{"id":724,"date":"2015-08-21T19:45:55","date_gmt":"2015-08-21T19:45:55","guid":{"rendered":"https:\/\/www.mc.vanderbilt.edu\/vanderbiltmedicine\/?p=724"},"modified":"2021-08-11T19:41:39","modified_gmt":"2021-08-11T19:41:39","slug":"undone-in-the-icu","status":"publish","type":"post","link":"https:\/\/medschool.vanderbilt.edu\/vanderbilt-medicine\/undone-in-the-icu\/","title":{"rendered":"Undone in the ICU"},"content":{"rendered":"
\"Illustration<\/a>
Illustration by Yuri Lobo<\/figcaption><\/figure>\n

\u201cI was under the impression that I was being held prisoner. There were people I was aware of who would come into the room, in the outer areas, and they wouldn\u2019t talk to me or look at me. I remember being aware that I couldn\u2019t move my arms. I was being held somehow. I started picking at what I thought was a line of threads, thinking, if I could just get these threads loose, I can be free. I felt that I was a prisoner and I was trying to escape.\u201d<\/p>\n

Six years after being admitted to Vanderbilt\u2019s medical intensive care unit (ICU) for acute respiratory distress syndrome, Melissa Akers, 55, still recalls with clarity the delusions she experienced while she was sedated and on life support. The images that haunted her as she slipped into a state of delirium over the course of six weeks in the ICU play on a continuous loop in what she refers to as \u2018snapshot memories.\u2019<\/p>\n

\u201cI remember to the left of my hospital bed there was a window that I thought was a dead end street with a Volkswagen parked in it, and I thought if my husband could just get me to it, I could get away,\u201d Akers recalled.<\/p>\n

Even more frightening than the hallucinations she experienced in the ICU is the cognitive impairment she has struggled with since she left.<\/p>\n

\u201cMy brain changed incredibly. My short-term memory doesn\u2019t stick. I am not back to where I was before I got sick,\u201d said Akers, who could not walk, talk or feed herself after her lengthy hospital stay. \u201cLearning to accept that I am disabled is something I struggled with and fought against. The words \u2018new normal\u2019 is the place I had to get to.\u201d<\/p>\n

Between 60 to 80 percent of ICU patients experience delirium, characterized by inattention and confusion and the inability to think clearly and make sense of what is happening. Delirium is typically caused by diseases like sepsis combined with the sedatives patients are given.<\/p>\n

When critically ill patients experience delirium, which can occur over a short period of time, it is a predictor of longer stays in the hospital, higher cost of care, threefold higher likelihood of death by six months, and long-term cognitive impairment that looks a lot like dementia.<\/p>\n

Akers prided herself on being a multitasker when she worked in the Medical Center\u2019s development office. Her executive function\u2014a group of thinking skills that help people plan, problem solve and set goals\u2014spiraled to the ninth percentile following her ICU stay, and she was unable to return to her job.<\/p>\n

Understanding the Scope of the Problem<\/strong>
\nMuch of what is known about delirium in the ICU and its long-term impact can be attributed to the work of Vanderbilt\u2019s ICU Delirium and Cognitive Impairment Study Group, led by Wes Ely, M.D., MPH, professor of Medicine and Critical Care, alongside an interprofessional team of other physicians, surgeons, nurses, psychologists, pharmacists, biostatisticians and health policy experts.<\/p>\n

In the late 1990s, Ely, a critical care pulmonologist who specializes in geriatric problems, started noticing a trend among his patients who were lucky enough to leave the ICU alive.<\/p>\n

\u201cI started seeing patients, both young and old, come back to the clinic who couldn\u2019t balance a checkbook, plan a party, remember where they parked their car, or walk without support. Sometimes they couldn\u2019t return to work or school,\u201d Ely said. \u201cPatients and families ask \u2018What happened, and what is this private nightmare I\u2019m living now?\u2019\u201d<\/p>\n

\"\"<\/a>
Photo by Joe Howell<\/figcaption><\/figure>\n

In an attempt to measure delirium, he and his colleagues developed and validated the Confusion and Assessment Method (CAM) for the ICU (CAM-ICU), a 2-minute nursing bedside assessment based on one developed for elderly patients, and began training intensivists and nurses at Vanderbilt and around the country.<\/p>\n

\u201cSo now people could measure something. It was valid, it was reliable. It meant something,\u201d Ely said. \u201cIt quickly became an \u2018if you build it, they will come\u2019 sort of phenomenon. People all over the world started using the CAM-ICU and translated it into more than 25 languages.\u201d<\/p>\n

Vanderbilt\u2019s ICU Delirium and Cognitive Impairment Study Group has spent the past decade connecting ICUs around the country, sharing information and collaborating to restore patients not only to good health physically, but emotionally and cognitively. The scope of the group\u2019s work is voluminous with more than 150 peer-reviewed publications on delirium alone. (See sidebar)<\/p>\n

\u201cDelirium in critically ill, hospitalized adults is a serious yet understudied issue,\u201d said Molly Wagster, Ph.D., chief of the Behavioral & Systems Neuroscience Branch in the National Institute on Aging, part of the National Institutes of Health. \u201cThese findings provide important evidence of the extent of the problem, the imperative for greater recognition and the pressing need for solutions.\u201d<\/p>\n

A 2013 New England Journal of Medicine study found that 74 percent of the 821 patients studied, all adults with respiratory failure, cardiogenic shock or septic shock, developed delirium while in the hospital, which the authors found is the strongest and most modifiable independent predictor of a dementia-like brain disease that can persist years after discharge from the ICU.<\/p>\n

\u201cAs medical care is improving, patients are surviving their critical illness more often, but if they are surviving their critical illness with disabling forms of cognitive impairment then that is something that we will have to be aware of, because just surviving is no longer good enough,\u201d said lead author Pratik Pandharipande, M.D., MSCI, professor of Anesthesiology and Critical Care.<\/p>\n

Akers\u2019 husband, Doug, said the hospital staff tried to prepare them for what lay ahead, including several months in rehab.<\/p>\n

\u201cIt wasn\u2019t the ARDS she was recovering from; it was the immobilization. Six months after rehab, Melissa still was barely able to go up steps. You might expect that with someone who has had a stroke, not just from lying in bed,\u201d he said.<\/p>\n

Escape Fire<\/strong>
\nEly describes the standard of care that had to be overcome in order to effect better outcomes for critically ill patients.<\/p>\n

\u201cIf a patient comes into the ICU and is dramatically sick, he is put on a ventilator. The old way of thinking was \u2018You are so sick, we don\u2019t want you to remember any of this. We are going to sedate you with drugs, tie you down, protect you from yourself; and when we think you\u2019re better, we\u2019ll wake you up, in six or seven days.\u2019<\/p>\n

\u201cIn the meantime the patient has now acquired brain disease and body disease; his muscles, brain and nerves are all screwed up, and it\u2019s not just because of the disease he came in with. We created more of a disease for him by immobilizing him with both chemical and physical restraints. We actually poured kerosene on the fire and made things worse.\u201d<\/p>\n

\"Photo<\/a>
Photo by Joe Howell<\/figcaption><\/figure>\n

The ICU Delirium and Cognitive Impairment Study Group,\u00a0in collaboration with the University of Chicago and others and building on evidence published in major journals like the Journal of the American Medical Association, New England Journal of Medicine and Lancet, developed the \u2018ABCDEF\u2019 protocol to help patients \u201cescape the fire of pain of suffering,\u201d Ely said.<\/p>\n

ABCDEF is a standard bundle of ICU measures that includes:<\/p>\n

Assess for and manage pain; Both Spontaneous Awakening Trials (SATs) & Spontaneous Breathing Trials (SBTs)\u2014i.e., turning off sedatives and the ventilator every day; attention to the Choice of sedation and analgesia; Delirium monitoring and management; Early mobility; and Family engagement.<\/p>\n

\u201cNow, instead of coming into the ICU and being thrown in the fire with the ventilator, sedatives and restraints, we\u2019re going to assess every single day for pain,\u201d Ely said. \u201cWe ask the families to keep us honest when we tell them we\u2019re going to check their loved one every day for delirium, we\u2019re going to stop sedatives and try to get them off the ventilator every day.\u201d<\/p>\n

ICU Liberation<\/strong>
\nEly was recently tapped to co-chair the ICU Liberation Campaign, created and funded by the Society of Critical Care Medicine (SCCM) with a grant from the Gordon and Betty Moore Foundation. The campaign is designed to educate providers on the clinical practice guidelines for the Management of Pain, Agitation, and Delirium (PAD) in Adult Patients in the Intensive Care Unit. Timothy D. Girard, M.D., MSCI, assistant professor of Medicine, serves on the task force.<\/p>\n

Vanderbilt will host a two-day conference in September with ICU simulation demonstrations that will teach implementation strategies and discuss application of the PAD guidelines. Additionally, there will be a collaborative process with 80 ICUs across the country (both adult and pediatric) to put the ABCDEF bundle into play.<\/p>\n

\u201cHospitals across the globe are implementing this,\u201d Ely said.<\/p>\n

Gordon Moore, co-founder of Intel, prompted the addition of the \u201cF\u201d to the bundle for \u2018family engagement\u2019 based on his own experience of ICU delirium.<\/p>\n

Having dedicated his career to improving the lives of patients not only while they are in the ICU but after they leave, Ely sums it up with what he calls his mantra:<\/p>\n

\u201cIt\u2019s about preservation of self-worth and human dignity,\u201d he said.<\/p>\n

\u201cIt is undignified to be lying in a hospital, suffering in pain. We have to show our patients that we know they have dignity. Historically, the ICU has not been geared to do that. In the past, providers did not care to look at how patients did after the ICU as long as they survived the life support,\u201d he said. \u201cThe patients were telling us their lives are awful afterwards. This is unacceptable.\u201d<\/p>\n

To hasten recovery, Vanderbilt now follows ICU patients after discharge through the Vanderbilt ICU Recovery Center led by Carla Sevin, M.D., neuropsychologist James Jackson, Psy.D., alongside pharmacists and nurse practitioners.<\/p>\n

Melissa Akers, who battled leukemia for two years before she developed ARDS that landed her in the ICU, can attest to the need for\u00a0follow up.<\/p>\n

\u201cI never dreamed after leukemia and chemo that anything else could be worse. And this was so much worse\u2014spiritually, emotionally, physically and intellectually\u2014than cancer. Presented with ARDS or cancer, I\u2019d choose leukemia,\u201d she said.<\/p>\n","protected":false},"excerpt":{"rendered":"

\u201cI was under the impression that I was being held prisoner. There were people I was aware of who would come into the room, in the outer areas, and they wouldn\u2019t talk to me or look at me. I remember being aware that I couldn\u2019t move my arms. I was being held somehow. I started…<\/p>\n","protected":false},"author":211,"featured_media":844,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"jetpack_post_was_ever_published":false,"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_publicize_message":"","jetpack_publicize_feature_enabled":true,"jetpack_social_post_already_shared":true,"jetpack_social_options":{"image_generator_settings":{"template":"highway","default_image_id":0,"font":"","enabled":false},"version":2},"_links_to":"","_links_to_target":""},"categories":[14,15,23],"tags":[],"class_list":["post-724","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-vm-features","category-vm-homepage-highlights","category-vm-summer-2015"],"acf":[],"jetpack_publicize_connections":[],"jetpack_featured_media_url":"https:\/\/cdn.vanderbilt.edu\/t2-main\/medschool-prd\/wp-content\/uploads\/sites\/82\/2015\/08\/undone-d.jpg","jetpack_sharing_enabled":true,"jetpack_shortlink":"https:\/\/wp.me\/pcDnub-bG","_links":{"self":[{"href":"https:\/\/medschool.vanderbilt.edu\/vanderbilt-medicine\/wp-json\/wp\/v2\/posts\/724","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/medschool.vanderbilt.edu\/vanderbilt-medicine\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/medschool.vanderbilt.edu\/vanderbilt-medicine\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/medschool.vanderbilt.edu\/vanderbilt-medicine\/wp-json\/wp\/v2\/users\/211"}],"replies":[{"embeddable":true,"href":"https:\/\/medschool.vanderbilt.edu\/vanderbilt-medicine\/wp-json\/wp\/v2\/comments?post=724"}],"version-history":[{"count":1,"href":"https:\/\/medschool.vanderbilt.edu\/vanderbilt-medicine\/wp-json\/wp\/v2\/posts\/724\/revisions"}],"predecessor-version":[{"id":3154,"href":"https:\/\/medschool.vanderbilt.edu\/vanderbilt-medicine\/wp-json\/wp\/v2\/posts\/724\/revisions\/3154"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/medschool.vanderbilt.edu\/vanderbilt-medicine\/wp-json\/wp\/v2\/media\/844"}],"wp:attachment":[{"href":"https:\/\/medschool.vanderbilt.edu\/vanderbilt-medicine\/wp-json\/wp\/v2\/media?parent=724"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/medschool.vanderbilt.edu\/vanderbilt-medicine\/wp-json\/wp\/v2\/categories?post=724"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/medschool.vanderbilt.edu\/vanderbilt-medicine\/wp-json\/wp\/v2\/tags?post=724"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}