Discomfort, awareness and recall in the intensive care-still a problem?

During surgery, anesthetists take extra care to prevent patient awareness done mainly under general anesthesia either by using inhalational or intravenous medications. However, patients in the ICU mainly those on ventilatory support with intubation and sedation, pass through lot of psychological stress and frustration. Most of the times this stress phenomenon is not documented in the general intensive care. This is the first report in our general ICU.

Assessment of this stress phenomenon in order to avoid it in future, and to elicit proper consensus regarding its existence and offer methods of re-solution.

Seventy patients aged (20-60) years were interviewed one day after discharge from the ICU, about their memory of events during their stay. Patients with head injury, CNS infection and those who were disoriented at the time of interview were excluded from the study. The remaining 55 patients were oriented as to place and time. Intravenous morphine was used for analgesia as required, while sedation was achieved using midazolam and morphine infusions in appropriate doses as decided by the attending doctors and nurses, to achieve appropriate Ramsay sedation score. Questions asked were patient's memory of events and their distressing experiences regarding pain, anxiety, dreams, fear, noises, and other discomforts. The same questions were repeated 5 days later.

The sample of patients were representative of our regular ICU admissions in their age group, APACHE II score and duration of stay. The most distressing experiences recalled were: Anxiety (68%), discomfort from endotracheal tube (60%), fear (54%), pain (52%), discomfort from N/G tube (48%), difficulty in communicating (33%), dreams and hallucinations (31%), discomfort from physiotherapy (24%), noise (15%), insomnia (13%), thirst (10%), muscle paralysis (100%), some of these like anxiety, fear, dreams, hallucinations and insomnia had continued since discharge in 6% of patients. None of the studied experiences correlated with age, sex or with the APACHE II score. On interviewing the patient 5 days later, there were no significant change in their responses.

Our sedation and analgesia in the ICU is not enough to prevent unpleasant experiences, mainly those related to patient awareness. More work is still needed i.e. using sedation measuring systems, to improve our sedation and analgesia in the ICU.