Intensive Care Patients




© Springer International Publishing Switzerland 2017
Maggi A. Budd, Sigmund Hough, Stephen T. Wegener and William Stiers (eds.)Practical Psychology in Medical Rehabilitation10.1007/978-3-319-34034-0_23


23. Intensive Care Patients



Jennifer E. Jutte1  


(1)
University of Washington/Harborview Medical Center, 325 9th Avenue Box 359740, Seattle, WA 98104, USA

 



 

Jennifer E. Jutte

Email:


Keywords
Acute lung injuryCritical careCritical illnessIntensive care unit



Topic


Patients participating in medical rehabilitation often come from an intensive care unit (ICU) environment and are recovering from critical illnesses or traumatic injuries. During ICU hospitalization patients can experience difficulties including lost autonomy, fear/anxiety, depressive symptoms, confusion/delirium, sleep/wake cycle dysregulation, or pain. These issues not only affect ICU and acute care hospitalization, but also can affect the rehabilitation process and recovery.

To be admitted to an ICU requires a severity of illness or injury that cannot be addressed on an acute care hospital floor. Patients often cannot breathe independently; thus their breathing is assisted via invasive or noninvasive mechanical ventilation. Patients admitted to an ICU are particularly vulnerable to psychological issues, both during their ICU stay and hospitalization, as well as longer term. Regardless of the reason for hospitalization, the ICU experience can affect patients emotionally and cognitively during their hospital stay and for years afterward.

Intensive care unit environments are characterized by high nurse-to-patient ratios and include the burns ICU (BICU), medical ICU (MICU), medical cardiac ICU (MCICU), trauma ICU (TICU), surgical ICU (SICU), and postanesthesia care unit (PACU) among others. And there are also pediatric-focused intensive care units including the neonatal ICU (NICU) and pediatric ICU (PICU). While each of these can be considered a critical care environment, for the purposes of maintaining chapter brevity, we focus solely on the MICU, MCICU, and TICU environments.

Key concepts in understanding the complexities of some common intensive care diagnoses, psychological issues experienced during intensive care hospitalization, and outcomes associated with critical illness are outlined below:


  1. A.


    Terminology


    1. 1.


      ABCDE Bundle

      A coordinated effort across disciplines for management of critically ill patients. It includes: (A) AWAKENING trials for ventilated patients; (B) Spontaneous BREATHING trials; (C) COORDINATED effort between respiratory therapist and nurse; (D) A standardized DELIRIUM assessment program; and (E) EARLY mobilization and ambulation .

       

    2. 2.


      Acute Respiratory Distress Syndrome ( ARDS )

      Within 1 week of a known clinical insult or new/worsening respiratory symptoms, ARDS is a type of acute, diffuse inflammatory lung injury characterized as respiratory failure not fully explained by cardiac failure or fluid overload and with clinical features including hypoxemia and bilateral opacities identified through chest radiograph or CT scan [1]. ARDS is further differentiated by level of severity as follows [1]:



      • Mild [PaO2/FiO2 between 200 and 300 mmHg with PEEP or CPAP ≥5 cmH2O];


      • Moderate [PaO2/FiO2 between 100 and 200 mmHg, with PEEP ≥5 cmH2O]


      • Severe [PaO2/FiO2 ≤ 100 mmHg with PEEP ≥ 5cmH2O].

       

    3. 3.


      Acute Stress Disorder

      The diagnostic criteria are similar to those for posttraumatic stress disorder (PTSD—see below), though there are two key differences (1) diagnosis is only made within the first month following a traumatic event and (2) there is greater emphasis on dissociative symptoms (e.g., numbing, reduced awareness, depersonalization, derealization, or amnesia). ASD is found to be highly predictive of development of PTSD. Risk factors include prior PTSD diagnosis, premorbid psychiatric dysfunction, and exposure to prior trauma.

       

    4. 4.


      Atelectasis

      Complete or partial collapse of a lung or lobe of a lung.

       

    5. 5.


      Bacteremia

      The presence of bacteria in the blood.

       

    6. 6.


      Bronchoscopy

      A visual or invasive examination of the breathing passages of the lungs. Involves placing a thin tube-like device (bronchoscope) through the nose or mouth and down the airways. The bronchoscope has a camera on the end of it. It is used for visual examination as well as biopsies and sample collection.

       

    7. 7.


      COPD (Chronic Obstructive Pulmonary Disease )

      Includes chronic bronchitis or emphysema or a combination of both. COPD is a preventable and treatable disease that makes it difficult to empty air out of the lungs and can lead to shortness of breath and fatigue.

       

    8. 8.


      CPAP (Continuous Positive Airway Pressure )

      Term is used interchangeably with PEEP (see below). Air is delivered to the lungs with slight pressure in an effort to prevent the airways from narrowing or closing. CPAP also is administered through a mask and often is used for treatment of obstructive sleep apnea (OSA).

       

    9. 9.


      Critical illness

      Condition in which life cannot be sustained without invasive therapeutic intervention. It is characterized by acute loss of physiologic reserve and can last hours to months depending on the underlying pathophysiology and response to treatment [2]. Critical illnesses often affect multiple organ systems including pulmonary, cardiovascular, renal, gastrointestinal, neurologic, and endocrine. Underlying reasons include a variety of factors such as infection, major trauma, burns, inhalation of noxious fumes, embolism, poisoning, radiation, and cancers. Although high morbidity and mortality are associated with critical illnesses, more and more people are surviving which, in turn, can lead to a host of long-term physical, cognitive, and emotional complications.

       

    10. 10.


      CF (Cystic Fibrosis)

      A life-threatening genetic disease in which a defective gene and its protein product cause the body to produce unusually thick, sticky mucous that clogs the lungs making it difficult to breathe. CF can result in death from lung infections.

       

    11. 11.


      Delirium

      A reversible, acute-onset syndrome that typically develops suddenly over a short period of time and results in transient global cognitive dysfunction that represents a change from baseline. Delirium has a waxing and waning clinical course marked by periods of confusion and lucidity.


      1. a.


        Three types: hyperactive, hypoactive, and mixed delirium.

         

      2. b.


        Four core features :


        1. (1)


          Fluctuations in level of attention and orientation

           

        2. (2)


          Reduced awareness and/or perceptual disturbance (e.g., hallucinations [mostly visual])

           

        3. (3)


          Changes in psychomotor behavior (e.g., agitation/restlessness and lethargy/slow reaction time)

           

        4. (4)


          Changes in cognition (e.g., high distractibility, reduced ability to focus, sustain, or shift attention)

           

         

      Note: There are several terms often used in error to describe delirium including: intensive care unit (ICU) psychosis, acute brain failure, acute brain syndrome, and reversible dementia. You should avoid using these terms because they misrepresent the typical causes of delirium and because they overemphasize psychosis that does not always occur (e.g., hypoactive delirium).

       

    12. 12.


      Early Mobility

      Mobility that occurs within 24–48 h after ICU admission. Mobilizing patients who are critically ill, and often mechanically ventilated, in the ICU has been shown to be important for reducing complications such as neuromuscular weakness, though it is not common practice across ICUs [2, 3].

       

    13. 13.


      Extubation

      Removal of an endotracheal tube (i.e., breathing tube).

       

    14. 14.


      F i O 2

      Fraction of inspired oxygen.

       

    15. 15.


      FEV (Forced Expiratory Volume )

      Measures how much air a person can exhale during a forced breath.

       

    16. 16.


      Healthcare Associated Infections ( HAIs )

      Infections that people acquire while receiving treatment for another condition in a healthcare setting. HAIs affect approximately 1 in every 20 patients in a hospital setting. They cost the U.S. healthcare system billions of dollars annually and are associated with mortality, though they are preventable.

       

    17. 17.


      Hypercapnic

      A condition of abnormally elevated carbon dioxide (CO2) levels in the blood. Also termed hypercarbic.

       

    18. 18.


      Hypothalamic–Pituitary–Adrenal (HPA) Axis

      A collection of structures involved in the regulation of the stress response. These structures include the periventricular nucleus of the hypothalamus, the anterior lobe of the pituitary gland, and the adrenal gland.

       

    19. 19.


      Hypoxemia/Hypoxemic

      A state in which there is low arterial oxygen supply.

       

    20. 20.


      Hypoxia/Hypoxic

      A state in which oxygen supply is limited in the tissues. Can be generalized or localized.

       

    21. 21.


      ICU-Acquired Weakness

      Diffuse, symmetric, generalized muscle weakness detected by physical examination and meeting specific strength-related criteria (namely, inability to overcome resistance on manual muscle strength testing) that develops after critical illness onset without other identifiable cause [4].

       

    22. 22.


      Intubation

      Endotracheal intubation is a procedure in which a tube is inserted through the mouth down into the trachea. The purpose is to allow air to flow freely into and out of the lungs to facilitate breathing. Intubation also permits use of a mechanical ventilator when patients are unable to breathe on their own.

       

    23. 23.


      Invasive Mechanical Ventilation (MV)

      A life-saving procedure for persons with respiratory failure. A mechanical ventilator is a machine that makes it easier for patients to breathe until they are able to breathe on their own.



      • ○ MV satisfies a couple of functions : (1) improvement of pulmonary gas exchange during acute hypoxemic or hypercapnic respiratory failure with respiratory acidosis and (2) redistribution of blood flow from working respiratory muscles to other vital organs thus aiding in the management of shock from any cause. Although life-saving, MV also can be toxic and, thus, should be removed as early as it is feasible to do so.


      • ○  Process of MV:



        • ▪ Successful intubation of the trachea


        • ▪ Endotracheal tube placement


        • ▪ Select ventilator settings


        • ▪ Ventilator mode (determines how the ventilator initiates a breath, how the breath is delivered, and the breath is terminated)


      • ○ There are several types of MV including:


        1. 1.


          Assist-control (AC) : The tidal volume (VT) of each delivered breath is the same whether generated by MV or the patient. AC is a patient- or time-triggered, flow limited and volume-cycled mode of ventilation. If the patient does not initiate a breath within a predetermined time interval, then the ventilator will deliver a determined VT—this is referred to as time-triggered. If the patient does initiate a breath, then the ventilator will deliver a determined VT—this is referred to as patient-triggered. Regardless of type of initiation, the breaths are limited to a particular flow rate and pattern.


          1. a.


            Benefits: low work of breathing because every breath is supported and tidal volume is guaranteed.

             

          2. b.


            Concerns: Tachypnea could lead to hyperventilation and respiratory alkalosis.

             

           

        2. 2.


          Synchronized intermittent mandatory ventilation ( SIMV ) : Similar to AC except that the breaths triggered by the patient are supported with pressure instead of set volumes (see PSV described below). The volumes are determined by the patient’s strength and lung abilities. Pressure support may be added to these breaths to supplement their volumes. With SIMV, ventilator-assisted breaths are different than patient-triggered breaths. If the respiratory rate on the ventilator is high, it allows for very little spontaneous breathing, whereas low respiratory rates allow for more opportunities for the patient to breathe spontaneously.


          1. a.


            Benefits: Allows spontaneous breaths and less ventilator support, thus allowing the patient to “exercise” their respiratory muscles.

             

          2. b.


            Concerns: May increase the work of breathing and cause respiratory muscles to become fatigued, perhaps delaying extubation and weaning.

             

           

        3. 3.


          Pressure support ventilation ( PSV ) : PSV can be used alone or in combination with SIMV. In PSV, inspiratory pressure is added to spontaneous breaths, which can be helpful for overcoming the resistance of the endotracheal tube or to increase the volume of spontaneous breaths. With PSV, patients can control the rate but not depth of breaths. When added to SIMV, PSV is added only to those spontaneous breaths that occur in between volume-guaranteed breaths. When PSV is used alone, all breaths are spontaneous; the patient determines respiratory rate and VT.

           

      Note: For patients who are heavily sedated, paralyzed, or otherwise unable to breathe on their own—AC and SIMV are identical.

       

    24. 24.


      Neuroleptic Malignant Syndrome

      Signs include severe muscle rigidity, elevated temperature, and other related findings (e.g., diaphoresis, incontinence, decreased level of consciousness, mutism, elevated or labile blood pressure, and elevated creatine phosphokinase) developing in association with the use of neuroleptic (i.e., antipsychotic) medication.

       

    25. 25.


      Noninvasive Mechanical Ventilation (NIV)

      Assisted ventilation that is offered through a mask. Patients with hypercapnic forms of respiratory failure are more likely to benefit, though those with hypoxic respiratory failure may also benefit. NIV allows patients to take deeper breaths with less effort.

       

    26. 26.


      PaO 2

      Partial pressure of arterial oxygen.

       

    27. 27.


      PEEP (Positive-End Expiratory Pressure)

      Refers to pressure that is applied at the end of expiration to maintain alveolar recruitment. It is a term that is used interchangeably with CPAP.

       

    28. 28.


      Personal Protective Equipment ( PPE )

      Specialized clothing or equipment worn by a hospital employee for protection against infection. In the ICU setting these include gloves, gowns, mask/respirator, goggles, and face shields.

       

    29. 29.


      Phrenic Nerve

      A nerve that originates in the cervical region (C3–C5) and passes through the lungs and heart to reach the diaphragm. It is important for breathing function. Damage to the phrenic nerve has been associated with prolonged hospitalization and duration of mechanical ventilation.

       

    30. 30.


      Postintensive Care Syndrome ( PICS )

      A term used to describe “new or worsening impairments in physical, cognitive, or mental health status arising after critical illness and persisting beyond acute care hospitalization” [4]. Given the high frequency with which patients experience multiple issues across domains (physical, psychological, and cognitive) following critical illness, the Society for Critical Care Medicine (SCCM) coined the term Postintensive Care Syndrome (PICS) in 2010.

       

    31. 31.


      Posttraumatic Stress Disorder

      According to the DSM-V, PTSD is diagnosed when an individual directly experiences a traumatic event (e.g., physical trauma, war exposures, and sexual violence). However, PTSD symptoms also can occur after critical illness and injury and is being recognized as a common consequence of ICU hospitalization. ICU-related risk factors include longer duration of sedation; memories of adverse ICU experiences; and delirium [5]. Note: As in other treatment settings, PTSD is not diagnosed until the duration of symptoms (intrusion symptoms, avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity) is at least 1 month.

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Jun 25, 2017 | Posted by in PSYCHOLOGY | Comments Off on Intensive Care Patients

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