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Wednesday, August 19, 2009

Ventilator Delerium should not be overlooked

I don't think this matters so much on day shift, but I think on the night shift we RTs and RNs and doctors when writing orders ought to have more consideration for the amount of sleep our patients get, especially patients in the critical care on a ventilator.

There's this thing called Ventilator Narcosis (Delirium) that I think is way underdiagnosed. In fact, I bet it hardly ever gets diagnosed.

According to the August, 2007, issue of Chest, Ventilator Delirium effects 85% of patients receiving mechanical ventilation, resulting in , "and has been linked to prolonged length of stay, reintubation, higher mortality, and higher costs of care."

Delirium, or cognitive decline, often effects elderly patients who are on narcotics or benzodiazepines and left in a state of coma (or "suspended animation") for lengthy periods of time, thus resulting in a poor quality of sleep.

Or, poor lighting coupled with the above and continued patient agitation resulting in lack of adequate sleep often causes a patient (particularly the elderly) to enter into a state of cognitive decline. This happens even in elderly patients who are in otherwise good physical condition.

Likewise, "recommendations by professional societies have established the importance of delirium monitoring and recommended it as standard practice in ICUs all over the world."

Roger Striker at provides a more cons ice definition:

"Delirium, as defined by the DSM-IV, requires an acute disturbance of consciousness with reduced clarity or awareness of the environment (eg, an inability to focus or to sustain or shift attention) and either (1) a new cognitive change (eg, deficits in memory or orientation, or a language disturbance) or (2) a new perceptual disturbance (eg, hallucinations or misinterpretations).2 Delirium frequently develops over hours or days, and fluctuates over time.
One of the major contributing factors is believed to be poorly dosed, or too much, narcotics for the age of the patient. Many experts who study ventilator delirium note that most doctors dose narcotics the same for most patients, when the dose should be adjusted for age and size -- particularly in the elderly.

Along with too much, or poorly dosed narcotics, we hospital staffers add to this problem by constantly irritating the patient.

Think about it though. You would go nuts too if the lights were on in your bedroom all night long, and every two hours someone came in to brush your teeth, and every hour between that someone came in to roll you over, or wipe your bottom, or break the circuit of the vent to give you a breathing treatment or squirt in an MDI, or dump water out of the circuit, or insert a new IV.

There have been studies done on this, and the result to every one I've read the experts conclude that the lights need to be out for at least 8 consecutive hours a night, and interfering with the patient needs to be kept to a complete minimum in order for that patient to get a good nights sleep to prevent Ventilator Narcosis.

However, at Shoreline Medical, we have a protocol that calls for 2 puffs of Ventolin every 6 hours, and a good mouth cleaning every 2 hours, and shifting the patient from side to side every hour. The result here is that the patient never gets more than one hour of consecutive sleep.

Since the average sleep cycle lasts 1.5 hours, one can assume that ventilated patient rarely if ever gets through a cycle. And, the result of lack of enough REM sleep is psychosis.

What has me most concerned is brushing the teeth every 2 hours. I understand that a good mouth cleaning is a great way to prevent ventilator acquired pneumonia, but I think there comes a time you use an amount of common sense and just let the patient miss a few of these mouth cleanings so he can get some sleep.

Some RNs I've talked to agree with me, and they ignore the protocol at night. Some, however (those who do everything by the book), never miss a mouth cleaning. To these individuals, the reasoning "I have to do it because it's protocol," or "I have to do it because the doctor ordered it," supersedes common sense.

I understand that rotating the patient often is a great way to prevent blood clots from forming, although I don't see why a little night time common sense can't prevail to allow the patient to sleep.

I understand why the overhead light needs to be on most of the day to so we can see the patient from the nurses station, but putting on the nightlight for six hours during the night shift is a great way to allow the patient to fall asleep and get some REM.

Thankfully most patients don't remember being on a ventilator anyway, even if they appear to be awake and appropriate at the moment. I have asked many patients a day or two after extubation if they remember anything, and a majority of them say, "No. I remember nothing."

Riker notes, "Most trauma patients have no recall of their ICU stay, but slightly more than one third do remember these events; 88 percent of the time, they have fantasies or hallucinations about being in prison and trying to escape."

So, the next time you are taking care of a patient on mechanical ventilation, ventilator psychosis or delirium or cognitive decline should be something for you to consider discussing with the attending physician.

1 comment:

Caiden said...