Patients’ Recollections of Therapeutic Paralysis in the ICU

Abstract & Commentary

By Karen L. Johnson, RN, PhD, Assistant Professor, School of Nursing, University of Maryland, is Associate Editor for Critical Care Alert.

Dr. Johnson reports no financial relationship to this field of study.

Synopsis: Patients who have neuromuscular blocking agents in the ICU often recall the experience, and frequently report a common group of recollections.

Source: Ballard N, et al. Patients’ recollections of therapeutic paralysis in the intensive care unit. Am J Crit Care. 2006;15:86-94.

Ballard and colleagues conducted this qualitative study to obtain recollections of critically ill patients who were given neuromuscular blocking agents (NMBAs) (for a minimum of 6 hours) and sedatives and/or analgesics. Patients were interviewed 48-72 hours after extubation. They were asked to describe what they remembered about the time when they were on the ventilator and unable to move, and what events or conversations they remembered. Eleven patients (7 women, 4 men) were interviewed. The mean age was 43 years (range, 19-69 years). Most patients had a diagnosis of respiratory failure (5) and the rest had various medical conditions (COPD, overdose).

Four themes emerged from the data: 1) back and forth between reality and the unreal, between life and death; 2) loss of control, especially when being restrained; 3) fear of almost dying; and 4) a sense of being cared for. Results from this study provide additional evidence that patients can remember having both positive and negative experiences during therapeutic paralysis.

Commentary

This study is a replication of a study we conducted 7 years ago.1 Our study was conducted with 12 patients in a trauma ICU and this study was conducted with 11 patients in a medical ICU. The results of both studies are strikingly similar: patients do recall events and experiences—both positive and negative—during therapeutic paralysis.

Patients in both studies could not distinguish reality from dreams. They reported they could not figure out where they are. One patient in the current study thought she left the hospital, got lost, knew she was sick, but could not find her way back to the hospital. One patient in our study dreamed she was on a roller coaster and couldn’t get off (actually she was on a kinetic therapy bed). The fact that patients don’t know where they are should be of concern to nurses. Nurses are supposed to do frequent reality orientation with ICU patients. Compliance with this intervention is probably sporadic.

This also raises the question of the adequacy of sedation. Patients in this study all received sedation (lorazepam, midazolam, or propofol), but the mean dose or method used to evaluate the level of sedation was not reported. Clinical practice guidelines2 call for adequate sedation with administration of NMBAs, in accordance with clinical judgment. However, it is difficult to assess sedation levels in these patients. Recently the American Association of Critical Care Nurses proposed a Sedation Assessment Scale,3 but clinical trials to determine its reliability and validity have not been done. The Bispectral Index (BIS), calculated from EEG data, was designed to measure the depth of hypnosis during sedation.4,5 BIS does correlate with the Ramsay Scale.6,7 However associations among the BIS and other sedation scales vary among medical, surgical, and trauma patients.8-11

Fortunately, patients in this study, as in our study, could not recall painful procedures or experiences while under therapeutic paralysis. However, in the current study 4 of the 11 patients did not receive analgesics while undergoing therapeutic paralysis! Most of us would agree with others12 who believe that the use of NMBAs in patients who have not received analgesics is ethically and therapeutically contraindicated.

Patients in this study had a sense of being out of control, especially when being tied down. Why are patients who receive NMBA—to induce paralysis of voluntary muscle activity—being restrained? Despite the fear of dying and loss of control, the patients in this study had a sense of being cared for. As in our study, patients recalled a sense of emotional support and encouragement from their nurses and family members.

This study provides additional evidence that patients recall experiences during therapeutic paralysis. Extensive research has been done on the experience of awareness during general anesthesia. JCAHO published a Sentinel Event Alert on awareness during anesthesia.13 JCAHO now recommends education of staff about awareness during anesthesia, effective anesthesia monitoring techniques, follow up of all patients who have experiences of awareness during anesthesia, and counseling for those who experience post-traumatic stress disorder.

Unfortunately, the subject of recollections and awareness of patients during therapeutic paralysis in the ICU has not garnered the same degree of scrutiny as awareness during general anesthesia in the OR. Fortunately the number of patients receiving therapeutic paralysis in the ICU is now relatively small as compared to when our study was done. However, we do need to evaluate how well we are managing pain and sedation in patients who receive therapeutic paralysis. Quality improvement programs should be instituted to assess for awareness during therapeutic paralysis and to provide follow-up and referral as needed.

References

  1. Johnson KL, et al. Therapeutic paralysis of critically ill trauma patients: Perceptions of patients and their family members. Am J Crit Care. 1999;8:490-498.
  2. Jacobi J, et al. Clinical practice guidelines for the sustained use of sedative and analgesics in the critically ill adult. Crit Care Med. 2002;30:119-141; Erratum in: Crit Care Med. 2002 Mar;30(3):726.
  3. De Jonge MM, et al. Development of the American Association of Critical Care Nurses’ Sedation Assessment Scale for critically ill patients. Am J Crit Care. 2005;14:531-544.
  4. Spencer EM, et al. Continuous monitoring of depth of sedation by EEG spectral analysis in patients requiring mechanical ventilation. Br J Anaesth. 1994;73:649-654.
  5. Bower AL, et al. Bispectral index monitoring of sedation during endoscopy. Gastrointest Endosc. 2000;52:192-196.
  6. Mondello E, et al. Bispectral Index in ICU: Correlation with Ramsay Scale on assessment of sedation level. J Clin Monit Comput. 2002;17:271-277.
  7. Nasraway SA, et al. Sepsis research: we must change course. Crit Care Med. 1999;27:427-430.
  8. Simmons LE, et al. Assessing sedation during intensive care unit mechanical ventilation with Bispectral Index-Sedation agitation scale. Crit Care Med. 1999;27:1499-1505.
  9. Nasraway SA, et al. How reliable is the Bispectral Index in critically ill patients? Crit Care Med. 2002;30:1483-1487.
  10. Vivien B, et al. Overestimation of Bispectral Index in sedated intensive care unit patients revealed by administration of muscle relaxant. Anesthesiology. 2003;99:9-17.
  11. Frenzel D, et al. Is the bispectral index appropriate for monitoring mechanically ventilated surgical intensive care unit patients? Intens Care Med. 2002;28:178-183.
  12. Arbour R. Mastering neuromuscular blockade. Dimens Crit Care Nurs. 2000;19:4-16; quiz 17-20.
  13. Joint Commission on Accreditation of Healthcare Organization. Preventing and managing the impact of anesthesia awareness. Oakbrook Terrace, Ill: Joint Commission on Accreditation of Healthcare Organizations: Sentinel Event Alert Issue 32, October 6, 2004.