Nightmares in the ICU ~ Delirium and how to help #icurehab

brochure copyWe started the day at the Johns Hopkins Hospital Fourth Annual Critical Care Conference with a chilling account of a patient’s experience in the Intensive Care Unit (ICU). She spoke about her trip to Johns Hopkins Hospital in a helicopter:

“It really felt like a scary scene out of Grey’s Anatomy!”

During her stay in the ICU, she reported having nightmares along the lines of vicious dinosaur chases akin to Jurassic Park and scary Lord of the Rings monster scenes . She reported that through the window there were construction workers on the roof and she believed they were snipers and frequently warned her family members to steer clear of the window. Her sister reports the marked change in personality even after discharge. Which speaks to a major theme here:

Delirium & deep sedation are a HUGE problem in the ICU


We learned that 20-80% of ICU patients develop delirium at some point and it is often misdiagnosed or goes unrecognized. However, here is the key:

“Just because something is COMMON, doesn’t mean that it is NORMAL.”

~ Dr. Dale Needham

This is another case where we need to shift our culture and preconceptions about the ICU and realize that while common, delirium can be prevented and when it is we WILL IMPROVE PATIENT OUTCOMES:

  • Delirium has been independently associated with a 2 – 13x increased risk of death
  • Associated with long term cognitive impairment
  • Increases ICU length of stay (8 vs. 5 days)
  • Increases hospital length of stay (21 vs 11 days)
  • Estimated nation costs of $4 to $16 BILLION !

There is good news though, we can help these patients. A randomized controlled trial in 2009 looking at mechanically ventilated critically ill patients who received early physical & occupational therapy showed nearly 50% decrease in days patients suffered from delirium  As well a much quicker return to independent functional status with discharge.

This is a complex issue and I encourage you to explore the resources at the bottom to learn more. But here are some tips to help with the management of of ICU delirium:

Identify and modify risk factors

    • Early mobilization of patients
    • Sedation – MINIMIZE use of benzodiaepines & narcotics
    • Improve sleep  – it is complicated in the ICU but as best as possible allow your patients some quality rest

Read more about it, click the article name for links:

Outcome of delirium in critically ill patients: systematic review and meta-analysisBMJ 2015;350:h2538

Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit  Ely, JAMA 2004; 291: 1753-1762

Early mobilization improves functional outcomes in mechanically ventilated critically ill patients, a randomized controlled trial. Schweikert, Lancet 2009; 373(9678): 1874-1882

There are also many great resources on the Acute Care Section of the APTA:

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