Page 172 - ACCCN's Critical Care Nursing

Psychological Care 149

A Note on Melatonin The current advice of the authors is that it is better to
Melatonin is used for the short-term alleviation of insom- provide conditions that encourage the normal circadian
nia. This naturally-occurring hormone is both sleep- secretion of endogenous melatonin (i.e. provide lighting
promoting and maintaining. Despite its popularity in the and activity levels appropriate for the time of day) than
treatment of primary insomnia, e.g. jet lag and shift to administer exogenous melatonin.
work, the effectiveness of exogenous melatonin as a sleep
medication is yet to be clearly elucidated. 155,156 Investiga- SUMMARY
tions performed in ICU did not use polysomnography
and were largely inconclusive. 157-159 Difficulties occur in Meeting the psychological needs of patients is essential
emulating the typical endogenous pulsatile secretion of in the care of critically ill patients. This chapter outlines
the hormone 160 together with its short half-life probably various methods that are available to assess and then
explain why many study results are inconclusive. The effectively manage aspects of patient care related to
high doses required to achieve an adequate plasma level anxiety, delirium, pain, sedation and sleep. Assessment
overnight when administered once at the beginning of of these aspects of patient condition require thorough
the night are likely to persist in the body and may upset clinical assessment, with a range of instruments available
normal circadian rhythm. Some studies investigating the to help improve consistency over time and between clini-
effect of melatonin on insomnia suggest that it may be cians, as well as to inform decisions regarding the most
more effective when administered to adults older than 55 appropriate interventions. Although these aspects of care
years as there is an age-related decrease in endogenous have been reviewed sequentially in this chapter, in reality
161
melatonin. The typical dose is 2 mg once a day (1–2 they are closely inter-related and should be considered
hours before settling). concurrently.

Case study

A 57-year-old man, Brad Smith was admitted to the intensive care agitated requiring both physical and chemical restraint. His agita-
unit with polytrauma following a road traffic incident in which he tion and reduced cognitive function meant that progress was
was involved in a collision with a car while riding his bicycle to slowed. For example the cervical collar could not be removed and
work. His injuries included extensive rib left sided fractures includ- his mobility was restricted because he was unable to provide
ing a flail segment, haemopneumothorax, lung contusions, frac- appropriate responses during assessment for soft tissue injury, and
tured scapula, liver laceration and contusions, lacerated head of he moved around the bed so that his injured leg could not be
pancreas, an adrenal gland haematoma, pelvic fractures with intra- elevated.
peritoneal bleeding and an open left tibial fracture. He had no After two days of delirium in which multiple doses of midazolam
obvious spinal injuries (no fractures were located on X-ray either) were administered and physical limb restraints were used to main-
however a cervical collar was applied at the accident scene.
tain Brad’s safety, a full assessment was performed. All of the pre-
Although he was conscious and orientated at the scene of the disposing and precipitating factors for delirium for Brad were
accident, Brad became profoundly hypotensive in the ambulance. considered:
On arrival his blood pressure was 80/40 and he was hypoxic. He ● Predisposing factors
was intubated and initially stabilised in the emergency department ● occasionally smoked marijuana but only while on holiday
until he was transferred to the operating theatre for surgery to ● ‘often anxious and frequently stressed by his job as a train
stabilise his tibial fracture. Upon arrival in ICU and for the first 36 driver’
hours Brad required pressure control ventilation with a high frac- ● briefly hypoxic on arrival at hospital
tion of inspired oxygen. At times muscle relaxants (vecuronium) ● sudden illness (traumatic injury)
were administered to enable ventilation together with high doses ● Precipitating factors
of analgesic (fentanyl) and sedative (midazolam) medication. ● large doses of opioids (fentanyl and oxycodone later) and
Copious blood was suctioned from his trachea. After five days benzodiazepines (midazolam) in ICU
during which he received multiple blood products he stabilised ● frequent infections
and after ten days Brad underwent tracheostomy which enabled a ● elevated liver function tests (LFTs)
reduction in sedative medication. Respiratory support was gradu- ● unrelieved pain. Pain intensity was 6/10 during movement
ally reduced with further reductions of sedative medications from on one occasion
day 14. Brad had several infections during his ICU admission: ● severity of illness (APACHE II score was 20)
urinary tract and chest. His liver function blood test results became ● noise from another patient.
increasingly elevated and only declined after ICU discharge.
Despite early administration of stool softeners and aperients, Brad Brad was assessed formally using the CAM-ICU and ICDSC; he had
was constipated for a five day period. Brad was discharged from all four features of the CAM-ICU and his ICDSC score was 7. Both
ICU after 21 days. brain CT and MRI scans revealed no abnormalities. However an
assessment of his EEG revealed slow wave activity even when he
From the time that sedative medication was reduced to discharge was awake making purposeful movements. Polysomnography
from ICU Brad experienced delirium. At times he was extremely revealed profound sleep disruption with a great deal of total sleep