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What are the main “treatments” or “tools” to prevent and treat delirium? How can we facilitate “quiet nights” without harming patients with sedation? Peter Nydahl, RN, MScN, PhD, teaches us how to walk them to sleep.
Episode Transcription
Kali Dayton 0:27
Hello, and welcome back on one of the videos or pictures posted an Instagram of a patient walking on the ventilator. Someone said, quote, “Yep, this is why I work night shift. I’m not doing that stuff.”UNQUOTE, to which I couldn’t resist responding, “The Awake and Walking ICU” team walks almost all patients every night shift around 9pm without any physical therapy present. That is how they insure a “quiet night”.
Nurse researcher Peter Nydahl recently published powerful information that validates this important practice. If you’re interested in current research, and are on Twitter, be sure to follow Peter. He joins us now from Germany. Peter, thank you so much for coming on the show with us. Can you introduce yourself?
Peter Nydahl 1:16
Yes, Kali. Thank you. I’m Peter Nigel from north of Germany. I’m a nurse and nursing researcher. I’m working now since 30 years in the intensive care unit, here at our University Hospital. Well, right now I’m working part time in the ICU, we say 25%. It’s every second weekend.
Kali Dayton 1:40
And the rest of the working time I’m working as a nursing researcher doing projects, quality improvement, research and things like that. And I’m working as a nurse in all shifts. And in Germany, we’ve got three different shifts, morning, afternoon and night shift. Actually, I prefer afternoon or night shift.
And during our night shifts, we take care usually for for two patients, one nurse takes care for two patients. And it’s a good kind of rocking, have to say and, but sometimes patients cannot sleep in the night. A lot of German people have sleep disturbances and when they are in the ICU, it does not become better. It’s, it’s even worse. And what I noticed also 20 years ago is when when patients become a little bit restless, it’s a good idea to to make some activities with them, especially in the night, or in the late evening. And because then they they that agitation can be guided into mobility, for example.
And it’s a good thing to put them on the edge of bed or place them in a chair, watching TV, and I don’t know to have a talk or what I really love is to offer them a warm footpath. Just just taking a board with it with warm water put feet in it. It’s an old German receipt to fall asleep, or offer them warm milk with honey. You know, this cannot sleep? Oh, you know, a couple of generations back, that’s what we used to do.
Peter Nydahl 3:32
Yes, we still use it here in Germany. And patients know this and like it, of course, then you can offer this and they have something to do watching TV drinking a warm milk and things like that. And after I don’t know, half an hour, you place them back into the bed and most times that they fell asleep or ever kind of better sleep than than compared to to the situation before.
So we have a long experience in mobilization of patients and the night. Of course, not always it depends on the nurse on the bedside. It depends on the physician who is on duty. A lot of nurses and physicians say well give them a little bit propofol midazolam, Lorazepam or or whatever.
But things are changing. And you in the last 10 years, I think we have a better quality of promoting natural sleep. So you can put down the lights, you’re not so loud, you are more more silent. And we are more avoiding sleep medications. And I think it’s a good it’s an interesting development in our sleep culture at all. And then, some years ago I
saw a lecture on a conference where a colleague posted one, one picture of a patient who was mobilized at 11 o’clock in the evening, and into a chair, delirious and so on. And after half an hour, he was placed back into the bed and slept the whole night. And I thought, this is perfect. This is the next goal we have to achieve.
And so then I started to talk with my colleagues. Also 10 years ago, I found the German network for all immobilisation, and we made a lot of projects and had a have a good cooperation across Germany, I can say. And so I developed the idea of let’s make a study about early mobilization in the evening.
And then our German Society of Critical Care Medicine, offer a price research was there I submitted a proposal and we won 10,000 iro. What is a lot of money for us. And this was the base for for developing the project because my idea was that we have a mobility team consisting of nurses and physiotherapists, who came in, in the evening again, and every nurse or therapist will get 100 oil per evening. And so we spent the money for for the mobility team.
And we had we collected three ICUs in my hospital, one in Mannheim. It’s in Middle Germany, and one in Birmingham, Birmingham because David McWilliams also joined our, our project. And then we started in June, of course, because in Germany in June, we’ve got when when the sun goes down, it’s called Dawn that’s come from dusted on the famous movie. Then the desk is round about 1030 Here in Germany. So this would be the best timeframe for conducting the study. And then we started, made a plan and so on, wrote a proposal, ethic approval on all the things and we started our study, and very interesting was, we limited the study for two weeks, because we had more money.
And the plan is to make a randomized trial to recruit patients of OT from mixed DILG ICUs and I’m working on a mixed ICU in with medical surgical trauma. Trauma Patients, neurosurgical patients are all different kinds of patients and mobilize them in the evening between nine and 11 o’clock in the evening. For three evenings in a row. Consequent teeth mobilization.
Yes, and it worked. It was a lot of fun. The physiotherapist physiotherapist in Germany are working from eight to four o’clock roundabout and it was very interesting for them to come back in the evening and to mobilize patients because they said it’s it’s more calm working you can more concentrate on one single patient and makes a lot of fun to work together with nurses and so on and walk around on the ICUs and they really like it.
I had an interview with a physiotherapist from Brazil afterwards and they have 24 hours shifts and this is amazing. They have they have a law. They they have a law in Brazil, that there should be physiotherapists 24 hours seven days a week. Not all ICUs in Brazil have this but they said run about half of ICUs have plenty for hours coverage with physiotherapists and this is amazing they also mobilize patients in the evening.
Then they have night night sleep for the patients from 11 till five o’clock round about six hours, which was fine and then they continue working and and so on. So it’s well established. It’s cost saving, reduces pneumonia, reduces the length of stay, based on mechanical ventilation and so on. So they’re amazing studies from Brazil, about physiotherapy. That’s why they have so many pictures and videos of patients working on ventilators so much reason out from there. I just keep noticing Brazil is rocking it. Yes, of course. So you can make some podcasts from the guys from Brazil.
Kali Dayton 10:05
I need to!
Peter Nydahl 10:05
Yes, yes. So we started our trial and actually have to look on my data or what we could collect run about, we had 185 patients present in the ICU. And we could recruit 28%, which were 53 patients. And actually, we mobilized 25% of the patients, which were 36 in the intervention group.
And finally, in the control group, so one quarter of ICU of all ICU patients could be mobilized in the evening, which is a good number. Of course, a lot of patients were excluded, because they were not present in the following night, they had on only a short stay, of course, after an operation, just waiting for them to wake up, extubate, and then discharge on the ward.
For example, some patients required deeper sedation, because of brain damage, big operations rds, for example, and pruning and so on. And some are not assessable for delirium, because they were they had disturbances in their consciousness. They were not assessable and we excluded them. You could not be f, if you mobilize patients in the evening, if that prevented delirium. So you couldn’t start with delirium. Yes, of course, they were already they had a pre existing delirium. And then we could also not prevent them. So, so we could include 25%, roundabout, and we wanted to mobilize them on three evenings in a row. And that led to 72 possible locations of mobilization.
Actually, we had some patients declined mobilization in the evening because they felt too tired. When when we came in at at nine o’clock, and have one patient had pain, severe pain, and they get purely painkiller, but it was not not enough. And he also declined and he didn’t want to mobilize. Or they had further investigations, CT, MRI, reoperations. Things like that happen.
Kali Dayton 12:28
Yeah, it’s ICU.
Peter Nydahl 12:31
Yes, that’s life. But the rest of the patients could be mobilized on the edge of bed, sitting in a chair, or some patients even could stand, walk on spot, walk was a little bit in the ICU. Of course.
Kali Dayton 12:46
Most of these were on ventilators correct? They were intubated?
Peter Nydahl 12:50
No, a quarter of them were on mechanical ventilation with an ATT or with a trial tube. Yes, but they were also mobilized. And we had some some offerings for the patients like mouth cleaning, watching TV, warm food baths, and things like that. But most of them wanted to talk, just sit on the edge of of bed and have time to talk. Even if you’re ventilated, then the nurses or fuser face therapists were talking and they were nodding or shaking their heads or writing on paper, their their thoughts and questions and so on.
Because it was a calm situation, and patients loved it. During the day everyone is busy and you have never time for a real talk. And in the evening, it was calm. One patient had one nurse and one physiotherapist for 20 minutes that was great for them and the patients really enjoyed this this communication this this encounter. Yeah, for them. So it was really good for them.
Yeah, mobilization took 30 minutes per patients run about mostly talks massage on the back. They like coming here mouth cleaning. So preparing for the evening and this time, like I normally would. And yes, yes night routine. Yes, of course. Most Germans do this in the evening. So it was patient centered it was usual activities that they are all know from from home.
And I think this is also a kind of re re orientating activities for patients who are in delirium or who are pre delirious, doing something normal for you. We are orientates yourself. And it tells your brain that it’s nighttime it’s preparing for sleep. Yes, if you’re in a room with very little window or light coming in from the windows, there’s nothing really showing you…..
Kali Dayton 15:00
What time of the day or night it is.
Peter Nydahl 15:02
Yes,
Kali Dayton 15:03
This is a routine that tells your brain it’s time to sleep.
Peter Nydahl 15:06
Yes. And this is one of our hypothesis that conducting sleeping rituals induces normal sleep, also, sitting, sitting on the edge of bed and doing some mobilization, will will make you tire, hopefully.
Kali Dayton 15:25
And so it’s easier to fall asleep afterwards.
Peter Nydahl 15:29
And maybe it will normalize your brain activity and the neurotransmitters and things like that.
Kali Dayton 15:39
Oh, that that makes so much sense. I’m just thinking about how we talk about these concepts like family engagement and cultural sensitivity. I had never thought about asking patients with different cultural backgrounds than me. What do you do in your culture before bed? I never would have thought of that.
Peter Nydahl 16:00
Yeah. When when we started 20 years ago, with rehabilitation on ICU, we often ask patients, how do you how do you wake up in the morning? How do you stand up? How do you become active? But we never asked, “How do you come to rest? How do you fall asleep?” because we wanted to become patients active, but you cannot be active 24 hours each day.
So it doesn’t make sense. So but now we are talking more in rhythms, activity, followed by rest or sleep. So good questions are, “How do you relax? After strengthening activities? Do you prefer sleep? Do you hear great podcasts? For example? Do you make relaxing, relaxing breathing? Activities? Things like that? Or do you just sleep for example?” Yeah. And the thing is, it’s a good way to have both activity, but also times of rest.
Kali Dayton 17:04
And this is so validating because in the wake of walking ICU, there is a mobility session every evening. So we don’t have a physical therapist in the evening. And yet the nurses and the rest of therapists get everyone up from any time between said like, eight, nine o’clock, even till midnight. It depends on if they’re awake, if they’re still awake, sometimes we’ll put in an extra session.
If they’re really agitated, if they’re anxious, if they’re restless, if they’re sundowning, then get them up again, because that we’ve seen time and time again that it helps with all of that agitation. And then ultimately, they sleep. I think we underestimate how exhausting it is for patients with critical illness to walk or sit up depending on where they’re at with their function. But you wear them out. And then they finally just collapse and go to sleep without any medications. And it’s real sleep. So what did you find in your study?
Peter Nydahl 18:03
Well, it’s it was a pilot study, and we our primary outcome was visibility and safety, of course. And what we found is yes, it’s feasible for one quarter of all ICU patients, it’s possible to mobilize them in the evening in three consecutive evenings or even more. It was safe, of course, we had some safety issues with exceeding blood pressure, oxygen saturation going down, we had one removal of a line of intravenous line, but that’s all on.
We had to stop mobilization, of course, in 7% of all mobilization, actually, it’s fine. It’s real life on on ICU, and things are gonna happen, even if your bed, right? Yes, yes. When we conducted our one day point prevalence study, including more than 760 patients, we found 20% of safety issues happening during mobilization. That’s life. So we have we have a pretty low safety event rate, we can say.
What was interesting was that we had less delirium in the intervention group of patients who were mobilized than in the control group, with we had a low number in patients in both group 26 patients, many patients but the rate of delirious patients in the intervention group was 27%. And in the control group 50%. This was not significant because we had low numbers at all, but it shows clear trend to have less delirium in the intervention group. That means it can work it can as a preventive effect.
Mobilization in the evening can have a preventive effect. In general ICU patients. We find also lower duration of existing delirium patients in the intervention group delirious patients in the intervention group at 1.5 days in delirium, and in the control group two days, that would be a reduction by 25%. But actually we had this is a pilot study was not significant.
And we need more confirming trials to to confirm these these data, of course. So, there is a promising signal, I have to say that mobilization in the evening makes sense in preventing, and tweaking delirium. And this is very exciting for me as a nurse, and maybe for you too.
So, what I can say that is also that David McWilliams from the United Kingdom wrote an approval for for logic ran because we want to repeat this study with a larger group of patients. And we calculated that we need 140 patients six weeks and 30,000 to conduct the full trial, and of course, we are planning to repeat this trial in the United Kingdom, Switzerland, and of course in Germany. So it will be a multicenter trial, and we hope that we can repeat or maybe even improve our results.
What we have to keep in mind, what we planned to analyze is does delirium help in different depths, mobilization help in different types of delirium. You own this novice type of hyperactive, hyperactive and mixed volume. This is not what we have in mind, but in their different phenomenons of delirium.
She had published a paper two years ago about shock induced delirium. So delirium may be caused by reduced cerebral perfusion, because your blood pressure is really low by by by a shock, for example, severe bleeding. But delirium may also be used by hypoxia rds, for example, severe problem on ER, and so on. And then the Oxy donation of the brain is also reduced, which may lead to delirium, or hyponatremia, for example, may lead to delirium.
So our idea was to make make an analysis, where does mobilization work best in patients with shocked delirium, with sedation, delirium, with hypoxia, delirium with metabolic delirium, actually, we had too few patients, and we could not analyze this. But of course, I think it’s reasonable. If you have a patient with possible delirium, which is caused by hypoxia would make sense to mobilize them because we know oxygenation is improved during mobilization.
And cause In consequence, the brain oxygen oxygenation must also be improved. So maybe preventing or treating delirium.
Kali Dayton 23:21
So you make such a good point. And yeah, that is a misunderstood concept in the ICU, right? If someone’s hypoxic, a lot of ICU, health care workers aren’t going to hesitate to mobilize them, they’re going to be afraid to get them up, right. So I just want to point out the irony of what you just said, because it’s what you said is true, but it goes against our cultural practices.
“Oh, they have really bad pneumonia, they have ARDS, so we can’t get them up.” And granted, if they completely desaturate and go, you know, extremely hypoxic at 60% with any kind of movement, and we, we can’t move them right. But otherwise we can get them up it improves their perfusion.
Peter Nydahl 24:07
Oh, very, very important point, is what we also said 10 years ago,in patients who are mechanically ventilated, you have to adapt the settings of the ventilator to the level of mobilization. So it’s this is very important. Usually, we we set the ventilator settings to lying patients, and patients who are lying in bed have a different metabolism than active patients.
So when you start mobilization, maybe you have to increase the pressure of support a little bit. Maybe you have to reduce the time when when the when the gas flow comes into the patients so that the patient can have a shorter breathing, increased breathing, maybe you have to increase the Oxygen delivery a little bit more from I don’t know 50 to 60%, or whatever. So if the patient feels fine breathing with personal support and standing up or even walking, otherwise, you haven’t yet hygienic weaning failure. Because if the ventilator settings are not adapted to mobilization, the patient with the period, so become worse.
Kali Dayton 25:25
And we, for patients that are not in mechanical ventilation, we apply this concept, right if they have their own two liters, nasal cannula that we turn up to six if they need to walk or they don’t have a breather on and we don’t think anything of it. And yet, we feel like those settings are permanent, or the only settings they might need if they’re laying down a mechanical ventilator.
So I think he makes such a good point that we can adjust that and improves their oxygenation when they get up and and improves the blood flow and oxygenation to their brain and improves their delirium.
Peter Nydahl 26:00
Yeah, makes sense! Yes, yes, of course. So this is very important during mobilization. But even if you don’t adapt the ventilator settings to the mobilization mode, we know by several studies, that the lung ventilation is improved when you when you come up when you’re sitting when you’re standing and so on. So, it may be lead to improve cerebral oxygenation. And this also will improve delirium or prevent from delirium.
But not, but not when you have a shock. So when you have reduced blood volume, reduced, mean arterial pressure, and you you come up, maybe the blowups the cerebral perfusion is reduced, and for some patients is reduced under a critical limit. And then the brain activity becomes worse. And maybe you you create delirium, we know from patients after stroke, that too early mobilization is bad for the brain, if you’re within within the 21st 24 hours after stroke, in severe stroke, mobilization leads to severe neurological problems afterwards, and it increases mortality.
And after 24 hours, it becomes a little bit better. But what you always should avoid is to place a patient into a chair after a stroke, and let them sitting for hours. This is not good for for a damaged brain. And I think we can transfer this knowledge to also non neurological patients, you all know, this ICU patients, when you place them into a chair and leave them there for hours, then the patients become tired cells asleep sitting in the chair.
And when you look at the feet, they they become full of edema. The complete volume goes down and the feet becomes blue and viral. And you know, the brain is not really good. perfused with with oxygen, so maybe it may be so that brain perfusion is an important factor we have to consider when we mobilize patients. And I think this will be the next step for research that that we mobilize patients that we look for possible causes of delirium.
And does delirium really improve under mobilization? Or does it become better? Yes? Or do we cause even more harm in terms of delirium? And this won’t be the next steps, I think, and in our large trial with David and others, hope that we have enough data to make first analyzers for this.
Kali Dayton 29:23
Yeah, this is so exciting. It’s so validating to what the Wake mark and ICU is always done. But you bring up such important considerations that when a patient is not well perfused it’s probably not the time to get them up. And I’ve always kind of said that if a patient’s in septic shock, and you’re pouring fluid in and you’re increasing vasopressors, that’s not the time to get them up. There are always exceptions to mobility, right? And it’s dose. It’s so simple. So if there’s and you can see how they do.
If they’re seemingly stable while they’re in shock, you know, We’re not pouring fluid in, they’re kind of settling down on one vase, a presser, you can sit up on the side of the bed and see how they do. But take it very gradually and keep assessing the perfusion and take that into consideration as you move forward.
Peter Nydahl 30:14
Yes, there are some few studies about mobilization in septic patients, which is amazing. This was also feasible and safe. But they they did not research delirium and brain function. Of course, this would be the next step. Of course.
Kali Dayton 30:43
So as a nurse researcher, I see you on Twitter posting, study after study after study. And it just reaffirms to me that there’s so much research out there. What would you have the ICU community understand? Or what would they what would you guide them to be reading and looking into to help change their perspective and their cultures and their ICUs?
Peter Nydahl 31:07
Oh, well, what I’m interested in is general early rehab, this can be physical, this can be mental, avoiding PTSD, anxiety, depression, and so on. You can also look for social functioning, integrating the family and so on. And the best summary is the ABCDEF approach. And when you’re looking at the website of the Society of Critical Care, medicine, it’s perfect.
You find everything you need to change your ICU team, they are doing an amazing job, I have to say on this website, because if you can download educational material, PowerPoints, videos, everything is there. You just have to use it. This is perfect. That’s a great resource. And they also have like work groups or support groups, right? When people are looking at working on projects.
And there’s a lot of collaboration going on, where everyone can give ideas and share what they’re doing and what’s working. Yes, yes. You’re asking me for favorite literature. And I’m a great, great fan of Dale neat him from from Baltimore. And Dale has a great newsletter, it comes out every month. And he is also listing several new studies and so on. And Dale and I, and Cheryl Hickman from the level as we are producing, collecting all this. We’re collecting all this literature in our literature list.
And you can download this literature list on globalization minus network.org. Under publications, I can send you the link, and I will put the links on the medium blog if you guys do credible literature reviews. Now we’ve got more than 2,500 titles in this world file, including links to PubMed and other databases, about sedation, delirium, early mobilization, occupational therapy, patient outcome, family integration, teamwork, and so on.
So it’s a huge list. What are some PhDs you will use it for the work because it’s really valuable? And every important study is in this list? I think. So I really liked it and recommend it to all who are listening that absolutely people reaching out to me all the time students, professionals, everyone’s asking for the links and literature.
Kali Dayton 33:42
And that’s why I created the blog. But I think everyone can be very convinced by all the research that’s out there. And yet we vastly under read it and under utilize it.
Peter Nydahl 33:54
Of course, yes, yes.
Kali Dayton 33:56
Anything else we could share the ICU community.
Peter Nydahl 33:59
Enjoy and have fun! Never Never give up. Listen to Kali’s podcasts, they are really amazing. And you have a broad, broad spectrum of topics. This is great. So I really love it and… never give up.
Kali Dayton 34:22
Absolutely, I think people get really overwhelmed by this prospect of change. And so they may never see it in their unit. But I really know that it’s possible that any unit can be an awakened walking, ICU. And I would encourage everyone to follow Peter on Twitter, I’ll put a link to your Twitter, you just you’re always posting such great research and insights.
And it just it’s exciting that you’re a researcher but you’re also actively at the bedside, applying these principles, real life experience. You’re just a great resource in our community. So thank you so much for enlightenment, and just posted on your next study.
Transcribed by https://otter.ai
References
Literature Review including 2,500 studies:
http://www.mobilization-network.org/Network/Publications.html
List of Current Literature:
Bailey P, Thomsen GE, Spuhler VJ, Blair R, Jewkes J, Bezdjian L, Veale K, Rodriquez L, Hopkins RO: Early activity is feasible and safe in respiratory failure patients. Crit Care Med. 2007 Jan;35(1): 139–45
Schweickert et al.: Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet. 2009 May 30;373(9678):1874–82
Needham DM, Korupulou R. Rehabilitation Quality Improvement in an Intensive Care Unit Setting: Implementation of a Quality Improvement Model. Top Stroke Rehabil 2010;17(4): 271–281
Schaller SJ, Anstey M, Blobner M, Edrich T, Grabitz SD, Gradwohl-Matis I, Heim M, Houle T, Kurth T, Latronico N, Lee J, Meyer MJ, Peponis T, Talmor D, Velmahos GC, Waak K, Walz JM, Zafonte R, Eikermann M; International Early SOMS-guided Mobilization Research Initiative.. Early, goal-directed mobilisation in the surgical intensive care unit: a randomised controlled trial. Lancet. 2016 Oct 1;388(10052):1377–1388
Pun BT, Balas MC, Barnes-Daly MA, Thompson JL, Aldrich JM, Barr J, Byrum D, Carson SS, Devlin JW, Engel HJ, Esbrook CL, Hargett KD, Harmon L, Hielsberg C, Jackson JC, Kelly TL, Kumar V, Millner L, Morse A, Perme CS, Posa PJ, Puntillo KA, Schweickert WD, Stollings JL, Tan A, D’Agostino McGowan L, Ely EW. Caring for Critically Ill Patients with the ABCDEF Bundle: Results of the ICU Liberation Collaborative in Over 15,000 Adults. Crit Care Med. 2018 Oct 18
Scheffenbichler FT, Teja B, Wongtangman K, Mazwi N, Waak K, Schaller SJ, Xu X, Barbieri S, Fagoni N, Cassavaugh J, Blobner M, Hodgson CL, Latronico N, Eikermann M. Effects of the Level and Duration of Mobilization Therapy in the Surgical ICU on the Loss of the Ability to Live Independently: An International Prospective Cohort Study. Crit Care Med. 2021 Jan 8;
Waldauf P, Jiroutková K, Krajčová A, Puthucheary Z, Duška F. Effects of Rehabilitation Interventions on Clinical Outcomes in Critically Ill Patients: Systematic Review and Meta-Analysis of Randomized Controlled Trials. Crit Care Med. 2020 Apr 28
Nydahl P, Sricharoenchai T, Chandra S, Kundt FS, Huang M, Fischill M, Needham DM. Safety of Patient Mobilization and Rehabilitation in the Intensive Care Unit. Systematic Review with Meta-Analysis. Ann Am Thorac Soc. 2017 May;14(5):766-777. doi: 10.1513/AnnalsATS.201611-843SR. PMID: 28231030.
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