Episode 62: The Right To Know

We say we respect patient autonomy. We provide informed consents prior to intubation. Should patients be warned of the risks and repercussions of sedation and immobility? When sedation is nonessential, should patients be given the choice to be comatose or awake and moving?

Should we treat sedation and immobility like any other medical intervention and informed patients that sedation will increase the risks of:

- Dying in the ICU or after the ICU [1,2]

- Infection [3,4]

- Pressure sores [5]

- Blood clots [6]

- Delirium [7–9]

- ICU acquired weakness [10]

- More time on the ventilator [1]

- More time in the hospital [11]

- Tracheostomy [12]

- Discharge from hospital to rehabilitation center or nursing home [13]

- Post-ICU PTSD [14,15]

- Post-ICU dementia (cognitive dysfunction) [16]

- Depression [17]

- Being readmitted to the hospital and ICU [18]

-Post-Intensive Care Syndrome [19]

As well as decrease their chances of:

- Discharging home from the hospital [13]

- Being able to walk upon transfer from the ICU [10]

-Returning to work [20]

-Optimal quality of life [21]

If we’re not providing this information, are we truly informing our patients prior to automatically sedating them?

Are we honoring their right to be informed and make their own decisions?

References:

1. Shehabi, Y., Bellomo, R., Reade, M. C., Bailey, M., Bass, F., Howe, B., McArthur, C., Seppelt, I. M., Webb, S., Weisbrodt, L., Sedation Practice in Intensive Care Evaluation (SPICE) Study Investigators, & ANZICS Clinical Trials Group (2012). Early intensive care sedation predicts long-term mortality in ventilated critically ill patients. American journal of respiratory and critical care medicine, 186(8), 724–731. https://doi.org/10.1164/rccm.201203-0522OC
2. Tanaka, L. M., Azevedo, L. C., Park, M., Schettino, G., Nassar, A. P., Réa-Neto, A., Tannous, L., de Souza-Dantas, V. C., Torelly, A., Lisboa, T., Piras, C., Carvalho, F. B., Maia, M., Giannini, F. P., Machado, F. R., Dal-Pizzol, F., de Carvalho, A. G., dos Santos, R. B., Tierno, P. F., Soares, M., … ERICC study investigators (2014). Early sedation and clinical outcomes of mechanically ventilated patients: a prospective multicenter cohort study. Critical care (London, England), 18(4), R156. https://doi.org/10.1186/cc13995
3. Lin, S. M., Huang, C. D., Liu, C. Y., Lin, H. C., Wang, C. H., Huang, P. Y., Fang, Y. F., Shieh, M. H., & Kuo, H. P. (2008). Risk factors for the development of early-onset delirium and the subsequent clinical outcome in mechanically ventilated patients. Journal of critical care, 23(3), 372–379. https://doi.org/10.1016/j.jcrc.2006.09.001
4. Rello, J., Diaz, E., Roque, M., & Vallés, J. (1999). Risk factors for developing pneumonia within 48 hours of intubation. American journal of respiratory and critical care medicine, 159(6), 1742–1746. https://doi.org/10.1164/ajrccm.159.6.9808030
5. Cox, J., Roche, S., & Murphy, V. (2018). Pressure Injury Risk Factors in Critical Care Patients: A Descriptive Analysis. Advances in skin & wound care, 31(7), 328–334. https://doi.org/10.1097/01.ASW.0000534699.50162.4e
6. Minet, C., Potton, L., Bonadona, A., Hamidfar-Roy, R., Somohano, C. A., Lugosi, M., Cartier, J. C., Ferretti, G., Schwebel, C., & Timsit, J. F. (2015). Venous thromboembolism in the ICU: main characteristics, diagnosis and thromboprophylaxis. Critical care (London, England), 19(1), 287. https://doi.org/10.1186/s13054-015-1003-9
7. Pandharipandh, P., Shintani, A., Peterson, J., Truman, B., Wilkinson, G., Dittus, R., Bernard, G., Ely, W.(2006). Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients, Anesthesiology, 104. Retrieved from https://pubs.asahq.org/anesthesiology/article/104/1/21/7483/Lorazepam-Is-an-Independent-Risk-Factor-for
8. Yang, J., Zhou, Y., Kang, Y., Xu, B., Wang, P., Lv, Y., & Wang, Z. (2017). Risk Factors of Delirium in Sequential Sedation Patients in Intensive Care Units. BioMed research international, 2017, 3539872. https://doi.org/10.1155/2017/3539872
9. Pereira, J. V., Sanjanwala, R. M., Mohammed, M. K., Le, M. L., & Arora, R. C. (2020). Dexmedetomidine versus propofol sedation in reducing delirium among older adults in the ICU: A systematic review and meta-analysis. European journal of anaesthesiology, 37(2), 121–131. https://doi.org/10.1097/EJA.0000000000001131
10. Vanhorebeek, I., Latronico, N., & Van den Berghe, G. (2020). ICU-acquired weakness. Intensive care medicine, 46(4), 637–653. https://doi.org/10.1007/s00134-020-05944-4
11. Strøm, T., Martinussen, T., & Toft, P. (2010). A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial. Lancet (London, England), 375(9713), 475–480. https://doi.org/10.1016/S0140-6736(09)62072-9
12. Brook, A. D., Ahrens, T. S., Schaiff, R., Prentice, D., Sherman, G., Shannon, W., & Kollef, M. H. (1999). Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Critical care medicine, 27(12), 2609–2615. https://doi.org/10.1097/00003246-199912000-00001
13. Pun, B. T., Balas, M. C., Barnes-Daly, M. A., Thompson, J. L., Aldrich, J. M., Barr, J., Byrum, D., Carson, S. S., Devlin, J. W., Engel, H. J., Esbrook, C. L., Hargett, K. D., Harmon, L., Hielsberg, C., Jackson, J. C., Kelly, T. L., Kumar, V., Millner, L., Morse, A., Perme, C. S., … Ely, E. W. (2019). Caring for Critically Ill Patients with the ABCDEF Bundle: Results of the ICU Liberation Collaborative in Over 15,000 Adults. Critical care medicine, 47(1), 3–14. https://doi.org/10.1097/CCM.0000000000003482
14. Davydow, D. S., Gifford, J. M., Desai, S. V., Needham, D. M., & Bienvenu, O. J. (2008). Posttraumatic stress disorder in general intensive care unit survivors: a systematic review. General hospital psychiatry, 30(5), 421–434. https://doi.org/10.1016/j.genhosppsych.2008.05.006
15. Nelson, B. J., Weinert, C. R., Bury, C. L., Marinelli, W. A., & Gross, C. R. (2000). Intensive care unit drug use and subsequent quality of life in acute lung injury patients. Critical care medicine, 28(11), 3626–3630. https://doi.org/10.1097/00003246-200011000-00013
16. Wilcox, M. E., Brummel, N. E., Archer, K., Ely, E. W., Jackson, J. C., & Hopkins, R. O. (2013). Cognitive dysfunction in ICU patients: risk factors, predictors, and rehabilitation interventions. Critical care medicine, 41(9 Suppl 1), S81–S98. https://doi.org/10.1097/CCM.0b013e3182a16946
17. Desai SV, Law TJ, Needham DM. Long-term complications of critical care. Crit Care Med. 2011 Feb;39(2):371–9. doi: 10.1097/CCM.0b013e3181fd66e5. PMID: 20959786.
18. Hopkins, R. O., Mitchell, L., Thomsen, G. E., Schafer, M., Link, M., & Brown, S. M. (2016). Implementing a Mobility Program to Minimize Post-Intensive Care Syndrome. AACN advanced critical care, 27(2), 187–203. https://doi.org/10.4037/aacnacc2016244
19. Rawal, G., Yadav, S., & Kumar, R. (2017). Post-intensive Care Syndrome: an Overview. Journal of translational internal medicine, 5(2), 90–92. https://doi.org/10.1515/jtim-2016-0016
20. Kamdar BB, Suri R, Suchyta MR, Digrande KF, Sherwood KD, Colantuoni E, Dinglas VD, Needham DM, Hopkins RO. Return to work after critical illness: a systematic review and meta-analysis. Thorax. 2020 Jan;75(1):17–27. doi: 10.1136/thoraxjnl-2019–213803. Epub 2019 Nov 8. PMID: 31704795; PMCID: PMC7418481.
21. Nelson, B. J., Weinert, C. R., Bury, C. L., Marinelli, W. A., & Gross, C. R. (2000). Intensive care unit drug use and subsequent quality of life in acute lung injury patients. Critical care medicine, 28(11), 3626–3630. https://doi.org/10.1097/00003246-200011000-00013