The Intensive Care Unit syndrome/delirium, patients' perspective and clinical signs

University dissertation from Department of Anesthesiology and Intensive Care, University Hospital, S-221 85 Lund, Sweden

Abstract: When a person becomes critically ill, injured and/or undergoes major surgery and requires intensive care, a complex dilemma can arise. The condition of the illness, the specific caring situation and the environment lead to significant changes and effects in the senses and perceptional abilities. Under these conditions some patients can develop symptoms of the Intensive Care Unit syndrome/delirium. The aim of this thesis was to describe, illuminate and explore the ICU syndrome/delirium from the patients perspective; and to investigate the clinical signs and some demographic and clinical data which could be related to the ICU syndrome/delirium seen in mechanically ventilated patients having had a stay at the ICU of more than 36 hours. Observations and interviews were used as methods in the hermeneutic approaches. A total of 31 patients were observed during their stay at the ICU and of these 19 patients were interviewed twice after discharge. Observations: The patients exhibited a great variety of clinical signs of the ICU syndrome/delirium. The clinical signs were characterised by a fluctuating ability to establish contact or communicate. Even the ability to control or move the body fluctuated; the ability to rest i.e. the patients could fall asleep for a few minutes and then suddenly become anxious, restless, plucking, and mumbling. Some patients could appear very communicative and active, moving about all the time, trying to get out of bed, and being in a good mood, but could suddenly recount odd experiences, become aggressive and unable to focus on any other person, or concentrate, or listen. Most patients were disoriented as to time and place. Interviews: Upon regaining consciousness, patients described a state of chaos. This chaos could result in a loss of control over body, mind and circumstances, and into a condition of persistent inner tension or prolonged fear. The patients remembered their time at the ICU with a "jigsaw puzzle" recall but their "unreal experiences" in detail. "Unreal experiences" are phenomena, which appear in an experienced total wakeful condition or in a condition between wakefulness and sleep, they are experienced as real, and can appear at any time, meaning that anything could cause or trigger them, but tend to appear more frequently, and usually with more severity, at night and when the patient tries to sleep. In the present paper, the 19 patients were classified into different groups of patterns and intensities of "unreal experiences" and i.e. severe delirium (SD) moderate delirium (MD) and mild/non delirium. Patients in the group SD had significantly lower haemoglobin concentrations than those in the other groups. There was a tendency towards a similar but less significant difference in PaO2 between the groups. SD patients had both significantly longer duration of mechanical ventilation, longer stays in the ICU, and significantly higher doses of both fentanyl and midazolam than those having moderate or no symptoms of delirium. The clinical signs do not seem to be separate phenomena, but related and connected to each other, and also to patients' verbal expressions. Therefore clinical signs and verbal expressions must be regarded as a coherent whole. The patient's experiences related in the interviews gave an inside perspective on the ICU world and what it feels like to suffer from the ICU syndrome.

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