Making the ICU More Humane: A Roadmap for the Future
Gilles L. Fraser, PharmD, FCCM*
Clinical Pharmacist in Critical Care
Maine Medical Center
Portland, Maine, USA
Richard R. Riker, MD*
Associate Director
Maine Health Vital Network
Maine Medical Center
Portland, Maine, USA
Thirteen years ago, John Hansen-Flaschen, MD, challenged critical care providers to move “beyond the Ramsay scale” to make the intensive care unit (ICU) a more humane environment by developing valid tools to assess the presence and severity of agitation and the clinical issues associated with it.1 These tools would allow clinicians to evaluate the effectiveness of therapy and facilitate documentation of patient tolerance of the ICU experience. In addition, he called for the development of practice guidelines to build a foundation for the rational, evidence-based provision of comfort to the critically ill.
Much has been accomplished over the last decade. Assessment tools for pain, agitation and delirium have been developed and validated, leading to a better understanding of risk factors, recognition of short- and long-term sequelae, and new prevention and treatment strategies for these common clinical issues. Our discussion will highlight these gains in clinical practice since the publication of the 2002 Society of Critical Care Medicine/American College of Critical Care Medicine sedation and analgesia guidelines.
Pain Assessment and Treatment
In 1990, Puntillo reported that 63% of ICU survivors recalled moderate to severe pain.2 Despite considerable attention paid to the concept of unmet analgesic needs over the last 17 years, at least 50% of surveyed patients still report inadequate analgesia.3 This may relate to the uncomfortable, but necessary, aspects of ICU care, such as repositioning and endotracheal suctioning. The number of patients reporting inadequate analgesia also may be exacerbated by an ongoing under-appreciation of the impact this repeated discomfort may have.4 The fact that only 25% of patients receive pre-emptive analgesia prior to noxious events presents an opportunity for improvement that also may reduce the incidence of related sequelae including anxiety, delirium and post-traumatic stress disorder (PTSD).5,6
Evaluating pain in sedated or non-communicative patients remains difficult and likely contributes to undertreatment. The American Society of Pain Management Nurses provides a suggested approach for these patients7:
• Serially assess patients with pain and discomfort self-reporting tools (e.g, numeric rating scale), recognizing that communication capability changes with time
• Identify potential causes of pain and acknowledge that nonverbal patients experience pain
• Identify patient behaviors associated with pain and appreciate that changes in vital signs, without corroborative data, are not sufficient to assess analgesic needs
• Use analgesic agents as therapeutic and potentially diagnostic tools when the cause of patient agitation is uncertain
Our ability to identify pain in non-communicative patients has been advanced by the recent development of two reliable and validated assessment tools: the Behavioral Pain Scale and the Critical-Care Pain Observation Tool.8,9 These instruments are similar and score patients based on the presence of pain-based behaviors and tolerance of mechanical ventilation. Although they represent a significant step forward in pain evaluation, we await data linking these assessment scores with patient self-reporting of pain severity.
A new treatment paradigm providing analgesia-first “sedation” is based on the concept that pain and discomfort are primary causes of ICU agitation. This strategy employs opiate analgesia initially, supplemented by conventional sedative agents only if needed. Data suggest that 30% to 50% of agitated patients achieve comfort goals without benzodiazepines or propofol when this strategy is employed, and preliminary results indicate that this approach may be associated with shorter durations of mechanical ventilation and ICU stay.10-12
Treatment Strategies Using Assessment Tools Dramatically Affect Outcomes
It is difficult to overstate the importance of the development of reliable and valid sedation and agitation assessment tools. Systematic patient evaluation with these tools prompts more timely recognition and remedial intervention of agitation before it evolves into extreme behaviors.13 Further, incorporating these tools into sedation protocols brings dramatic improvements in a variety of ICU outcome measures by facilitating dose titration to established treatment goals (Table 1).14,15 These benefits likely are related to more consistent provision of sedation, resulting in calm but arousable patients while avoiding drug-induced coma, delirium and other adverse events.
Disappointingly, recent surveys suggest that less than 60% of ICUs employ a sedation scoring tool, and even fewer mandate daily sedation lightening.16 Without proper sedation monitoring, it is not surprising that more than 40% of patients are more deeply sedated than desired and that drug-induced coma complicates ICU care nearly one-third of the time.16,17 Some clinicians believe that a patient who appears to be sleeping without motor activity represents a comfortable patient. Others think that the ICU is an inhumane environment requiring blunted awareness to reduce unpleasant memories. However, recent data indicate that sedation-induced coma to achieve these patient goals may actually be counterproductive.18-20 Deep sedation (especially if benzodiazepine-induced) appears to be associated with delusional memories and delirium.19,20 Multivariate analysis indicates that drug-induced coma is a major risk factor associated with the development of delirium.20 This is a critical issue to recognize, as emerging data from many centers strongly link delirium with increased mortality and cost, longer ICU and hospital stays, and long-term cognitive dysfunction.21
Another long-term psychological consequence of the ICU experience is the development of PTSD. Its estimated prevalence in ICU survivors ranges from 3% to 59%.22 Recent work has found that delusional memories (rather than the recall of factual unpleasant events) commonly serve as PTSD triggers.23 Although causality has not been confirmed, data implicate benzodiazepines as risk factors, with the cumulative lorazepam dose correlating with formation of delusional memories and severity of PTSD symptoms.24,25
Looking Ahead
Strengthening evidence now suggests that the way clinicians evaluate agitated or comatose patients, and the way they use sedation and analgesia medications, have a tremendous impact on short- and long-term clinical outcomes. To improve outcomes, it is important to remember these points:
• Simply evaluating agitation and pain in a systematic fashion reduces their incidence by more than 30%.
• Implementing sedation and analgesia protocols that incorporate patient evaluation tools can reduce patient time on the ventilator and in the ICU by more than 25%.
• Drug-induced coma is associated with delirium and its associated poor outcomes.
• Benzodiazepine use (especially when administered for deep sedation) is an identified risk factor for delusional memories and PTSD.
In her recently published article, “Memories of Critical Illness: What Do We Know?” Christina Jones, PhD, suggested that it is time to re-evaluate our approach to patient comfort in the ICU and to broaden our definition of clinical success beyond mortality to include issues such as quality of life and cognitive function.26 These are important considerations as we build a roadmap for the future.
*Author has no disclosures to report.
References
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