ICU delirium is a known condition that can happen in critically ill patients.
In this article, we learn more from Dr. Alvin Ng, Consultant Respiratory Physician and Intensivist at The Respiratory Practice, on how hospitals’ intensive care unit (ICU) today has advanced to manage side effects such as delirium, dependence on a ventilator and even post traumatic stress disorder (PTSD).
Delirium in the ICU
Being admitted to an ICU sometimes means that patients’ condition may be critical, but the problems that accompany while one is in an ICU can be a distress itself. Among it can be a state of delirium, where patients could be in a mentally confused state with less awareness of the surrounding. Sometimes, this also translates into an inability to differentiate day from night. These are primarily due to the result of bright lights, heavy sedation and immobility.
“When a patient is on a ventilator with a tube down their throat, it’s very uncomfortable. We need to keep patients sedated to prevent them from moving around too much, pulling out those IV lines and breathing tubes, and more importantly, make them comfortable,” explained Dr. Ng.
In response to the sedation, patients can become confused and can lose touch with reality. With older people getting delirious too, this shows that delirium is not exclusive to the intensive care unit. However, with the use of sedatives, such cases can have a high incidence in the ICU.
Dr. Ng said traditional ICUs are set up in rooms with no windows. Immobile patients are subjected to the constant beeping of monitors and have no reference of day and night.
The modern ICUs are different and this includes the change in technique of sedation to the way ICUs are designed. Doctors have also changed their strategies to use minimal sedation and may even stop the sedation if patients feel comfortable enough on the ventilator. ICU facility designs have also evolved.
“The newer designed ICUs in some hospitals now have large windows for patients to look outside. It helps them with the orientation of day and night,” he emphasized.
Another common practice seen these days in the ICU is to help patients with mobilization. Some patients, although still connected on a ventilator, may be able to do simple physiotherapy such as getting in and out of bed, and mobilising so as to maintain good muscles tone.
While mobilizing patients on a ventilator does increase the chance of getting them off the ventilator, Dr. Ng cautioned that it has to be closely managed.
“As patients are lying in bed all the time, their muscles might start to atrophy because of the lack of use. We want our patients to go back to the state before they were intubated. This is why we need to keep the rest of their muscles going.”
Lasting Effects of Delirium
In Singapore, all these measures have led to a decrease in the number of delirium cases in ICU patients. However, in cases where a patient is still diagnosed to have ICU delirium despite all the changes, medication is prescribed to relieve that. Another factor is that more hospitals now have the means to check the state of patients and thus diagnose a delirious patient earlier in its course.
One of the most common lasting effects in the ICU is PTSD, a side effect that can present with variable severity.
“Patients find being on a ventilator quite stressful and they don’t want to go through that uncomfortable experience again. They remember that it’s not comfortable to be on the ventilator. But sometimes, this is necessary because we’re trying to buy time for them to recover,” Dr. Ng said.
Generally speaking, patients who are kept on ventilators for some time may experience some cognitive impairment for up to three years after they are discharged from the hospital. This may present as incoherent speech or inability to recognize loved ones.
According to Dr. Ng, the incidence in Singapore may not be as much compared to cases in other countries.
“This is perhaps due to the use of lighter sedation to cater to the Asian physique. Further study, however, is still required to understand this concept fully,” Dr. Ng concluded.