How Management of Delirium in the ICU Can Vastly Improve Patient Outcomes

As a rule, ICU sufferers at present are subjected to insufferable bouts of sedation, immobility, and the inevitable delirium that accompanies an absence of evidence-based therapy.

Sadly, many of those sufferers don’t survive, and much more of them are robbed of their potential to thrive, each whereas they’re within the ICU, and after they’ve left the intensive care unit.

Nonetheless, when evidence-based practices are understood by ICU crew members, and utilized accordingly, even essentially the most agonizing ICU admissions can nonetheless have a silver lining.

That being mentioned, whereas the case I’m about to doc is disturbing and tough to digest, it additionally does a fantastic job of highlighting how evidence-based practices can dramatically enhance ICU affected person outcomes.

It includes a girl who realized first-hand how administration of delirium within the ICU and early mobility within the ICU can actually save lives.

Her title is Megan, and that is her story.

How Administration of Delirium within the ICU Saved Megan’s Life

Megan Wakley is a 32-year-old girl with a historical past of malnutrition, PTSD, and alcohol dependence, in addition to benzodiazepine, marijuana, and tobacco use.

She was admitted to an outdoor hospital for ALPS (alcoholic leukopenic pneumococcal sepsis) and was promptly intubated and positioned on mechanical air flow.

She developed necrotic and cavitary pneumonia, septic shock, alcohol withdrawal, and ARDS (acute respiratory misery syndrome).

She then spent seven days deeply sedated and immobilized, and her situation continued to say no.

The ICU crew that handled her began to debate choices, corresponding to consolation care, with Megan’s household. Because of this, the choice was made to switch Megan to the “Awake and Strolling ICU.”

Upon arrival to the “Awake and Strolling ICU,” Megan was nonetheless sedated with midazolam and fentanyl, and on one vasopressor, with ventilator settings of help management, a PEEP of 14, and a FIO2 of 60%.

As soon as the “Awake and Strolling ICU” crew knew Megan had secure oxygenation and hemodynamics along with her present ventilator settings and vasopressor wants, they instantly seemed on the large image.

They acknowledged that Megan was in essential situation with septic shock and extreme respiratory failure from necrotic and cavitary pneumonia and ARDS, and so they recognized the necessity to deal with these situations and stop additional problems.

Along with her acute an infection, Megan had vital danger elements for poor outcomes, corresponding to ICU-acquired weak spot and delirium, which may make her survival much less seemingly.

With that mentioned, let’s take a look at how Megan’s expertise pertains to some widespread afflictions for ICU sufferers, and the way the ICU crew members who handled her have been capable of mitigate these points by means of an understanding of evidence-based practices.

ICU-Acquired Weak spot

Megan was malnourished at baseline, which may double her size of keep and healthcare prices, in addition to her possibilities of discharging to a care facility, additional rising her dangers of ICU-acquired weak spot and mortality.

Her growth of sepsis and septic shock additionally put her at considerably larger danger of fast muscular atrophy and ICU-acquired weak spot.

As well as, Megan had already spent seven days immobilized underneath sedation, and the muscle mass and use she had already misplaced may pose a menace to her survival.

Fortunately, the ICU crew that handled her understood that the extra muscle and performance Megan misplaced, the longer she could be on the ventilator, the extra seemingly she was to die, and the harder rehabilitation could be.

On the identical time, her high quality of life could possibly be impacted by her bodily deficits for years to return.

That being mentioned, they knew it was crucial to cease muscular atrophy and begin rebuilding muscle mass and performance instantly.

Delirium

Megan suffered alcohol withdrawal, septic shock, and skilled seven days of steady sedation.

Because of all these elements, her possibilities of silently affected by traumatic delirium whereas sedated have been immeasurably excessive.

Analysis reveals that Megan’s baseline PTSD elevated her danger of getting post-ICU PTSD, and her ICU care crew feared that though she gave the impression to be sleeping, she was most likely repeatedly and vividly reliving the traumatic occasions that brought about her preliminary PTSD, which might seemingly worsen her psychological operate and psychological well being after the ICU.

The “Awake and Strolling ICU” crew was panicked about Megan’s delirium, particularly contemplating they have been conscious that proof reveals for each someday of delirium, her danger of loss of life would enhance by 10 %.

As well as, they knew that research present delirium doubles the danger of loss of life within the hospital, and there’s proof to point out that it triples the danger of loss of life inside six months after being discharged from the hospital.

Furthermore, they knew that proof reveals liberating her from sedation and delirium could be important to enhancing her possibilities to outlive and thrive.

Fortuitously for Megan, her ICU care crew was additionally conscious that by making use of the ABCDEF Bundle to Megan’s care, they may:

Reduce her danger of ICU readmission in half

Scale back delirium and coma days by 25-50 %

Scale back bodily restraint use by greater than 60 %

Lower the probability of hospital loss of life inside seven days by 68 %

Scale back her possibilities of being discharged to a nursing house/rehabilitation facility by 40 %

Serving to Megan to Stay Awake and Strolling

Finally, their purpose was to get Megan awake and strolling on the ventilator so she may ultimately stroll herself out of the ICU and resume her life.

Step one towards such a purpose was to carry out a real sedation trip.

Sadly, as they steadily decreased her doses of midazolam and fentanyl, Megan’s torturous hyperactive delirium was revealed.

She was agitated and energetic, fought her restraints to achieve for her endotracheal tube, and was shortly capable of chunk by means of the tube, so she ended up requiring emergent re-intubation.

Induction sedation was given for the tube trade and the crew mentioned their technique shifting ahead.

As a substitute of contemplating the occasion a failed sedation trip, they realized Megan’s delirium was an emergency.

They knew steady deep sedation would exacerbate and delay her delirium, and so they have been additionally conscious of the truth that delirium is a life-threatening situation, so that they formulated a plan to assist Megan work by means of her delirium.

At this level, they realized that as a result of Megan’s baseline benzodiazepine use and extended midazolam course, she wanted benzodiazepines.

Alternatively, additionally they knew that being deeply sedated with benzodiazepines corresponding to midazolam would enhance her danger of dying.

So, they determined to present her Klonopin by means of her feeding tube to assist with anxiousness and canopy her benzodiazepine wants.

As well as, they determined to trade midazolam for propofol and bridge to dexmedetomidine.

The final word purpose was to make sure Megan was awake and alert sufficient to use the principle interventions for delirium, which embody:

Mobility

Household involvement

Actual sleep (not sedation)

Avoidance of delirium-causing medicines

The ICU care crew acknowledged that although her household was current, they may not assist her come again to actuality if she was deeply sedated, and so they knew mobility and actual sleep could be inconceivable with sedation.

With these elements in thoughts, they used propofol and have been then capable of wean her down to simply dexmedetomidine and attain a RASS rating of 0 to +1.

As quickly as she was calm and awake sufficient, whereas remaining inside that RASS purpose, they instantly had her up on her toes and strolling.

Megan’s preliminary walks have been clumsy, weak, and required assist, and after every stroll, she was exhausted and would instantly sleep.

Fortuitously, dexmedetomidine and fentanyl have been capable of be discontinued. She remained delirious however her anxiousness and agitation began to enhance.

The subsequent day, she began writing on a board, asking questions, corresponding to “The place is my daughter?” and “The place is my canine?” so her household introduced her canine in to assist along with her anxiousness.

After just a few days, her delirium was gone, she was capable of be unrestrained, and her anxiousness was managed with household, mobility, and low-dose Klonopin, at her request.

Her ARDS and cavitary pneumonia worsened and she or he required a chest tube for cavitary pneumonia and adjusted ventilator settings, together with a PEEP of 18 and a FIO2 of 100% for the ARDS.

Inexplicably, despite all this, Megan was capable of be freed from sedation and delirium, and continued to stroll.

If you wish to be taught extra about Megan’s story, you’ll be able to take a look at Episode 71 of my Strolling Residence From The ICU podcast.

How Did Issues Flip Out for Megan?

Megan spent over a month on mechanical air flow – an exceptionally lengthy stretch in comparison with most sufferers within the “Awake and Strolling ICU.”

Her lungs have been severely broken, and she or he did require a tracheostomy for night time relaxation (a uncommon incidence within the “Awake and Strolling ICU”).

Because of the unknowns and fears of recent COVID sufferers coming into the ICU for the primary time, she was transferred to a long-term acute care hospital (LTACH).

She walked herself out of the ICU, independently respiratory by means of her tracheostomy, and spent solely every week within the LTACH earlier than being decannulated and capable of discharge house and be along with her household.

Talking to me as a visitor on my Strolling Residence From The ICU podcast, Megan expressed her gratitude for being allowed to be awake and strolling throughout her ICU keep, and her appreciation that she’s now house along with her daughter and capable of proceed her life.

She firmly believes her life was saved on account of being liberated from the phobia of delirium and being able to be awake and alert throughout her essential sickness.

Do you need to know extra about how administration of delirium within the ICU can drastically enhance affected person outcomes and dealing situations within the intensive care unit in your hospital? When you’re able to do what’s greatest on your sufferers, your ICU crew, and your backside line, we’re prepared to assist. We will stroll you thru your complete course of, so please don’t hesitate to contact us.