Nightmares in the Pediatric ICU ~ Delirium & how to help #icurehab

The first official day at the Johns Hopkins Hospital Fifth Annual Critical Care Conference started with an amazing account of a patient’s experience in the Pediatric Intensive Care Unit (ICU) at Johns Hopkins Hospital.

celeste

Dr. Sapna Kudchadkar (@SapnaKmd) and patient Celeste (@Akituan_) shares her story.

During her stay in the ICU, Celeste reported having nightmares of strange things like cats on the table and gunshots. When intubated, Celeste had a hard time communicating and she felt scared and nervous to share what she was experiencing.  She reports that she was having nightmares even months after discharge. This speaks to a major theme here:

Delirium & deep sedation are a HUGE problem in the ICU

delirium

The ICU can be a scary place, even when not delirious 

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 (@DrDaleNeedham)

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 benzodiazepines & narcotics
    • Improve sleep  – it is complicated in the ICU but as best as possible allow your patients some quality rest

When working together as a multidisciplinary team of PTs, OTs, SLPs, RTs, Nurses, MDs, and Techs we can maximize our patient’s function and recovery.

“Get back to a normal life or even a better life, like I did!” Beautiful closing words from Celeste’s experience in the #PedsICU #ICURehab

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

Outcome of delirium in critically ill patients: systematic review and meta-analysisBMJ2015;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: www.acutept.org

 

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