Innovative ICU Solutions to Prevent and Reduce Delirium and Post–Intensive Care Unit Syndrome

Alawi Luetz, MD, PhD; Julius J. Grunow; Rudolf Mörgeli, MD; Max Rosenthal, MD, PhD; Steffen Weber-Carstens, MD, PhD; Bjoern Weiss; Claudia Spies, MD, PhD

Disclosures

Semin Respir Crit Care Med. 2019;40(5):673-686. 

In This Article

Intensive Care Unit Solutions Then and Now

The concept of the medical environment as an influential factor in shaping how patients experience their illness and eventual outcome has long been part of clinical medicine.[1–3] Nevertheless, the notion of reshaping the environment in the setting of intensive care unit (ICU) to improve patient outcome is comparatively new, and interest has resurfaced in the last two decades. A brief look at the history of intensive care medicine, from its dawn in the 1940s and 1950s, can help to illustrate the development of this notoriously harsh environment. In these very early stages of intensive care, when the iron lung tremendously decreased poliomortality by locking thousands of patients in iron boxes, without the possibility for any safe pharmacological stress reduction, physicians faced a seemingly unsolvable task of creating an ICU environment that provides some quality of life for the patients. There were two developments at this time, targeted at the ICU-environment as follows: on the one hand, the chronically critically-ill were sent home with the iron lung, provided the economic situation of the patients permitted it; on the other hand, the even more unphysiological, uncomfortable positive pressure ventilation was used with increasing frequency, allowing for the development of subsequent strategies for sedation and pharmacological stress reduction.[4,5] The resulting sedation protocols isolated the patient from the ICU environment. With increasing technological possibilities, the ICUs were consistently developed to accommodate organ-support and technical workflow, while overlooking the patient's perception of their surroundings. Deep sedation took place despite criticism that sedation was potentially not the best solution for these patients.[6]

Common sedation practice, as recently as in the 1980s and 1990s, mandated high levels of sedation to shield patients from the tolls of their acute illness and the related treatment. Evidence of the adverse effects that this form of sedation management on a patient's cognition, morbidity, and mortality has led to a gradual shift in routine clinical practice. This was initiated by the spontaneous breathing trial (SBT) and spontaneous awakening trials (SAT) and their coordination (ABCs) in the late 1990s and early 2000s.[7–9] It further developed with trials aiming at early light and "no sedation" approaches.[10,11] This newly emerged body of evidence has ultimately led to clinical guideline recommendations advocating for alert and cooperative patients.[12,13]

It is important to mention that this body of evidence is a fundamental prerequisite in, first, patients perceiving and potentially interacting with their environment and second, using this perception for the prevention of complications and the treatment.

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