Psychological symptoms in difficult-to-sedate critical care survivors.

BACKGROUND: Critical care survivors often experience symptoms of anxiety, depression, or post-traumatic stress disorder (PTSD). AIMS: To determine the prevalence and severity of psychological symptoms during the first 6 months after discharge from the intensive care unit (ICU) and to evaluate its association with patients who are difficult to sedate during admission. DESIGN: Descriptive, prospective analysis of psychological symptoms in survivors from medicosurgical ICU over a 2-year period. METHODS: All ICU survivors who required mechanical ventilation (MV) for more than 24 hours were followed for 6 months after their ICU discharge. ICU outcome and complications as well as the presence of psychological symptoms, 1 to 3 to 6 months after discharge were prospectively evaluated through phone interviews comparing the incidence and intensity of patients who were difficult to sedate during their ICU stay with those who were not. Descriptive analysis and multivariate logistic regression were performed. RESULTS: Data were obtained for 195 patients, of whom 30% experienced difficult sedation (DS). Difficult-to-sedate patients were younger (P = .001), less critically ill (APACHE II score P = .002), and more likely to engage in harmful use of alcohol (P = .001) and psychoactive/psychotropic drug abuse. They also spent longer times on MV and in the ICU (P = .001). Anxiety incidence at 1 to 3 to 6 months post-discharge was significantly higher in DS patients than in those who were not (87.7% vs 45.4%, 75.5% vs 29.0%, and 70.8% vs 23.7%; P < .01), respectively. Depression incidence was also significantly higher in the DS group (82.4% vs 43.1%, 66% vs 33.9%, and 60.4% vs 27.2%; [P = .001]) at 1 to 3 to 6 months, respectively. A higher percentage of patients in the DS group reported symptoms of PTSD at 1 month (28.1% vs 11.5%) (P = .007) when compared with non-DS group. CONCLUSIONS: Critical care survivors who are difficult to sedate during their ICU stay are more likely to present psychological sequelae. Early identification of at-risk patients is necessary to implement appropriate preventive strategies. RELEVANCE TO CLINICAL PRACTICE: Patients who are difficult to sedate in the ICU may develop psychological disorders upon discharge, which may negatively affect their recovery. The prevention of DS and the early detection of psychological disorders are essential to minimize its subsequent impact.

Impact of difficult sedation on the management and outcome of critically ill patients.

BACKGROUND: The term "difficult sedation" (DS) refers to situations of therapeutic failure, tolerance, or deprivation of the sedatives administered. AIMS: To characterize the profile of patients who developed DS and to assess its impact on the duration of mechanical ventilation (MV) and intensive care unit length of stay (ICU-LOS), as well as other complications related to their stay. DESIGN: A prospective descriptive analysis was conducted of the practices of analgesia/sedation in a medical-surgical intensive care unit (ICU) over a 2-year period. METHODS: All critically ill patients undergoing MV and sedation for more than 24 hours were prospectively followed until death or discharge. Demographic data, type, duration, complications of analgesia/sedation, and clinical outcome during ICU stay were recorded. Patients who developed DS were compared with those who were not difficult to sedate (not-DS). RESULTS: A total of 327 patients were included, 24.1% of whom were difficult to sedate (DS). Patients in the DS group were younger (P = .001); less severely ill (P = .003); and were more likely to have a history of smoking (P = .045), alcohol (P < .001), and psychotropic use (P = .001) than the not-DS group. Patients included in the DS group were sedated for longer periods (P < .001) and required higher doses of midazolam (P < .036), propofol (P = .023), and remifentanyl (P = .026) than those in the not-DS group. Difficult-to-sedate patients were twice as likely to require more than one sedative simultaneously (P < .001), presented more periods of over-sedation (P = .031)/under-sedation (P = .024), and suffered more pain (P < .001) than patients in the not-DS group. Patients in the DS group had prolonged MV times (P < .001), developed more pressure ulcers (P > .001) and ventilator-associated pneumonias (P = .025), and were more likely to require tracheotomy (P = .001) than those in the not-DS group. CONCLUSION: DS develops in one of four critically ill patients and has a negative impact on their outcomes. Early identification of the clinical profile of this group and active prevention and treatment are essential strategies in order to minimize its impact. RELEVANCE TO CLINICAL PRACTICE: A quarter of mechanically ventilated patients may develop situations of DS, which negatively affects their outcome. Early detection and prevention of DS are essential to minimize its impact.