To Hell and Back: Demons of ICU Past

**juan de la cruz, MSN, RN, NP**

Teresa, a woman in her 40's, a wife and mother of two young boys, felt tightness around her chest as she suddenly woke up from sleep. She was breathing heavily and bathing in a pool of sweat as she clasped her arms over her chest. She was having nightmares again. In the dark and troubling dream she was having, she was being tortured by men and women in light blue outfits. They were laughing at her, taunting her while she lay helpless in the middle of a dark alley. They were trying to suffocate her with what appears to be an oval-shaped plastic contraption covering her nose and mouth. They were trying to make her breathe air that looked like smoke. Before she knew it, her arms were tied up and she was unable to move, unable to scream for help. She was crying inside but nobody could hear her. That's when she woke up all of a sudden and sat there in the bed trying to catch her breath, her husband at her side reassuring her that it was just a dream.

She's been having recurring bad dreams. One particular ugly scene involved being incarcerated against her will at a filthy jail. Inmates were screaming left and right. They were crying in pain but nobody listens. All she hears are laughter from the guards who should be helping the poor inmates. They were slamming glass sliding doors at her as she cried in pain. Another vision involves seeing the sad face of her two boys peeking at the glass door in her small square room but they couldn't get in. She wanted them inside so she could hug them but she couldn't. Then, at one point her husband showed up with one of the female guards, the meanest of the bunch. She had her arms around him as they both smiled at her. In her mind, there was no doubt he was having an affair with that woman. She wakes up realizing it was just a bad dream but the anger she felt in the nightmares seemed so real.

Teresa was never a victim of a sexual assault. She has never lived in a town destroyed by a natural calamity. She was neither a war veteran nor a refugee from a war-ravaged country at any point in her life. Teresa was a patient in the ICU last year. She had a severe form of pre-eclampsia called HELLP which also led to the demise of her fetus, a baby who would have been her third child. She had a prolonged and complicated ICU stay marked by multi-organ failure. She required intubation and mechanical ventilation for respiratory failure, multiple transfusions of blood products due to bleeding from liver failure, and continuous renal replacement therapy due to kidney failure. Teresa won her battle physically, her body fought a hard fight and she recovered from all the physiologic derangements with minimal sequelae. However, she is now left psychologically scarred from the experience. She is seeing a mental health provider and is diagnosed with Post-Traumatic Stress Disorder (PTSD) as a consequence of her ICU experience.

PTSD Among ICU Survivors: Scope and Prevalence

All individuals who experience events perceived as traumatic undergo a cascade of emotional and physiologic reactions as the body's normal defense to stressors, a "fight or flight" reaction if you will. We all go through incredibly rough times in our lives as we live in this imperfect existence but what sets PTSD sufferers apart is that long after the experience has ended, the trauma still haunts in a profound way. PTSD affects an individual's ability to live life to the fullest by interfering with life's tasks such as employment and other roles in society we all need to fulfill.

Symptoms of PTSD

Re-Experiencing Symptoms include nightmares, frightening thoughts, and flashbacks
Avodiance Symptoms include staying away from places or situations that remind the individual of the trauma, emotional numbness, depression, guilt, and lack of interest.
Hyperarousal Symptoms include insomnia, outbursts of anger, feeling "on edge".

To be diagnosed with PTSD, an individual must manifest at least 1 of each of the above symptom clusters for at least one month. PTSD is well-documented among all survivors of traumatic events particularly war veterans but a growing body of Critical Care literature is describing PTSD among survivors of an ICU stay as early as the 1980's. In 2008, Davydow et al found 19% median point prevalence of clinician-diagnosed PTSD among ICU survivors after a systematic review of fifteen studies on the topic. A more recent longitudinal study by the same primary investigator published in 2012, found the prevalence of substantial PTSD and depressive symptoms were 16% and 31% at 3 months post-ICU and 15% and 17% at 12 months post-ICU respectively.

Who Are at Risk?

Multiple studies have tried to identify which of the individuals who had an ICU admission are more likely to suffer from PTSD later. A small study by Girard et al in 2007 published in Critical Care found high levels of PTSD symptoms in patients following critical illness necessitating mechanical ventilation and that these symptoms were more likely to occur in females who received high doses of Lorazepam. Older patients, they found, were less likely to have PTSD.

The previously mentioned review by Davydow et al in 2008, however, had more extensive findings. His group's research found that consistent predictors of post-ICU PTSD are pre-ICU psychopathology, greater ICU benzodiazepine administration, and post-ICU memories of in-ICU frightening and or/psychotic experiences. Interestingly, his group found that female sex, younger age, and severity of critical illness were less consistent predictors of post-ICU PTSD. He also found that the duration of mechanical ventilation and length of ICU stay has little evidence to support the later occurrence of post-ICU PTSD.

Hope: Our Role as Nurses

As Critical Care Nurses, we are proud of being thorough and for looking out for the whole patient from head to toe. We clock a great deal of patient care time at the bedside, more than any other healthcare professionals who see patients in the ICU. Thus, we hold the key to advocating for patients' rights to be free from harm intentional or not.

A great deal of post-ICU PTSD sufferers appear to be younger with a pre-existing psychopathology prior to the ICU admission. However, knowing these risk factors is only half the battle. The literature on post-ICU PTSD recommends screening of patients after an ICU stay as a way to make sure that patients at risk are identified and future referrals for counselling and mental health assistance are provided in order to assure a recovery that is whole, one that involves wellness of mind and body.

We know that ICU patient management involves a lot of frightening, painful, isolating, and traumatizing events. These are unavoidable because they are part of the patient's treatment in order to get better. Involving the patient and his/her family in our thoughts and planning by preparing them in a manner that is least intrusive to their well-being could make a big difference in how the ICU experience is perceived later.

A growing movement in Critical Care Nursing is the use of ICU Diaries. These have been introduced in European ICU's initially but have slowly but surely reached our US soil. ICU Diaries are written accounts by family members, nurses, and providers during a time when the patient is unable to understand or comprehend his/her physical surroundings while sedated and/or mechanically ventilated.

The Diary allows for unlimited creativity. Not only are events of the day easily transcribed to add a reality-based affirmation of the ICU stay to the patient who could read it later during recovery but messages of support, prayers, and love are a way for family members and friends to extend a connection to the patient who is unable to interact at the time. Pictures can also be posted and serve as a reminder of what is real and happening at the time. ICU Diaries have been studied in the Critical Care literature as well and have been shown to be favorable to patient recovery later.

Please share your thoughts and experiences and don't forget to check out the following links:

ICU Diaries

**tnbutterfly - Mary, BSN, RN** · Apr 28, 2014

Great article! Thanks for reminding us of what some of our patients go through.......after they leave our care.

francoml, ASN, RN · Apr 29, 2014

One thing I have noticed in my practice is the fact that we are "snowing" people on benzos for sedation. We have to get away from high dose ativan and versed when it is not needed. I feel that benzodiazapines are a leading cause of psychosis and delirium in the ICU. One thing we are starting to do is using high dose fentanyl over ativan/versed. Studies show if you treat pain first then there is a significantly smaller need for sedation. Propofol is also a great choice when a true sedative is needed as it does not have the long lasting effects of benzos. Just my humble opinion.

TeacupPom · Apr 29, 2014

I remember, I remember. As a kid, I'd had to stay in the hospital multiple times. The nurses and doctors were good. Treatment was good. My parents came to visit all the time. Everyone tried to make my stays comfortable. The physical aspect was great! The mental aspect, not so much. Harsh lights, so bright. Loud sounds, all around. Tests leaving me not feeling my best. The OR lights, the smell of anesthesia. I still remember.

vianne · May 1, 2014

Thanks juan de la Cruz I only visit ICU as part of my job rather than work on it directly and can see how the human part of the 24/7 might be lost to the onlooker as much as to the patient, diaries are used very effectively here plus there's a survivors group, which has a high profile too, I wonder that the figures of incidence aren't higher, that isn't a criticism of care obviously as im full of admiration for these front line staff more a recognition of the growing and welcome voices of patients telling us what they'd prefer to see as usual treatment

**juan de la cruz, MSN, RN, NP** · May 1, 2014

Vianne and others, thanks for your comments. You will find a wide range of incidence depending on the study and the methodology used. I cited the 2 studies in my article because one was a systematic review of 15 previous post-ICU PTSD studies and the other one was a longitudinal study that specifically identified PTSD as a diagnosis.

Some studies do have higher incidence of PTSD symptoms (as high as 1 in 3 patients). These are the ones that identified post-ICU PTSD symptoms, not necessarily PTSD diagnosis. Remember that all 3 symptoms (re-experiencing, avoidance, hyper-arousal) must be present in order for the diagnosis to be made. Of course, that does not lessen the impact on quality of life for patients who didn't get diagnosed formally just because all they have are part of the entire spectrum of PTSD symptoms.

If you're interested, there are also studies that looked at specific diagnoses and Acute Lung Injury/ARDS is mentioned frequently in patients who later developed post-ICU PTSD. Not surprisingly, Trauma patients are up there too as well as those who had an MI or CABG. I'm not aware of the incidence in Pediatric patients, I think that's what your experience is TeacupPom, am I correct?

I agree that nurses do a lot being in the frontlines of care and I am proud of the work ICU nurses do at the bedside. I wanted to bring this issue to the surface as something to ponder on and hopefully we make positive changes in the way we deliver care for the better. There's always room for improvement.

A new terminology already emerged from our interest in post-ICU issues and some literature have referred to these collectively as Post-Intensive Care Syndrome or PICS. These run the gamut of ICU acquired myopathies, cognitive dysfunctions, and mental health symptoms such as PTSD. It is an interesting source of research in Critical Care at the moment.

icushiftnurse · Oct 18, 2015

G'day. Interesting article. We have used ICU patient diaries in my ICU, (I'm in Australia in case the G'day didn't give it away) for years and with good effect. We have had patients come WALKING back into ICU to say thank you and after reading their diaries and coming back we have been able to clear up any lingering doubts or nagging feelings of 'what really happened when this was written?' feelings. It helps, everything helps. At the end of the day, it is taking the best care of your whole patient that you can. Seeing them as a person and not just as the dialysis, nitric dependent patient in Bed 17.

You never know what they hear, and what they remember, so we always talk to our patients and explain what we are doing, even if there is no visible reaction. Diaries help. They are a tangible reminder... you survived. We have a discharge drop down on our EMR.. it says 'survived ICU'. Yes they survived ICU and the patient diaries help put into perspective just how sick they were and what they survived on a daily basis which brings peace to many..jsut my two cents worth.

To Hell and Back: Demons of ICU Past

PTSD Among ICU Survivors: Scope and Prevalence

Symptoms of PTSD

Who Are at Risk?

Hope: Our Role as Nurses

About juan de la cruz, MSN, RN, NP

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