back to work as a sales representative for a computer-software firm. He also has returned to playing bridge and tennis.
Though he says he feels challenged at times when he has to multi-task, "I think I'm a lot better off than people who didn't get this kind of care and have to face significant changes in their lives."
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