Post–Intensive Care Syndrome and Post–Intensive Care Syndrome-Family. AACN Advanced Critical

124 Pages·2016·6.97 MB·English

www.aacnacconline.org APRIL-JUNE 2016
AACN
Advanced
Critical Care
Evaluation of Pain Assessment Tools in Patients
Receiving Mechanical Ventilation
Factors Related to Successful Transition to
Practice for Acute Care Nurse Practitioners
SYMPOSIUM: PATIENT AND FAMILY
POST–INTENSIVE CARE SYNDROME
Implementing a Mobility Program to Minimize
Post–Intensive Care Syndrome
A Clinic Model: Post–Intensive Care Syndrome
and Post–Intensive Care Syndrome-Family
Developing a Diary Program to Minimize
Patient and Family Post–Intensive Care
Syndrome
Peer Support as a Novel Strategy to Mitigate
Post–Intensive Care Syndrome
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AACN
A d v a n c e d
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C o n t e n t s
FEATURES
1 6 2 Evaluation of Pain Assessment Tools in Patients Receiving Mechanical
Ventilation
Zainab Q. Al Darwish, Radwa Hamdi, and Summayah Fallatah
1 7 3 Factors Related to Successful Transition to Practice for Acute Care Nurse
Practitioners
Deborah L. Dillon, Mary A. Dolansky, Kathy Casey, and Carol Kelley
SYMPOSIUM
PATIENT AND FAMILY POST–INTENSIVE CARE SYNDROME
Judy E. Davidson, RN, DNP, and Maurene A. Harvey, MPH,
Symposium Editors
1 8 4 Introduction: Patient and Family Post–Intensive Care Syndrome
Judy E. Davidson and Maurene A. Harvey
1 8 7 Implementing a Mobility Program to Minimize Post-Intensive Care
Syndrome
Ramona O. Hopkins, Lorie Mitchell, George E. Thomsen, Michele Schafer,
Maggie Link, and Samuel M. Brown
2 0 4 A Clinic Model: Post–Intensive Care Syndrome and Post–Intensive Care
Syndrome-Family
Elizabeth L. Huggins, Sarah L. Bloom, Joanna L. Stollings, Mildred Camp,
Carla M. Sevin, and James C. Jackson
2 1 2 Developing a Diary Program to Minimize Patient and Family Post–Intensive
Care Syndrome
Meaghan Locke, Sarah Eccleston, Claire N. Ryan, Tiffany J. Byrnes,
Cristin Mount, and Mary S. McCarthy
2 2 1 Peer Support as a Novel Strategy to Mitigate Post–Intensive Care Syndrome
Mark E. Mikkelsen, James C. Jackson, Ramona O. Hopkins, Carol Thompson,
Adair Andrews, Giora Netzer, Dina M. Bates, Aaron E. Bunnell, LeeAnn M. Christie,
Steven B. Greenberg, Daniela J. Lamas, Carla M. Sevin, Gerald Weinhouse, and
Theodore J. Iwashyna
VOLUME 27 • NUMBER 2
APRIL-JUNE 2016
DEPARTMENTS
1 3 3 Drug Update
Medication Management to Ameliorate Post–Intensive Care Syndrome
Joanna L. Stollings, Sarah L. Bloom, Elizabeth L. Huggins, Scottie L. Grayson,
James C. Jackson, and Carla M. Sevin
1 4 1 Technology Today
Analytics 1.0, 2.0, 3.0
Linda Harrington
1 4 5 Issues in Advanced Practice
Strategies for Success: Cultivating Emotional Competence in the
Clinical Nurse Specialist Role
Elizabeth Kozub, Leah Brown, and Laurie Ecoff
1 5 2 Creating a Healthy Workplace
Shared Governance for a Healthy Work Environment in a Pediatric
Cardiothoracic Intensive Care Unit
Nida Sulit Oriza, Victoria Winter, and Flerida Imperial-Perez
1 5 8 Pediatric Perspectives
Impact of Family-Centered Care on Pediatric and Neonatal Intensive
Care Outcomes
Lori Williams
2 3 0 Clinical Inquiry
Overcoming Barriers to Using Patient-Reported Outcomes for
Clinical Inquiry
Maria Javier, Jae Youn Kim, Ellie Toone, and Bradi B. Granger
2 3 6 Ethics in Critical Care
The Ethics of Post–Intensive Care Syndrome
Judy E. Davidson and Karen Stutzer
2 4 1 ECG Challenges
2015 Advanced Cardiac Life Support Updates and Strategies for
Improving Survival After Cardiac Arrest
Gerard B. Hannibal
AACN
A d v a n c e d
Cr i t i c a l Ca r e
EDITOR
Mary Fran Tracy, RN, PhD, CCNS
Minneapolis, Minnesota
EDITORIAL BOARD
Earnest Alexander, PharmD Cynda Hylton Rushton, RN, PhD
Assistant Director for Pharmacy Services Anne and George Bunting Professor of Clinical Ethics
Department of Pharmacy Services Professor of Nursing and Pediatrics
Tampa General Hospital, Tampa, Florida Program Director, Harriet Lane Compassionate Care
Johns Hopkins University
Richard Arbour, RN, MSN, CCRN, CNRN, CCNS Berman Institute of Bioethics, Baltimore, Maryland
Liver Transplant Coordinator
Thomas Jefferson University Hospital Christine Schulman, RN, MS, CCRN, CNS
Philadelphia, Pennsylvania Consultant in Trauma and Critical Care Nursing
Portland, Oregon
Nancy Blake, RN, PhD, CCRN, NEA-BC
Director, PCS Critical Care Services Mary Lou Sole, RN, PhD, CCNS
Children’s Hospital Los Angeles Dean and Professor, College of Nursing
Valencia, California University of Central Florida, Orlando, Florida
Elizabeth Bridges, RN, PhD, CCNS Karen Stutzer, PhD, RN, APN-C
Biobehavioral Nursing and Health Systems, University of Washington Assistant Professor of Nursing
Seattle, Washington College of St. Elizabeth
Morristown, New Jersey
Denise Buonocore, RN, MSN, CCRN, ACNP-BC
Heart Failure Service, St. Vincent’s Medical Center Gregory M. Susla, PharmD
Bridgeport, Connecticut Associate Director of Medical Information
Medimmune, Inc, Rockville, Maryland
John Gallagher, RN, MSN, CCRN, CCNS, RRT
Clinical Nurse Specialist/Trauma Program Coordinator Lori Williams, RN, DNP, RNC-NIC, CCRN, NNP-BC
Hospital of the University of Pennsylvania Clinical Nurse Specialist, Universal Care Unit
Philadelphia, Pennsylvania American Family Children’s Hospital
University of Wisconsin Hospital and Clinics, Madison, Wisconsin
Bradi B. Granger, RN, PhD
Associate Professor, Duke University School of Nursing
Director, Heart Center Nursing Research Program American Association of Critical-Care Nurses
Associate Director, Duke Translational Nursing Institute Editorial Office
Durham, North Carolina
Publishing Manager Michael Muscat
Gerard B. Hannibal, RN, MSN, PCCN Managing Editors Melissa Jones, PhD
Staff Nurse, Progressive Care Unit Rebecka Wulf
The Louis Stokes Cleveland Department of Veterans Affairs Medical Center
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Linda Harrington, RN-BC, PhD, DNP, CNS, CPHQ, CENP, CPHIMS Copy Editors Barbara Halliburton, PhD
Independent Consultant, Health Informatics and Digital Strategy Katie Spiller, MS
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Houston, Texas
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Serena Phromsivarak Kelly, RN, MS, CCRN, FNP-BC Senior Publishing Associate Sam Marsella
Nurse Practitioner, Pediatric Critical Care
Oregon Health & Science University Statement of Purpose
Portland, Oregon
AACN Advanced Critical Care is a quarterly, peer-
Mary Beth Flynn Makic, RN, PhD, CNS, CCNS reviewed publication of in-depth articles i ntended for
Associate Professor experienced critical care and acute care clinicians at
University of Colorado College of Nursing, Anschutz Medical Campus
the bedside, advanced practice n urses, and clinical and
Aurora, Colorado
academic educators. Each issue includes a topic-based
Patricia Gonce Morton, RN, PhD, ACNP-BC symposium, feature a rticles, and columns of interest to
Dean and Professor, Louis H. Peery Endowed Chair critical care and progressive care clinicians.
University of Utah College of Nursing
AACN Advanced Critical Care contains concisely
Salt Lake City, Utah
written, practical information for immediate use and
Carol Rauen, RN, MS, CCNS, CCRN, PCCN, CEN, RN-BC future reference. Self-paced continuing nursing
Independent Critical Care Clinical Nurse Specialist & Education Consultant education units are available for selected articles in
The Outer Banks, North Carolina each issue.
AACN Advanced Critical Care
Volume 27, Number 2, pp. 133-140
© 2016 AACN
D r u g
Earnest Alexander, PharmD, and
Update Gregory M. Susla, PharmD
Department Editors
Medication Management to Ameliorate
Post–Intensive Care Syndrome
Joanna L. Stollings, PharmD, BCPS
Sarah L. Bloom, AG-ACNP
Elizabeth L. Huggins, AG-ACNP
Scottie L. Grayson
James C. Jackson, PsyD
Carla M. Sevin, MD
Mortality rates of critically ill patients have decreased markedly in recent
years thanks to advancements in care.1 Given the improved survival
rates of critically ill patients, investigators have broadened their focus from
short-term mortality to long-term mortality and morbidities that are often
underrecognized by intensive care unit (ICU) practitioners. The Society of
Critical Care Medicine (SCCM) has defined post–intensive care syndrome
(PICS) as a new or worsening decrement in mental, cognitive, or physical
health following critical illness that persists beyond the acute hospitalization.2
Many medication-related risk factors are associated with development of
cognitive impairment in critically ill patients, including glucose dysregulation,3,4
delirium,5 and medications.6 Medications have also been associated with acute
neuromuscular weakness following an ICU admission.7 In the past decade,
the increased risk of adverse drug events (ADEs) during transitions of care
has become widely known. This column focuses on how medication manage-
ment strategies in the ICU, after the ICU, and after hospitalization may prevent
or help manage PICS.
In the ICU
Glucose Dysregulation
Both hyperglycemia and hypoglycemia are associated with cognitive dys-
function in critically ill patients. Hyperglycemia decreases cerebral blood flow,
Joanna L. Stollings is Clinical Pharmacy Specialist in the Medical Intensive Care Unit (MICU) and Pharma-
cist in the ICU Recovery Center, Department of Pharmaceutical Services, Vanderbilt University Medical
Center, 1211 Medical Center Drive, BUH-131, Nashville, TN 37232 (joanna.stollings@v anderbilt. edu).
Sarah L. Bloom is Acute Care Nurse Practitioner in the MICU and the ICU Recovery Center, Department
of Medicine, Vanderbilt University Medical Center.
Elizabeth L. Huggins is Acute Care Nurse Practitioner, Department of Medicine, Vanderbilt University
Medical Center.
Scottie L. Grayson was a patient in the ICU Recovery Center at Vanderbilt University Medical Center.
James C. Jackson is Neuropsychologist and Assistant Director of the ICU Recovery Center, Center for
Health Services Research, Department of Medicine, Department of Psychiatry, Vanderbilt University
Medical Center, and Geriatric Research, Education and Clinical Center (GRECC) Service, Department
of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee.
Carla M. Sevin is Assistant Professor of Medicine and Director of the ICU Recovery Center, Vanderbilt
University Medical Center.
The authors declare no conflicts of interest.
DOI: http://dx.doi.org/10.4037/aacnacc2016931
133
Drug Update WWW.AACNACCONLINE.ORG
injures the vascular endothelium, increases been started by SCCM to aid in the imple-
permeability of the blood-brain barrier, and mentation of the PAD guidelines in 77 hospi-
increases excitatory neurotransmitter release tals in the United States that are committed
and resultant neuronal death.8 A retrospective to improving outcomes for patients and their
study of 74 survivors of acute respiratory families.
distress syndrome (ARDS) demonstrated that Delirium. In 2013, a large, multicenter,
having a blood glucose value of 153.5 mg/dL prospective observational cohort study5 of
(to convert to millimoles per liter, multiply 821 adult medical and surgical ICU patients
by 0.0555) was associated with a 2.9 times with respiratory failure, cardiogenic shock,
greater chance of cognitive impairment.3 or septic shock, called Bringing to Light the
Additionally, a retrospective, case-control Risk Factors and Incidence of Neuropsycho-
study of 37 surgical ICU patients who had logical Dysfunction in ICU Survivors (BRAIN-
experienced at least 1 episode of hypoglyce- ICU), was reported. The researchers sought to
mia during treatment showed that cognitive estimate the prevalence of long-term cogni-
dysfunction, specifically in visuospatial skills, tive impairment following critical illness.
was higher in the hypoglycemia group than The strongest independent predictor of cogni-
in the control group (P < .01).4 tive impairment was ICU delirium, which
Hyperglycemia is also a risk factor for was found in 50% of study patients. Three
critical illness polyneuropathy (CIP) and months following hospital discharge, a Repeat-
critical illness myopathy (CIM). Insulin has able Battery for Neuropsychological Status
anti-inflammatory effects, protects endothe- (RBANS) score similar to what has been seen
lium, improves the metabolism of lipids, and in individuals with mild Alzheimer’s disease
is an anabolic hormone.7 Intensive insulin (2 standard deviations below the population
therapy (maintaining blood glucose levels mean) was found in 26% of patients, and a
between 80 and 100 mg/dL) in surgical ICU score similar to the scores seen in patients
patients decreased neuropathy from 51.9% with moderate traumatic brain injury (1.5
to 28.7%. Also, intensive insulin therapy standard deviations below the population
decreased the prevalence of CIP and CIM mean) was found in 40% of patients.5
from 49% to 25% in surgical ICU patients Pain. Inadequate pain management has
(P < .001) and from 51% to 39% in the been associated with numerous complications,
medical ICU (P = .02) in patients who had an including nosocomial infections, increased
ICU stay of at least 1 week.9,10 Moreover, the duration of mechanical ventilation, and delir-
percentage of patients receiving mechanical ium.14 The treatment of pain with opiates in
ventilation for at least 2 weeks was reduced critically ill patients has been associated with
from 42% to 32% in the surgical ICU (P = .04) an increased risk of delirium in some studies15
and from 47% to 35% in the medical ICU and a decreased risk of delirium in others.16
(P = .01).9,10 However, a subsequent study, Although other medications such as gabapen-
NICE-SUGAR,11 showed increased mortality tin (Neurontin), nonsteroidal anti-inflammatory
in the intensive insulin group (27.5%) com- drugs, and acetaminophen (Tylenol) are good
pared with conventional glucose control (< 180 adjunctive therapies, opioids are the medication
mg/dL; 24.5%; P = .02). On the basis of that class of choice for treating pain in critically
study, SCCM guidelines for the use of an insu- ill patients.13 The potential for the develop-
lin infusion in critically ill patients suggests ment of delirium highlights one of the many
that patients with a blood glucose level of reasons why pain assessment in critically ill
150 mg/dL or greater receive an intervention patients is so imperative. The PAD guidelines13
to maintain blood glucose level at less than recommend that all adult critically ill patients
180 mg/dL while avoiding hypoglycemia.12 be routinely assessed for pain. Self-reporting
of pain is considered the reference standard
Pain, Agitation, and Delirium for pain assessment. However, if a patient is
The pain, agitation, and delirium (PAD) nonverbal, the PAD guidelines13 recommend
guidelines13 were published by SCCM in 2013 use of the Behavioral Pain Scale or the Criti-
and summarize the best evidence available for cal Care Pain Observational Tool in ICU
providing physical and psychological comfort patients who are unable to self-report pain.
through management of PAD. A program Sedation. Benzodiazepines have been asso-
called the ICU Liberation Collaborative has ciated with the development of delirium in
134
VOLUME 27 • NUMBER 2 • APRIL - JUNE 2016 Drug Update
Table 1: Stop, THINK, and Medicate
Stop THINK Medicate
Do any medications need to be Toxic situations No published studies report
stopped or lowered? that haloperidol (Haldol)
Congestive heart failure,
Especially consider sedatives decreases the duration of
shock, dehydration
delirium
Is patient receiving minimal
New organ failure (liver/kidney)
amount necessary? Atypical antipsychotics may
Daily sedation cessation Hypoxemia decrease the duration of
Targeted sedation plan delirium
Infection/sepsis (nosocomial),
Assess target daily
immobilization Dexmedetomidine (Precedex)
Do sedatives need to be changed? may result in more days alive
Nonpharmacological interventions
without delirium and lower
Remember to assess for pain!
Hearing aids, eyeglasses, daily prevalence of delirium
reorient, sleep protocols,
music, noise control,
ambulation
Electrolyte problems (eg,
potassium)
several studies.15,16 The PAD guidelines rec- Richmond Agitation-Sedation Scale (RASS)
ommend using nonbenzodiazepine sedation were more likely to be at the target RASS score
strategies (eg, dexmedetomidine [Precedex]) with dexmedetomidine (74%) than with
in delirious patients.13 Three studies17-19 have standard care (64%).
demonstrated that patients are less likely to In a phase 3, multicenter, randomized, double-
remain delirious if dexmedetomidine is used. blind trial,19 MIDEX, researchers found that
In a double-blind, randomized, controlled the composite outcome of agitation, anxiety,
trial of 106 patients receiving mechanical and delirium occurred in 27% of patients who
ventilation, The Maximizing Efficacy of Tar- received midazolam versus 29% of patients
geted Sedation and Reducing Neurological who received dexmedetomidine (P = .69). In a
Dysfunction (MENDS) study,20 researchers second phase 3, multicenter, randomized, double-
found that the median number of days alive blind trial,20 PRODEX, researchers found that
without delirium or coma was 7 in the dex- the composite outcome of agitation, anxiety,
medetomidine group versus 3 in the lorazepam and delirium occurred in 29% of patients who
(Ativan) group (P = .01). The daily prevalence received propofol versus 18% of patients who
of delirium was lower in the dexmedetomidine received dexmedetomidine (P = .008). Overall,
group than in the lorazepam group (P = .004) these studies suggest that the use of dexme-
after the day of randomization.20 detomidine results in increased days alive with-
In a second double-blind, randomized, out delirium and reduced daily prevalence of
controlled trial of 375 medical/surgical ICU delirium compared with benzodiazepines.
patients, the Safety and Efficacy of Dexme-
detomidine Compared with Midazolam Management of Delirium
(SEDCOM) study,17 researchers found that Nonpharmacological management of delir-
60.3% of dexmedetomidine patients and ium through risk factor reduction has been
59.3% of midazolam (Versed) patients were studied in non-ICU patients, and the results
delirious at baseline according to the Confusion generalize to the ICU population. However,
Assessment Method for the ICU. During the these interventions need to be investigated
study period, the prevalence of delirium was further in critically ill patients. An example
54% in the dexmedetomidine group compared of risk-reducing strategies that can be simpli-
with 76.6% in the midazolam group (P < .001).17 fied into a simple phrase “Stop, THINK, and
A pilot, phase 3, double-blind, randomized Medicate” is presented in Table 1.
study was conducted by Ruokonen et al18 in Pharmacological interventions should be
2009 to compare dexmedetomidine with stan- considered only after nonpharmacological
dard care (midazolam or propofol [Diprivan]). strategies have been implemented and modifi-
Patients with a target score of 0 to -3 on the able risk factors have been addressed.
135
Drug Update WWW.AACNACCONLINE.ORG
Beneficial effects of haloperidol (Haldol) or
Table 2: Medication Strategies to Avoid
atypical antipsychotics on decreasing the
Post–Intensive Care Syndrome
duration of delirium in adult ICU patients
have not been definitively demonstrated (ie, no Medications
large randomized controlled trials). In a pro- Associated With
spective pilot study,21 18 delirious patients Acute Neuromuscular
were randomized to receive scheduled que- Deliriogenic Medications Weakness
tiapine (Seroquel) and 18 delirious patients Steroids Neuromuscular
were randomized to receive placebo. All blockers
Anticholinergics
patients could receive intermittent haloperi-
Antihistamines Steroids
dol. Faster resolution of delirium was found
Medications for overactive
in the quetiapine group compared with the Aminoglycosides
bladder
placebo group (1 day vs 4.5 days, P = .001) as Antispasmodics Clindamycin (Cleocin)
well as a shorter duration of delirium (36 days Tricyclic antidepressants
vs 120 days, P = .006). Additionally, less inter- Paroxetine (Paxil)
mittent haloperidol was required in the que- Disopyramide (Norpace)
tiapine group (3 vs 4 days). Both groups
(cid:96)-Blockers
experienced a similar amount of QT interval
Lithium (Lithobid)
prolongation and extrapyramidal symptoms,
but more somnolence was found in the que- Diuretics
tiapine group (22% vs 11%, P = .66).
Digoxin (Lanoxin)
Currently, a multicenter, randomized,
placebo-controlled, study sponsored by the Dopamine agonists
National Institutes of Health called Modifying Antibiotics
the Impact of ICU-Associated Neurological Quinolones
Dysfunction-USA (MIND-USA) is being con- Cefepime (Maxipime)
ducted in delirious medical and surgical ICU
Narcotics
patients with respiratory failure or shock to
Nonsteroidal
determine the effects of haloperidol versus
anti-inflammatory drugs
ziprasidone versus placebo on the number of
days alive without delirium or coma, mortal- Histamine blockers
2
ity, and long-term cognitive function.
Skeletal muscle relaxants
Sedatives
Medications That Cause Delirium
Benzodiazepines
Medications are a common yet easily
Inhaled anesthetics
reversible cause of delirium, accounting for
Ketamine (Ketalar)
12% to 39% of all cases. The American
Geriatric Society recently updated the Beers Theophylline (Theo-24)
criteria, listing potentially inappropriate
medications to be prescribed in elderly adults. antibiotics have weak dopaminergic activity.
In addition, the Society also published a list Morphine also increases the release of dopa-
of alternative medications to use instead of mine.24 Anticholinergic medications result
high-risk medications. Although narcotics in a cholinergic deficiency and are a modifi-
and benzodiazepines have been discussed in able risk factor for delirium. Additionally,
prior sections, many other deliriogenic medi- digoxin (Lanoxin), lithium (Lithobid), and
cations are commonly prescribed to patients histamine blockers demonstrate some cho-
2
in the ICU22 (Table 2). linergic binding activity, although they are
Excess dopamine, decreased acetylcholine, not traditionally classified as anticholinergic
and alterations in (cid:97)-aminobutyric acid are agents.22 The proposed mechanism behind
all mechanisms behind the development of benzodiazepine-induced delirium is altera-
delirium.23 Dopamine agonists used as anti- tions in (cid:97)-aminobutyric acid.24
parkinsonian agents can contribute to delir- A prospective cohort study25 of 1112 criti-
ium. If these medications are deemed necessary, cally ill patients in a 32-bed medical-surgical
a dosage reduction or change in schedule ICU for a total of 9867 days was conducted
may alleviate the problem. Quinolone to determine whether anticholinergic exposure
136