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150 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

Case study, Continued
time during daytime hours. The drug and alcohol liaison nurse was Brad’s delirium gradually improved during his stay but he remained
consulted but made no recommendations (his marijuana use was intermittently delirious up to five days after ICU discharge. The only
thought to be very small). The elevated LFTs were thought to be physiological factor that appeared to change dramatically during
mainly a result of a combination of the administration of multiple that period was that his LFTs started to return to normal (on dis-
blood products and antibiotics. The ICU pharmacist was consulted charge: ALP:605, AST 45, ALT 69, GGT 519 and five days later ALP:
and suggested a gradual reduction in benzodiazepines, a trial of 205, AST 39, ALT 51, GGT 219).
dexmedetomidine and the administration of the atypical antipsy-
chotic, quetiapine, twice a day. Recovery
Physically Brad’s recovery was largely uneventful. He went to a
Treatment private rehabilitation hospital for two weeks after hospital dis-
In the first instance a dexmedetomidine infusion (a request was charge. However over time he became increasingly disturbed by
made for ‘off label’ use) was administered with good effect. At the circumstances of his injury and his lack of memory of ICU. He
the same time a multifaceted intervention was devised and returned to ICU three months later while attending an orthopaedic
implemented: outpatient’s appointment to speak to the ICU team. He visited the
● Regular assessments using the ICDSC were performed. It was bed spaces where he had been a patient while in ICU but could not
agreed that a score of >6 (or behaviour likely to cause acciden- recall the experience. He described his increasing distress when-
tal self-harm) was the cut-off for ICU staff specialist review. ever road traffic incidents were mentioned on the TV or radio news
● The midazolam infusion was gradually discontinued. and his attempts to avoid listening. Brad also expressed exaspera-
● Small bolus doses of diazepam (2 mg) were administered tion with his inability to sleep (a new problem) and his constant
when Brad was extremely anxious ruminating about the incident in which he could see ‘the scenario
● Quetiapine 100mg was administered twice a day replaying’ in his mind (i.e. ‘flashbacks’). This social worker was called
● Brad was moved into a quieter area of the intensive care unit. and he received a referral for a specialist centre for post traumatic
● His wife and children were encouraged to provide constant stress disorder. Brad made a full recovery after several months.
reminders of the time and place, read to him and play music
during the day. Discussion
● Photographs and personal items were placed around Brad’s Brad’s story is not an unusual one. His injuries were extensive and
bedspace. His wife brought his pillow from home. complicated. He was at high risk of developing delirium. His delir-
● Extra attention was given to ensuring that the room lighting ium may have improved despite the instigation of the intervention.
was appropriate for the time of day. The only risk factors which remained present for his ICU stay were
● A settling period was implemented in which a routine was the elevated LFTs and unrelieved pain (pain assessment was diffi-
established to encourage Brad to go to sleep by 2300hrs. cult, his response to the visual numerical analogue scale varied).
● Care was clustered (members of the ICU team consulted with His cognition improved dramatically after the LFTs began to return
the nurse to time their visit/treatment so that Brad had several to normal. Despite the administration of analgesics and use of
1.5–2 hour intervals in which he was not disturbed). other pain relieving interventions it is possible that pain led to
● The speech pathologist was involved to improve communica- agitation. Dexmedetomidine is an alpha 2 -adrenoreceptor with
tion (both before and after the tracheostomy cuff was able to both analgesic and sedative effects. Either or both effects may have
be deflated). reduced the agitation. Nevertheless Brad was less agitated and
● During a period when Brad was not delirious, an assessment of appeared to be less distressed once the multifaceted intervention
his C spine was performed and the protective collar was began. The multi-disciplinary healthcare team approach was also
removed. undoubtedly responsible for his recovery.

Research vignette
Arbour C, Gelinas C. Are vital signs valid indicators for the assess- design was used. A convenience sample of 105 patients from a
ment of pain in postoperative cardiac surgery ICU adults? Intensive cardiology health centre in Canada participated. Patients were
and Critical Care Nursing 2010; 26(2): 83–90. observed during three testing periods: (1) unconscious and
mechanically ventilated, (2) conscious and mechanically ventilated
Abstract and (3) after extubation. For each of these testing periods, vital
The aim of this study was to examine the discriminant and criterion signs were assessed using the ICU monitoring at rest, during a
validity of vital signs (mean arterial pressure [MAP], heart rate nocioceptive procedure and 20 min postprocedure. Conscious
[HR], respiratory rate [HR], transcutaneous oxygen saturation patients’ self-reports of pain were obtained. Discriminant validity
[SpO 2 ], and end-tidal CO 2 ) for pain assessment in postoperative was supported with significant changes in most vital signs during
cardiac surgery ICU adults. A repeated-measure within-subject the nociceptive procedure. Some of the vital signs (HR, RR, and