LDS Emergency Preparedness

Be Prepared, Not Scared!

How to Survive in the Intensive Care Unit

Posted by Elise on May 5, 2011

adamci (sxc.hu)

If we’ve learned one thing about hospital care in recent years it’s this — being a patient can be more dangerous than whatever medical problems you already had! It’s one of those perplexing ironies, but the intensive care unit (ICU), in particular, can be destructive to one’s health and well-being. As many as 80% of patients who have survived a critical illness that required a stay in intensive care paid a price. While recovering from the immediate problem — such as a heart attack or pneumonia — many patients develop cognitive problems, for example, trouble with focus and concentration. They may also have difficulty performing simple, everyday tasks and experience a decreased quality of life, and once they’ve left the hospital, they may find themselves unable to return to work. In some cases, individuals continue to feel these ill effects up to one or two years later… and for an unlucky few, the impact is even longer term.

Memory and thinking difficulties after a stay in the ICU can make it seem as if your brain is stuck in molasses, observes E. Wesley Ely, MD, MPH, an expert in critical care at Vanderbilt University School of Medicine. Now he and his colleagues have designed a five-step protocol to improve care and outcomes for ICU patients.

 THE CODE: A-B-C-D-E

At Vanderbilt, Dr. Ely and his colleagues have devised what they call the A-B-C-D-E model of care:

  • Awakening (stopping sedation)
  • Breathing Coordination (stopping respirator)
  • Choice of Proper Sedation
  • Delirium Monitoring
  • Early Exercise and Mobility

Some four out of every 10 US hospitals have already introduced at least some of these steps, but the guidelines are basic enough that family members can check to see if they’re being followed. (Note: This is a key reason why it is so important to stay with a loved one during a hospitalization.)

 YOUR ROLE IN THE HOSPITAL

Here is what you can do to make sure that caregivers know their A,B,C,D,Es and that you or your loved one gets the best possible care in the ICU…

WAKE PATIENTS AT REGULAR INTERVALS

Many hospitals now make it a habit to wake sedated patients and those on ventilators to see whether they can breathe on their own — the idea being that the earlier that breathing tubes and ventilators can be removed, the lower the risk for delirium and subsequent cognitive difficulties. But the flip side of this guideline may be equally important — hospitals should let patients sleep through the night whenever possible! As many of us know from personal experience, sleep is often the casualty of a hospital stay. Caregivers should wake patients a few times a day, and if they’re sleeping through the night, leave them be.

GO LIGHT ON THE SEDATION

Like sleep deprivation, heavy and prolonged sedation can cause or worsen delirium. Some sedatives (such as benzodiazepines) are more likely than others to produce delirium, but Dr. Ely emphasizes that sedation is not a one-size-fits-all proposition and must be carefully individualized. A good approach, Dr. Ely says, is to ask your physician to use the lightest possible postsurgical sedation — a level that effectively relieves pain but still leaves the patient’s mental state as intact as possible.

GET OUT OF BED

Most ICU patients should move around as much as possible because we now know that immobility leads not only to loss of muscle strength and increased frailty, but also a higher risk for confusion and delirium. ICU patients can often receive physical therapy that helps them stay limber with range-of-motion exercises. When patients are able, it’s good for them to leave the bed and sit in a chair (with help of course) a few times a day and eventually work their way up to a walk down the hall.

WATCH CAREFULLY FOR SIGNS OF DELIRIUM

It’s vital to make sure that the doctors and nurses are watching for signs of delirium (and loved ones and family members should also be closely attuned for telltale signs) because the longer delirium persists in the ICU, the greater the likelihood of later cognitive impairment.

To catch delirium early on, doctors and nurses (and you, too) need to check patients for such early signs as inattentiveness — for instance, the inability to stay focused or follow a command for 10 seconds (such as being able to squeeze the nurse’s hand every time she says a word with the letter “A” in it). If confused responses suggest delirium, your physician can take prompt steps to control it, including cutting back on sedatives… helping the patient to get out of bed and move around (with appropriate assistance)… removing physical restraints and catheters… and allowing him/her to sleep through the night by performing only nonintrusive monitoring of vital signs.

IF YOU SEE SOMETHING, SAY SOMETHING

ICU patients are very sick, typically not well enough to advocate for themselves, which means it’s up to family members and close friends to step in and fill the breach. Dr. Ely advises that you do this by keeping in very close touch with the patient’s medical team. If you notice, for example, that your mother suddenly seems “not herself” — even if there are no obvious signs of delirium — tell her physician right away and bring up the possibility of early delirium. Dr. Ely says that alerting doctors is half the battle and can unquestionably lead to better, happier outcomes all around. The new model, he hopes, will make ICU care much easier — almost as simple as knowing your A,B,C,D,Es!

Source(s): E. Wesley Ely, MD, MPH, professor of medicine, Vanderbilt University School of Medicine,Nashville. He is founder of Vanderbilt’s ICU Delirium and Cognitive Impairment Study Group and the associate director of aging research for the VA Tennessee Valley Geriatric Research and Education Clinical Center (GRECC).

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