Adjuncts to analgesia. Sedation and neuromuscular blockade

Quantitative electroencephalography and behavioural correlates of daytime sleepiness in chronic stroke

Sleepiness is common after stroke, but in contrast to its importance for rehabilitation, existing studies focus primarily on the acute state and often use subjective sleepiness measures only. We used quantitative electroencephalography (qEEG) to extract physiological sleepiness, as well as subjective reports, in response to motor-cognitive demand in stroke patients and controls. We hypothesised that (a) slowing of the EEG is chronically sustained after stroke; (b) increased power in lower frequencies and increased sleepiness are associated; and (c) sleepiness is modulated by motor-cognitive demand. QEEGs were recorded in 32 chronic stroke patients and 20 controls using a Karolinska Drowsiness Test protocol administered before and after a motor priming task. Subjective sleepiness was measured using the Karolinska Sleepiness Scale. The findings showed that power density was significantly increased in delta and theta frequency bands over both hemispheres in patients which were not associated with subjective sleepiness ratings. This effect was not observed in controls. The motor priming task induced differential hemispheric effects with greater increase in low-frequency bands and presumably compensatory increases in higher frequency bands. The results indicate sustained slowing in the qEEG in chronic stroke, but in contrast to healthy controls, these changes are not related to perceived sleepiness.

Psychological implications of admission to critical care

Admission to critical care can have far-reaching psychological effects because of the distinct environment. Critical care services are being re-shaped to address long-term sequelae, including post-traumatic stress disorder, anxiety and depression. The long-term consequences of critical illness not only cost the individual, but also have implications for society, such as diminished areas of health-related quality-of-life in sleep, reduced ability to return to work and enjoy recreational activities (Audit Commission, 1999; Hayes et al, 2000). The debate around the phenomenon of intensive care unit (ICU) syndrome is discussed with reference to current thinking. After critical care, patients may experience amnesia, continued hallucinations or flashbacks, anxiety, depression, and dreams and nightmares. Nursing care for patients while in the critical care environment can have a positive effect on psychological well-being. Facilitating communication, explaining care and rationalizing interventions, ensuring patients are oriented as to time and place, reassuring patients about transfer, providing patients,where possible, with information about critical care before admission and considering anxiolytic use, are all practices that have a beneficial effect on patient care. Follow-up services can help patients come to terms with their experiences of critical illness and provide the opportunity for them to access further intervention if desired. Working towards providing optimal psychological care will have a positive effect on patients' psychological recovery and may also help physical recuperation after critical care.

A Continuous Quality Improvement Approach to Improving Clinical Practice in the Areas of Sedation, Analgesia, and Neuromuscular Blockade

BACKGROUND

Practice concerns associated with the medical prescription and nurses' administration and monitoring of sedatives, analgesics, and neuromuscular blocking agents were identified by the clinical nurse specialist within a surgical intensive care unit of a large, tertiary-care referral center. These concerns were identified using a variety of needs assessment strategies. Results of the needs assessment were used to develop a program of care, including a teaching initiative, specific to these practice areas.

METHODS

The teaching initiative incorporated principles of andragogy, the theory of adult learning. Educational techniques included inservice education, bedside instruction using "teaching moments," competency-based education modules, and integration of instruction into critical care orientation. Content and approach were based on the background and level of experience of participants.

RESULTS

Educational program outcomes included increased consistency in monitoring neuromuscular blockade by clinical assessment and peripheral nerve stimulation. A second outcome was more accurate patient assessment leading to the provision of drug therapy specific to the patients' clinical states, including anxiety or pain.

CONCLUSION

The continuous quality improvement approach offers a model for improving patient care using individualized needs assessment, focused educational interventions, and program evaluation strategies.

Neuromuscular-blocking drugs. Use and misuse in the intensive care unit

The use of NMB agents for more than 24 to 48 hours in critically ill patients is associated with many potential complications. Neuromuscular-blocking drugs should be used only when their use is essential for optimal patient care. The indications for neuromuscular blockade must be defined clearly, and patients should be evaluated during treatment for the need for continued muscle relaxation. The smallest doses of NMB agents that will accomplish clinical goals should be used. This dosage can be determined through clinical evaluations and peripheral nerve monitoring. It is essential that all patients treated with NMB drugs receive appropriate sedation and analgesia. Myopathies, neuropathies, and alterations of the neuromuscular junction can occur in the ICU setting, and nondepolarizing muscle relaxants seem to be involved in the development of these disorders. Clinicians should be aware of risk factors that may predispose certain patients to neuromuscular complications, including sepsis and the use of high-dose steroids. Neuromuscular-blocking agents should be avoided in these patients if possible. Although not proved, early recognition and treatment of iatrogenic neuromuscular complications may improve patient outcome.

Tertiary survey of the trauma patient in the intensive care unit

The issues surrounding the arrival of trauma patients to the ICU have been defined. By necessity, many of these topics are dealt with elsewhere in greater detail. The basic framework within which this phase of care could be optimized has been provided. Pitfalls related to patients' mode of arrival to the ICU affect subsequent management and should direct specific clinical activity. The tertiary survey is a complete summation and cataloguing of a patient's injuries. The need for ongoing resuscitation determines how much attention can be paid to the tertiary survey. Clinical suspicion based on mechanism and pattern of injury and thorough, repeated, complete physical examination are the essential elements of the tertiary survey. The survey is affected by factors that alter patients' mental status because examination is most reliable in patients who can localize pain. Medications, intoxication, and head injuries are common factors that interfere with the reliability of the tertiary survey for variable periods. Radiographic assessment is used to identify injuries suspected on the basis of mechanism of injury, injury pattern, and findings on physical examination. Some studies may be done portably; others require transport within the hospital. The intensivist must prioritize these ongoing diagnostic studies based on patient stability and the need for ongoing resuscitation.