Blog dedicated primarily to randomly selected news items; comments reflecting personal perceptions

Sunday, September 27, 2015

Post-Intensive Care Syndrome

"Back when I started, everybody was heavily sedated. We didn't want to wake them up until we thought they were getting better."
Louise Rose, TD nursing professor, critical care research, Sunnybrook Health Sciences Centre, Toronto

"I'll tell people 'I can assure you that you were not sexually assaulted in the ICU', and they'll say, 'How do you know that for sure'?"
"I think this is why we're on a crusade about this -- why on Earth do we invest so much in the ICU, and the critical illness portion of this person's care, but we're not investing in their recovery? It makes no sense."
Dr. Margaret Herridge, professor of medicine, University of Toronto

These are the sickest of the sickest of the ICU survivors."
"It's almost as if they have survived the acute illness but now suffer from the consequence of every last reserve in their body being drained."
Dr. Ian Fraser, respirologist, medical director, Toronto East General Hospital

"...It was when I was being brought out of the drug-induced coma that I became fully psychotic [convinced one of her doctors was attempting to kill her]."
"[Being on a ventilator] was awful beyond belief."
"We owe it to our most vulnerable patients that their care doesn't stop when they exit the doors of the ICU."
"These things can happen to any one of us."
Cheryl Misak, patient, Toronto

As a patient, Cheryl Misak experienced a life-changing episode post-surgery when she hosted an infection that caused acute respiratory syndrome and septis, in 1998. Her profession as an academic guaranteed that she had a rational mind and was highly intelligent, as a philosopher and formerly provost at University of Toronto. Her ordeal in the ICU, however challenged her rationality, leading her to believe she had become a victim in a conspiracy to murder her in hospital.

When she did leave the hospital, frail and emaciated, the slightest exertion led to searing nerve pain in her body, shooting up from the soles of her feet to her neck. Sleep eluded her with the sound track of the ICU fixed in her mind and memory; the sound of the ventilator she was hooked up to, and other patients suffering the agonies of the same kind of "utter insanity" that had afflicted her. What afflicted her and the others is being identified by scientists, but little understood by them.

It is a phenomenon that afflicts mind and affects body, called "post-intensive care syndrome", where a full range of symptoms that may include muscle weakness, cognitive dysfunction similar to the onset of Alzheimer's disease or traumatic brain injury, anxiety, depression and post-traumatic stress disorder sets in. A study published in April concluded that 25 percent of patients who survive an ICU admission present with symptoms of post-traumatic stress disorder between one and six months following their hospital stay.

Some of these people suffering the symptoms of paralyzing depression struggle with thoughts of committing suicide. It is a problem of immense dimensions since over a quarter-million people are admitted every year in Canada to ICUs. Of the seventy-five percent who survive and are discharged from hospital, up to half of the patients will go on to experience symptoms of post-ICU syndrome, a situation that knows no age boundaries.

In a hospital's intense care unit, physical restraints and the overuse of sedation is common. And this can result in patients' impressions that they are being tortured, an impression that it is conjectured could lead to the after-shocks of intensive care. Cheryl Misak recalls that she hallucinated improbable scenarios from her hospital bed in the ICU while she was being treated from the devastating infection that put her there.

The protocols used in the ICU were led by the medical profession being convinced that deep sedation has the effect of decreasing patient agitation, making them less likely to withdraw breathing tubes or otherwise interfere with care given them. It was believed that patients would be more psychologically disturbed to be fully alert than to be under the influence of drugs. And yet high doses of some sedatives could contribute to ICU delirium, the widespread brain dysfunction capable of promoting paranoid delusions.

Distortion in apprehension occurs, however, when people are heavily sedated and also physically restrained, leading to "persecutory" delusions in the belief that someone is determined to hurt, perhaps even kill them. Now, research shows that lucid and accurate memories can be dealt with, however uncomfortable the situation, whereas delusional memories become harmful to the patient's mind. Leading to a move to use less sedation.

People can leave the ICU feeling anxious, depressed and weak, unable to return to normal life. The situation can be responsible for ruining marriages. Moreover, there is no best-practices standard of followup care for ICU patients. What brought Ms. Misak then 38, and the mother of two young children to hospital, was an invasion of group A streptococcus, the toxic bacteria known to 'eat' flesh, leading to amputations and sometimes death.

Follow-up research now suggests that one in three ICU patients requiring mechanical ventilation experience PTSD symptoms that can remain with them up to two years following discharge from hospital. Hundreds of ICU beds are filled daily with medically stable patients on a ventilator for 21 days or longer, and where the use of heavy sedation can cause an increase in the time that patients are on ventilators.

A "weaning" centre at Toronto East General Hospital is where a skilled team works to have patients breathe on their own again. And there, with the specialized weaning program, for patients who have been on ventilators for an average of two months there is minimal or zero sedation. The longer someone is on a mechanical breathing machine, the more likely the risk of dying, or never being able to breathe on their own.

The program that Dr. Herridge and her colleagues have organized is called the RECOVER program, teamed with the Canadian Critical Care Trials Group. Their focus is on minimizing the use of powerful sedatives, and to have an knowledgeable health care team screen for  symptoms of delirium in the ICU, to treat it aggressively before it makes its mark on the patient. The team is intent on establishing national standards for organized ICU followup and rehabilitation.

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