The complex interplay between delirium, sedation, and early mobility during critical illness: applications in the trauma unit

Abstract

Purpose of the review Critically ill patients are prescribed sedatives and analgesics to decrease pain and anxiety, improve patient – ventilator dyssynchrony and ensure patient safety. These medications may themselves lead to delirium and ICU-acquired weakness, which are associated with worse clinical outcomes. This review will focus on the epidemiology of these two disease processes and discuss strategies aimed at reducing these devastating complications of critical illness. Recent Findings Delirium and ICU-acquired weakness are associated with longer hospital stay, increased cost and decreased quality of life after discharge from the ICU. Delirium has also shown to be associated with increased mortality. Strategies aimed at reducing sedative exposure through protocols and coordination of daily sedation and ventilator cessation trials, avoiding benzodiazepines in favor of alternative sedative regimens and early mobilization of patients have all shown to significantly improve patient outcomes. Summary Delirium and ICU-acquired weakness are complications of critical illness associated with worse clinical outcomes and functional decline in survivors. An evidence-based approach based on the following tenets; minimization of sedative medication, particularly benzodiazepines, delirium monitoring and management and early mobilization may mitigate these complications.

Acquired Neuromuscular Weakness and Early Mobilization in the Intensive Care Unit

“…In a recent review citing the safety and benefits of early mobilization in medical ICU patients, Banerjee et al endorse early mobilization in the trauma ICU without providing specific recommendations on patient selection or treatment plan. 41 Similarly, Markandaya et al recently published a treatment plan for patients with acute spinal cord injury, in which they recommended "early mobilization (with spinal column stability ensured by operative fixation, external braces, or both), including frequent turning, out-of-bed to chair, and passive range of motion of the limbs," 42 …”

Long-Term Mechanical Ventilation: Management Strategies

“…In the acute care setting a bundled approach has been proposed in an attempt to both shorten MV time and also optimize function following critical illness. For example, Banerjee et al 32 have proposed the "ABCDE" bundle (attention to daily Awakening, spontaneous Breathing trials, sedation Choice, Delirium monitoring, and Exercise/early mobility) to improve functional and cognitive abilities of survivors of critical illness. The relevance of this type of approach to patients undergoing PMV is unclear, but accumulating data indicate that opportunities exist to improve the management of delirium and immobility in the LTAC setting at least.…”

“…The relevance of this type of approach to patients undergoing PMV is unclear, but accumulating data indicate that opportunities exist to improve the management of delirium and immobility in the LTAC setting at least. 32 A summary of data available to date in 2005 was presented at the National Association of Medical Directors for Respiratory Care conference. 3 At that conference, liberation from PMV for 7 consecutive days was, by consensus, considered to be weaning from PMV.…”

Zastosowanie deksmedetomidyny na oddziale intensywnej terapii dorosłych

“…Zachowanie orientacji autopsychicznej jest mylącym objawem, pod którym kryją się głębokie zaburzenia allopsychiczne -omamy wzrokowe, słuchowe, dotykowe z towarzyszącym tym doznaniom lękiem i sygnalizowanymi zaburzeniami snu. Pokrycie tego okresu niepamięcią jest pozytywnym rozwiązaniem dla chorego, jednak z punktu widzenia strategii leczenia, wystąpie-nie delirium nie jest jednak obojętne i wykazano, że ma ono bezpośredni wpływ na zwiększenie śmiertelności chorych leczonych na OIT [7,[13][14][15]. Wydawało się, że rozwiązaniem powyższego problemu może być okresowe przerywanie sedacji w celu zmniejszenia jej niekorzystnych następstw, dzięki skróceniu czasu wentylacji mechanicznej i leczenia na OIT.…”