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Despite the high risks and harm of prolonged deep sedation, why do most ICUs place every patient on a ventilator into a medically-induced coma? Let’s talk straight about the history and big picture of our ICU sedation culture.

Episode Transcription

Now that you understand delirium, we have to address medically-induced comas. In all honesty, this a little hard and awkward for me to navigate with your side of the bed. I am bold and blunt with the ICU community, but this is a little more sensitive from your position. Please understand a few things.

1. The ICU community is full of wonderful and benevolent people that have dedicated a significant portion of their lives to save your loved one’s life. They would never intentionally harm anyone.
2. COVID has created a difficult scenario for the ICU world, and so optimal care is often impossible.
3. There are significant gaps in our healthcare system. One of which is standardized education and knowledge for our clinicians. What you will learn here is supported by the research but not often known to ICU providers themselves. I am working on this in my other podcast and webinar program.
4. Every case is different. What I mention here is not to be projected into every situation with hard lines.

Nonetheless, there are some difficult truths that you have a right to know. Even if it is not common knowledge among those that professionally work with this every day.

Let’s zoom out and rewind to the history of medically-induced comas. Anesthesia, or, deep sedation, was developed and implemented for use during surgeries even back in the mid 1800’s. We started to be able to place breathing tubes and breath for patients in surgery in the later 1800’s. Since then it has been an evolution of what medications can prevent pain and memories in surgery and cause the least harm. One of the favorite medications, propofol, now known as that milky “Michael Jackson drug” started to become popular in the operating room in the 1970’s. All of this was intended for brief use- for a few hours- and usually on patients with functional organs to metabolize and clear those medications out.

As medicine evolved, we started to be able to treat sick patients with ventilators. Back in the 1960’s and 1970’s, it was said to be pretty normal to have patients awake, playing chess, and walking with tracheostomies and connected to the ventilator. Yet in the 1990’s, we started to be be able to keep sicker patients on the ventilator alive for longer. We started to be able to treat ARDS- Acute respiratory distress syndrome – which requires much higher ventilator support and is likely to be more uncomfortable for patients.

At that time, ventilators were very different than they are now. The breathing tubes were stiffer, the ventilators were not sophisticated, they essentially rhythmically pushed air in and pulled it out but didn’t have the sensors and technology like modern ventilators to able to synchronize with a patient’s own breaths and regulate the volume and timing with their natural rhythm depending on the setting. Also, during that era of medicine, the theory was, the more pressure, the better patients could get oxygen, but this was incredibly uncomfortable for patients. They likely fought against the ventilator, could not tolerate it, and made it difficult to oxygenate such sick lungs. So, they started to give them anesthesia and eventually continuous paralytics. They found that this made everything so much “easier”. There was no spontaneous breathing to coordinate with and patients looked so much more comfortable. They didn’t have to talk to patients, calm them down, answer questions or entertain them- it seemed to make nursing care less laborious. They ended up using benzodiazepines and barbiturates- so medications like Ativan were dripping into them continuously for weeks.

At that time, this was all so new that there were no studies to show the real effects of deep sedation with those medications, immobility, and paralytics. In the first decade of the 2000’s, they looked back at patients that were treated this way in the 90’s and realized that they had very high death rates in and after the ICU, and then the majority of those few survivors were severely disabled and impacted.

They came to realize that those medications can be very harmful to the brain and body. During this time, my mentor, Polly Bailey, (who is on episode 21 of my other podcast) was a nurse in a shock trauma ICU in Salt Lake City, Utah. A young mother in her 30’s was cared for in her ICU for ARDS and had the routine cocktail of deep sedation, paralytics, and immobility. She was from her hometown and neighborhood. She followed her throughout the hospital, and at that time, there was no rehabilitation facility to send them to. They would literally scoop up these survivors that had NO muscle left after weeks of toxic drugs and no use of their muscles, and they would carry them from the stretcher to their cars and say, “good luck”.

Well, Polly followed up with this woman in her home. She would voluntarily go and help care for her numerous times a week and was in shock watching her husband help her use a bedpan in bed, and she spent almost a year to get to the point of being able to make it up the stairs. She was cognitively very impaired and psychologically traumatized by her delirium. Polly was mortified. She went back to her medical director, Dr. Terry Clemmer who is on episode 2 of my other podcast, and said, “What are we doing here? What are we saving these people for? We cannot continue to break and torture people like this. Something has to change. What if we didn’t let them atrophy in bed? What if we didn’t break their brains? Can we try to move them while they’re on the ventilator?”

Of course, that had never been done, there was no research showing that was possible, safe, or helpful, and Dr. Clemmer was very doubtful. Yet, he trusted nursing instincts, and he knew Polly would keep her patients safe. So, she started to try it with her patients in that shock trauma unit. They realized that the outcomes and results of those patients that were awake and mobilized were totally different. Polly became obsessed. More people started to support the movement… but not everyone.

This was a really shocking thing for nurses that had worked with flaccid and sedated patients for their whole careers. It was too scary and too different for them. Most did not want to do it. In episode 40 of my other podcast, I interview a few of the nurses with Polly during that time. They thought she was crazy, but those that were converted are still, decades later, some of the most powerful advocates for avoiding sedation and getting patients up on the ventilator.

The hospital system started a new hospital and Polly was able to spearhead their new ICU and that became the “Awake and Walking ICU”. In 2007, she published a study demonstrating that it was safe and feasible to walk patients on ventilators in the ICU. That really sparked curiosity in the medical community, there became a new movement to study post-ICU PTSD, post-ICU dementia, and mobility in patients that were on the ventilator and especially ARDS patients- like COVID patients. The research is now vast and very compelling. We KNOW that the less sedation we use and the more we move patients- the more likely they are to survive and thrive.

Thanks to the research, here’s what we know about medically-induced comas. Here is what I think we should be telling patients like your loved one, and/or families like you, before automatically starting sedation after placing the breathing tube.

If we treated medically induced comas with transparent information for informed consent, we would tell you and your loved one the following while providing the option for or against a medically-induced coma when it is not essential.

Giving prolonged sedation to cause a medically-induced coma will increase the risk 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]

So, here we are in 2021. You may be asking yourself, so, why is my loved one on a ventilator in a medically induced coma? Why aren’t they getting them up? Or why when I pass through the unit do I see everyone in bed and seemingly sedated. This is what is hard to discuss.

Remember- not every case is the same. There are cases such as when there is swelling and pressure in the brain, the most severe alcohol withdrawal, certain drug overdoses, open abdomen, or the extremes of ARDS- like COVID patients- in which they can’t absorb enough oxygen to lift a finger without becoming extremely low on oxygen. So, though the harm from this depth and duration of sedation is still there, there are moments in which it is absolutely essential to survival. The difficult thing is that the ICU community has been trained to believe that being on a ventilator is an indication for giving prolonged sedation.

The problem is- the culture. Way back in the 90’s when they found how much easier it was to have patients totally unresponsive during ARDS, then those practices of deeply sedating and even paralyzing patients started to creep into the care of other patients on mechanical ventilation for other reasons. So, it didn’t take long until the nurses that knew what it was like to have patients awake on the ventilator were retired and gone, and then the only thing the next generation of ICU clinicians knew was: deep sedation.

In addition to habit and culture, there are deeply rooted beliefs in the ICU community that sedation is more comfortable and humane for the patient. In truth, some patients don’t experience anything under sedation, but 81% of ICU patients suffer from delirium. The high risks associated with prolonged sedation risks are rarely worth it. Yet… we call sedation “sleep”. We assume they are as comfortable as they look. They rarely have heard the reality from survivors or been taught the research.

So, there is not a single nurse in the world that WANTS patients have a risk of dying or to psychologically watch babies burn for weeks and suffer panic attacks the rest of their lives. That’s not who they are, that’s not why they got into this. Yet, when I mention this concept of having patients awake and walking on the ventilator to the ICU community, the standard response is, “That is inhumane. If it was me on the ventilator, you had better give me all the drugs possible to make sleep through such a miserable ride.” This is the normal belief and response from most members of the ICU team- except maybe physical, occupational, and speech therapists since they’re the ones that have to rehabilitate them after the comas and they see the damage that is done.

Ultimately, ICU clinicians often do not understand delirium. What you heard from survivors last episode has given you far more insight into the reality of medically-induced comas than many ICU clinicians have after working with it for decades. There is a wall between the ICU and the Post-ICU world and they are not being exposed to the life after the ICU. The patients that were so traumatized by delirium when they deeply believed they were held prisoner and abused are not going to go back to the place where it happened. Many continue to internally struggle to believe was just the ICU with people that saved their lives. It is too traumatic. We also don’t invite them to come back and teach us. It is a huge systemic problem that has fueled this erroneous belief that sedating them is “humane”.

We also don’t learn and apply the research. Before sedating a patient after intubation, we don’t say, “Ok, do we really want to sedate them? Is it worth the risk of increasing their chances of dying and suffering in the ICU and after?” –no,  that is not our discussion.  Instead, it is standard practice for the provider that did the intubation to turn to the nurse and habitually ask, “what do you want for sedation?”. There is no question that the patient is going to be sedated. Without any reason in the research to support it, we automatically start sedation on every single patient that needs the ventilator. They are married- sedation and ventilators are deeply bound. Yet, I am filing for a divorce. Yet, breaking them up is a complicated process.

There was movement in the 2010’s. We had this research come out and many were very upset and moved by the harm that we’ve been doing. Dr. Wes Ely is a leading delirium researcher. He developed a tool to assess for delirium and then developed a protocol called the ABCDEF bundle to guide teams to choose better sedatives, decrease the dose and duration, and implement interventions such as family and mobility. We will discuss the ABCDEF bundle more in an upcoming episode. The difficult part is that the education as to “WHY” we need to change this treatment- was not widely received. So, it is required in the documentation systems that nurses do “sedation vacations” per the ABCDEF bundle. That means that that they lower sedation and try to get it off.

Here is why this is difficult. They have still continued the error of starting sedation on everyone. This often causes delirium. They have given, prolonged, or exacerbated delirium. Then we push nurses to turn the sedation off- and patients come out wild. They are agitated, thrashing, breathing fast and erradic, biting the tube, trying to put the tube and their lines out, trying to get out of bed- it is dangerous, difficult, and wild. Worst of all, you can see the terror in their eyes. It breaks your heart. No one wants to see a patient like that. So, to keep the patient “safe”, and “comfortable”, they rush to turn the sedation back on.

They have understood that the discomfort and agitation is soley from the ventilator or breathing tube and that by turning the sedation back on and seeing the patient become motionless again, they have spared them suffering. If they “look comfortable”, therefore they are more comfortable” – is the belief system.

What they are missing is that what they likely witnessed were clear symptoms of delirium. The patients may not have even been aware of the breathing tube, but in their reality, they were trying to save their kidnapped children, or get away from the demons that were chasing them. They thought they were handcuffed, not restrained. They thought the breathing tube was a snake- of course they were trying to get it out.

Susan East is a 3 times ARDS survivor on episode 3 of my other podcast. She was sedated her first time and watched babies burn for weeks. She was so deconditioned and traumatized that she had her attorney draft up a statement protecting her from sedation. Her next two times on the ventilator, then awake and her experience and outcomes were different. She said that she is not afraid of the ventilator or ARDS, but she is TERRIFIED of sedation. She is a “DNS- Do NOT Sedated ME”.

IF they understood that, these clinicians would hesitate the turn on the very thing that causes those experiences. They would be eager to re-orient them and bring them back to reality so they can see and connect with you, be aware of the truth, and know that they are safe in the ICU with people that care about them and are trying to help them. They would hate and avoid sedation. Yet, that is not the understanding they have.

They sincerely think that they are sleeping under sedation. They may tell you that. So, let’s talk about that. Sedation is NOT sleep. Among the research listed on the blog from this episode, you will find studies demonstrating that medications like midazolam or versed, propofol, and opioids like fentanyl, disrupt the brain. When they do EEG monitoring and watch the brainwaves of patients sedated on these medications- it does not remotely resemble sleep. The closest to it is precedex, but it’s still not the real deal.

So, interestingly enough, when you compare the rates of delirium to the level of disruption to the brain preventing sleep among these medications, they fall in line. For example, the type of medication called “benzodiazepine” causes brain activity that least resembles sleep and has the highest rate of delirium. One benzodiazepine called Lorazepam, or Ativan, has a 20% risk of delirium for every 1 mg given. Another common benzodiazepine to be given in a continuous drip is midazolam or versed- you’ll hear both names- has a 7-8% risk for every 1mg given. So if your loved one is on a low dose drip at 5mg/hr, then at a conservative 7% risk increase, that is an 840% risk increase of delirium within 24 hrs. Midazolam shows brain waves that have the LEAST resemblance to sleep- so we can suspect that is one of the ways it causes delirium- absolute sleep deprivation.

Propofol is a little closer to sleep, and has lower rates of delirium compared to versed, but still not great. Of note with propofol, is that it’s a great drug for surgery- it is short acting, meaning when you give in for a short amount of time, like surgery, when you turn it off, they wake up. It isn’t supposed to linger. Now, this can change depending on the circumstances and situation. Propofol loves to settle into fat tissue. So when we give it for days to weeks in patients with extra fat for it to be stored in, you can’t just turn It’s affect off when it’s time to wake up the patient and try to get the breathing tube out. It can take hours to days or longer to even metabolize out. This is further complicated by organ injury during critical illness. Many medications do not leave the body in a normal way or timing when the kidneys or liver can’t clean it out. So these are not the best medications to give really sick patients- especially for such a long time.

A commonly asked question is, “They turned sedation off days ago, but my loved one isn’t waking up yet. What is going on?” When sedation is off and a patient still is not waking up, it’s hard to tell if it is a stroke, residual sedation that the body is full of, or if they are in hypoactive delirium. Even when the sedation is cleared from the body, the brain can continue to be so deeply injured from the sedation and delirium that it can take days to weeks to be able to be aroused again. I have families calling me panicked asking if they are brain dead. Over the phone, I can’t tell, but considering these situations and medications given, there is reason to suspect this may be because of the medically induced coma they were put into. Once they start to wake up, they are usually still very delirious, confused, and lost. It can take weeks of physical and mental rehabilitation to bring them back to reality. Even patient is different, but this is not uncommon.

I need to also mention that even if your loved one is not on a ventilator, it is still important to be aware of what medications they have been given. An inclination in the emergency department or medical floors is to give medication like Ativan when someone is confused. Yet, Ativan is notorious for causing delirium. This has a terrible domino affect.

For example, if a patient comes the emergency department because they had a severe infection such as sepsis and they’re starting to get confused, scared, agitated, and even combative, the impulse is often to give them Ativan. They see that it calms them down, that they’re “sleeping”, and they’ve fixed the problem. A few hours later, the Ativan wears off, and the patient emerges from it with even MORE anxiety, agitation, and thrashing- so they hurry and give them an additional dose of Ativan- perhaps even more this time.

Then they send them to the medical floor, where they will continue to give him Ativan when the previous dose wears off… and he has been locked and loaded into the delirium rollercoaster. After a few days of being totally immobile and delirious, the muscle breakdown may fuel his sepsis, he may not be coughing and clearing his secretions because he’s laying flat and somnolent, so he’s not at risk of aspirating, developing pneumonia, or going into septic shock and ending up in the ICU- higher risk of needing a ventilator- signs him up for a medically induced coma… then everything that follows that.

The failure to recognize and treat delirium can be lethal. I have consulted on medical malpractice cases from wrongful death due to failure to treat delirium and inappropriate use of Ativan. I recognize that this is not on one person or department- it is a systemic problem. If you had been allowed to be with them in the emergency department, and the team had recognized, “ok, he has a bad infection, he’s getting confused, he is developing delirium. Let’s find ways to keep him safe while we give him antibiotics and treat the cause of the delirium and avoid things like Ativan that will make it all worse and risk causing terrible outcomes such as death, PTSD, dementia, intubation, and so forth for him. ” Then we can start using the tools such as family, mobility, sleep, and avoiding medications.

Yet, unfortunately, this is one of our barriers- that is not how many of us are trained to think and respond to such a scenario. If your loved one has received such medication, make sure the team understands that you are worried about delirium. If they are agitated, ask guiding questions such as, “Is it possible that they have ICU delirium? How can we treat that? Does that sedative help liberate them from delirium?” – Avoid jumping to accusations or building tensions… but do not be afraid to ask about the research and bring delirium into the discussion. That is your right. You can say, “When he gets agitated, can we get him up? Can we help him sit up? I think it would help him wake up more and I can scratch his back, and he can exercise and get real sleep,” and so forth. Show the team you are ready to help them as well as your loved one.

In “Awake and Walking ICUs”- I say this plurally, because I am aware of at least 3 ICUs- in Utah, Denmark, and Brazil- this is clearly understood. This drives them to avoid sedation. Not just shorten the duration, or try to lighten it- they seriously avoid it for all patients that don’t have extreme exceptions. I’m also aware of pediatric ICUs that are keeping children awake and playing on the ventilator. The ICU I worked in located in Utah is a medical-surgical ICU with a detox unit and a bone marrow transplant unit. This means that they receive patients with severe alcohol withdrawal, multi-organ failure, severe sepsis with immunocompromised patients, and severe ARDS. They have a COVID ICU with some of the sickest patients in Utah during this pandemic. They have continued to allow almost all patients to wake up after intubation. Listen to the episodes linked on the blog in which this ICU shares their approach to treating COVID19.

This is the key to success in having a patient be awake, calm, cooperative, and safe on the ventilator. Allowing them to wake up after the intubation procedure is far easier. They can quickly re-orient the patient when they don’t have days to weeks of sedation and delirium on board. Patients are given the chance to understand their situation, communicate, have autonomy, call/text/connect with their families- even in the isolation. They usually get up hours after intubation and walk. Rarely do they ever lose their ability to walk. We’ll talk in another episode about how sedation affects the muscles, but just understand how much harm is prevented by keeping patients awake and walking right away.

Ultimately, it is easier for everyone. They preserve their respiratory muscles and brain function, so when their lungs and other systems are ready to be off of the ventilator, they don’t need a tracheostomy and weeks to months of rehabilitation- they can independently breath without the tube and they walk themselves out the door. A data collection in 2012 showed that 98% of their survivors were discharged home, compared to only 46% in a neighboring hospital with the same kind of patients.

On my other podcast, I interview survivors from the “Awake and Walking ICU” and they share what it was like to be awake on the ventilator and even walking. I’ll share the episode numbers on the blog. No one loved it. Yet they were not in the agony that you see in patients with delirium. They are so grateful they could communicate, be informed, call the shots, and be able to have a much shorter time on the ventilator as well as survive and actually return to their normal lives. Some of them walked on PEEP 18, 100%- they were extremely sick and critical, yet THAT is why they walked them. Mobility is a life-saving intervention- and we’ll get more into that later.

Please understand that it is possible and important for most patients on the ventilator to be awake and mobile. The research repeatedly demonstrates that. Yet, we have a lot of gaps in our system that prevent your loved one from receiving that care. From being short staffed, to absolute lack of knowledge and experience- proposing that your loved one be awake and moving on the ventilator may only be believed by a few physical therapists. Telling the ICU community about an “Awake and Walking ICU” is like telling them the world is flat. Nonetheless, you should know the truth. I have included powerful studies on the blog for you to look over and share.

This may be a difficult part of your advocacy. Work closely with your ICU team to figure out how to best optimize your loved one’s short and long-term outcomes. You want to bring home the same person that was brought to the hospital. Understanding the reality of delirium and medically-induced comas is key. Next episode, we will talk about mobility. Hang in there, I know this is a lot. I want you to be as prepared for your role as an advocate as much as possible.

1. 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
2. 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
3. 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
4. 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
5. 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
6. 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 fromhttps://pubs.asahq.org/anesthesiology/article/104/1/21/7483/Lorazepam-Is-an-Independent-Risk-Factor-for
7. 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
8. 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
9. 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
10. 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
11. 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
12. 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
13. 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
14. 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
15. 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
16. 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.
17. 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
18. 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
19. 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.
20. 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
21. https://pubmed.ncbi.nlm.nih.gov/22583009/

 

Notes:

Early deep sedation predicts death:

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

 

1mg Ativan = 20% risk increase of delirium:

Pandharipande, P., et al. (2013). New England Journal of Medicine, 369(14). Long-term cognitive impairment after critical illness. https://pubmed.ncbi.nlm.nih.gov/24088092/

 

Midazolam is an independent risk factor for delirium:

Yang, et al. (2017). Risk factors of delirium in sequential sedation patients in intensive care units. Biomed Research International. https://www.hindawi.co

 

1 mg Midazolam = 7-8% increased risk of delirium:

Taipale, P., et al. (2012). The association between nurse-administered midazolam following cardiac surgery and incident delirium: an observational study. International Journal Nursing Student, 49(9). https://pubmed.ncbi.nlm.nih.gov/22542266/

 

Sedation prevents sleep:

Weinhouse, G., & Watson, P. (2011). Sedation and sleep disturbances in the icu. Anesthesiology Clinic, 29(4). https://pubmed.ncbi.nlm.nih.gov/22078916/

Weinhouse, G., Schwab, R. (2006). Sleep in the critically ill patient. Sleep, 29(5). https://pubmed.ncbi.nlm.nih.gov/16774162/

Peruzzi, W. (2005). Sleep in the intensive care unit. Pharmacotherapy, 25. https://pubmed.ncbi.nlm.nih.gov/15899747/

 

Survivor testimonial from the Awake and Walking ICU:

15, 16, 17, 18, 19, 20, 34, 44, 71

 

How the Awake and Walking ICU has treated COVID19:

93, 86, 45, 58

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