The Intensive Care Unit – Part 1 – Dennis M., Occupational Therapist
The intensive Care Unit (ICU) provides treatment of the sickest hospitalized patients. Advances in ICU have rescued many who would have previously died. Many survivors suffer from severe symptoms of disease processes acquired or accelerated during their ICU stay. ICU’s are experiences an epidemic of patients with delirium and weakness, both associated with increased mortality and long term disability. These conditions are commonly acquired in the ICU and are often initiated or exacerbated by sedation and ventilation decisions and management. Despite greater than ten years of evidence revealing the hazards of delirium and weakness the gap exists with current and ideal processes of care exist.
Monitoring of delirium and sedation levels remains inconsistent. Sedation, ventilation and Physical and Occupational Therapy practices have proven successful at reducing the frequency and severity of adverse outcomes are not routinely practiced. Delirium is an acute, fluctuating change in consciousness and cognition that develops over a brief time period. ICU delirium is a frequent complications of critical care, developing in approximately two-thirds of critically ill patients. Despite the high prevalence, without active monitoring, it goes under diagnosed in up to 72% of cases. ICU acquired weakness is the acute onset of neuromuscular/functional impairment in the critically ill, for which there is no plausible etiology other than critical illness. Generalized weakness impairs ventilator weaning and functional mobility and ADL’s. An additional key risk factor for ICU acquired weakness is the duration of mechanical ventilation experienced by patients, with weakness occurring in up to 58% of patients who receive mechanical ventilation for at least seven days. ICU acquired weakness require approximately 20 additional days of mechanical ventilation with increased mortality 48% versus 19%. Effects of ICU weakness persists well after hospital discharge with 60% of patients experiencing continued muscle dysfunction up to one year after illness.
A preventative strategy must take advantage of shared and reinforcing features to be more efficient and effective in minimizing delirium, weakness and other adverse outcomes. One set of practices that have been put forth is known at the ABCDE bundle. This is a multicomponent process that is interdependent and designed to: 1. Improve collaboration among clinical team members, 2. Standardize care processes; 3. Break the cycle of over sedation and prolonged ventilation, which appears to be leading to delirium and weakness. The next article in this two part series will discuss the ABCDE bundle in greater detail.