I don’t want to say that, but I want to tell you that it is nothing new.

The unnecessary pain I described has occurred several times because of the ICU’s customary culture and the lack of support or investment for baseless practices.

Unfortunately, for many people who finally enter the ICU, the use of these old practices will produce a domino effect. One old practice will lead to complications, and the other will further worsen the complications.

The story I want to tell is one of the worst examples of domino effect I have ever seen. The unfortunate victim is a man named Jim.

This is his story.

How Jim suffered from the wrong attempt to reduce complications in the ICU

Jim is a 70 year old man with a history of bipolar disorder, general anxiety, and knee replacement. He retired from the hockey industry and likes to actively participate in the life of his descendants.

Unfortunately, he finally got a compression fracture of C6-C7 vertebra and had to undergo cervical decompression. He was discharged on Friday, May 15, 2021.

The pain was uncontrollable and he returned to the emergency room on May 16. He received intravenous morphine, respiratory failure and cardiac arrest. He immediately successfully performed CPR, then intubated and put on a respirator.

According to his family, it is unclear whether his neurological status has been assessed. His MRI did not show any signs of hypoxic damage during cardiac arrest. It is speculated that Jim immediately continued to calm down just because of intubation and mechanical ventilation.

His family did not know what real vacation had taken place during his two days of mechanical ventilation. On May 18, he was transferred and found to have cast a good vote on the staff and his family and carried out physical attacks. At this time, Jim plugged in the pipe again and calmed down automatically.

On May 20, he had to pull out the tube again. He was excited, self-control, and lay in bed again. He used a high flow nasal cannula with 80% FiO2. Then he intubated again and injected the sedative again.

On May 25(9 days of mechanical ventilation, sedation and floating), he suffered from ventilator-associated pneumonia. His ventilator installation increased, and his family was called to the bedside to prepare for his death. Fortunately, he responded to antibiotics and survived.

And the mechanical ventilation and sedation on June 7 and 22, After floating, he once again realized the 40% ventilator installation of PEEP 5 and Fi02. He pulled out the tube and did not use the ventilator all night. He became more and more excited and confused, and developed hypercapnia. Once he said to his wife, “I can’t breathe, it’s too difficult to breathe!” Then ask her to push his partition to help him breathe.

On June 8, he was intubated again due to hypercapnia and respiratory failure(possibly diaphragm dysfunction), and was again automatically sedated.

As of June 16, he had deep vein thrombosis in his lower extremities, had pulmonary embolism, and needed intravenous anticoagulation. After almost continuous sedation and floating for a month, he received tracheostomy and PEG intubation, and finally stopped sedation.

On June 17, he was sent to the decompression device. Soon after, he suffered from intestinal obstruction, the PEG tube was removed, and was infected again due to complications of the PEG tube. After that, he underwent emergency surgery to replace the PEG tube, and was sent to the ICU.

He was sent to the Long Term Acute Care Hospital(LTACH) within 24 hours after re entering the ICU.

In the following months, he continued to vomit in the PEG tube with terrible fibrous network. Due to extreme weakness and diaphragm dysfunction, he was difficult to leave the ventilator for more than a few hours.

He developed MRSA into the second case of ventilator-associated pneumonia. After several months of active rehabilitation, he finally got rid of the ventilator and was able to remove tracheostomy.

He was discharged from hospital on 11 August and cared for by his wife and family health personnel.

He has been plagued by cognitive impairment and unspeakable PTSD, unable to participate in the puzzles and activities he used to like.

He refused to talk about the fears he experienced in his calm state.

Fortunately, by January 2022, his bipolar disorder was under control again. He was hospitalized again, but his family reported that he had finally stabilized at home and made progress.

Later, Jim was hospitalized in the intensive care unit for about 6 months, and finally began to live again, so he returned to the lawn mower.

Jim’s daughter, Leah, unfortunately showed how the first domino in this series of results was hit when she calmed down automatically after intubation. She shared her father’s journey in the podcast episode “I walk home from intensive care unit” 81.

What problem: Jim and the ICU team members treating him may have different situations

Jim’s journey clearly shows the impact of his decision to start staying calm after each intubation.

If Jim wakes up immediately after a cardiac arrest, he will be able to pull out the catheter soon.

However, Jim had to continue using the ventilator unnecessarily because he automatically started sedation without clear instructions.

When sedation stopped two days later, his impatience and improvement showed severe fibrillation. However, he realized that his fibrillation had not been treated. Fibrillation was automatically reinserted, and the tranquilizer for fibrillation had also recovered.

The respiratory organs are deprived of the opportunity to maintain physical strength and normal function. Therefore, in addition to the fibrous network, diaphragm dysfunction may also occur, which may be the reason why he needs high flow nasal intubation after the second extubation.

After 22 days of floating and sedation, this kind of diaphragm dysfunction became more obvious after the third decannulation. He reported that although he could not breathe and had the lowest ventilator setting, he still needed the support of the third intubation.

This is the best example of how sedation and immobility can keep the patient awake and moving during ventilation, rather than staying on the ventilator for days or months.

Because he was calm, he experienced three hospital infections, including two ventilator-associated pneumonia and one PEG tube infection.

although this is usually not taken into account, the more patients who are intubated, leaning, and unable to cough, the greater the risk of developing ventilator-associated pneumonia.

If Jim could wake up and pull out the tube in time after inserting the tube, he would not need a ventilator or PEG tube. This infection led him to be sent to the ICU again. He spent more time on the ventilator, spent more time in the hospital, and finally suffered more.

Jim was discharged from hospital due to anticoagulation treatment for pulmonary embolism, probably because he was inactive for a month. Long term anticoagulation made him hospitalized again later due to bleeding complications.

On the tenth day of his stay in the ICU, Jim’s family began to promote calmness and early cessation of activities. As expected, they often heard the ICU team say, “There is no time and no resources.”

The heartrending irony is that they did not invest time and resources for patients like Jim. They practiced according to the evidence, which ultimately led to the ICU team spending a month’s time, money, manpower and resources. This kind of care may be unnecessary.

This needs to remind all ICU teams that the treatment of bad patients is expensive for them and their patients.

In a word, Jim had back pain after the operation. He came to the emergency room and was too calm after intravenous morphine injection. His heart suddenly stopped beating and soon came to.

Sadly, shortly after the intubation, a simple neurological examination and assessment of mechanical ventilation needs can completely change his life trajectory in the ICU, which can benefit everyone including him, his family, and members of the ICU team who treat him.

Fact: Methods for reducing ICU complications and mature practices for what happens when not used

The research is clear.

Calm down will increase the following risks:

● ICU or death after ICU [1,2]

● Infection [3,4]

● Pressure sore [5]

● Blood clot [6]

● Destroy [7,8,9]

● ICU acquired weakness [10]

● Increased ventilator use time [11]

● More hospital stay [12]

● Tracheostomy [13]

● Discharge to a rehabilitation center or nursing home [14]

● Post ICU PTSD [15,16]

● Post ICU dementia(cognitive dysfunction) [17]

● Depression [18]

● Re hospitalization and ICU [19]

● Intensive care syndrome [20]

If you keep calm, the following situations will be reduced:

● Go home after discharge [14]

● All staff can walk in the ICU [21]

● Return to business [22]

● Best quality of life [23]

According to the recommendations of ABCDEF Bundle, avoiding calmness and ensuring initial activities can reduce the following risks:

● Death [24]

● Ventilators and hospital associated pneumonia [25]

● centerline and catheter infection [26]

● Pressure injury [27]

● Falls [28,29]

● Destruction [24]

● Aspiration pneumonia [30]

● Constipation/intestinal obstruction [31]

● Intubation [14]

● Re intubation [14]

● Tracheostomy and PEG tube placement [32]

● Discharge to nursing institution [24]

● Re hospitalization in hospitals and ICUs [24]

● Diaphragm dysfunction [33]

● ICU acquired weakness [34]

In this way, you can also get the following opportunities:

● Tube pulling succeeded [24]

● ICU discharge [24]

● Go home after discharge [24, 35]

● Survival [24]

● Functional independence after discharge [36]

● Best quality of life [37]

● Proper pulmonary ventilation [38]

● Removal of secretions [39]

After intubation, Jim chose to be given sedative automatically, but failed to apply proven practices such as ABCDEF binding to nursing, resulting in the following results:

● ICU network orders and/or months

● Diaphragm dysfunction

● ICU acquired weakness

● Deep vein thrombosis(blood clot)/pulmonary embolism

● Three tube pulling failures

● Triple intubation

● Tracheostomy

● 2 cases of ventilator-associated pneumonia

● Three hospital infections

● Re enter ICU

● Preventable one month ICU hospitalization

● Risks and burdens of ICU staff

● Painful and hard recovery in LTACH for several months

● Post ICU PTSD

● ICU Post Dementia

● Bleeding complications caused by long-term anticoagulation

● Injuries and burdens of family guardians

● Decreased quality of life

● Two hospitalizations in the first 5 months after discharge

Jim also went to the hospital when he felt painful after back surgery and needed treatment before going out.

Unfortunately, so many ICUs failed to implement this evidence-based practice, causing unimaginable unnecessary pain, and burdening Jim, their families, and the ICU team of the hospital where they were treated.

But this is not necessarily the case. With the implementation of mature practices such as ABCDEF bundles, global ICUs can go beyond the outdated management currently provided and do the best for themselves and patients.

Do you want to know in detail how proven practices can reduce ICU complications and how to implement these practices in ICU? I can help you in the whole process. Please do not hesitate to contact me.

Carly Dayton

Reference documents:

1. Shehabi et al.(2012). Sedation in early severe patients can predict the long-term mortality of patients with critical respiratory disease. American Journal of Respiratory and Critical Care Medicine, 186(8), 724-731.

2. Tanaka Light(2014). Early sedation and clinical outcome in mechanically ventilated patients: a prospective multicenter cohort study. Severe patients(London, UK), 18(4), R156.

3. Linden(2008). Risk factors and subsequent clinical outcomes of early fibrillation in mechanically ventilated patients. Journal of Critical Care Patients, 23(3), 372-379.

4. Rello，J.，Diaz，E.，Roque，M.，&amp；Vallés，J.(1999). Risk factors for pneumonia within 48 hours after intubation. American Journal of Respiratory and Critical Care Medicine, 159(6), 1742-1746.

5. Cox, J., Roche, S. and; murphy，V.(2018). Risk factors of stress injury in severe patients: descriptive analysis. Advances in skin and skin research; wound Management, 31(7), 328-334.

6. Minet，C.，Potton，L.，Bonadona，A.， Hamidfar Roy, R., Somohano, C.A., Lugosi, M., Cartier, J.C., Ferretti, G., Schwebel, C. and Timsit, J.F.(2015). ICU venous thrombosis: main characteristics, diagnosis and thrombosis prevention. Severe patients(London, UK), 19(1), 287.

7. Pandharipandh, P., Shintani, A., Peterson, J., Truman, B., Wilkinson, G., Dittus, R., Bernard, G. and Ely, W.(2006). Lara Siban is an independent risk factor for ICU patients to die. Anesthesiology, 104.

8. Yang, J, Zhou, Y, Kang, Y, Xu, B, Wang, P, Lv, Y and; wang，Z.(2017). The ICU has consistently stabilized the risk factors of patient death. International Biomedical Research, 20173539872.

9. Periera, J.V., Sanjanwala, R.M., Mohammed, M.K., Le, M.L. and Arora, R.C.(2020). Comparison of Umtomidine and Propofol Sedation in Reducing Fibrous Reticulation in the Elderly in ICU: A Systematic Review and Meta analysis. European Journal of Anesthesiology, 37(2), 121-131.

10. Vanhorebeek，I.，Latronico，N.，& amp；Van den Berghe，G.(2020). ICU is weak the day after tomorrow. Intensive Care Medicine, 46(4), 637-653.

11. Shehabi et al.(2012). Sedation in early severe patients can predict the long-term mortality of patients with critical respiratory disease. American Journal of Respiratory and Critical Care Medicine, 186(8), 724-731.

12. Strom, T., Martin Nussen, T. Wow; toft，P.(2010). There is no sedation scheme for critically ill patients receiving mechanical ventilation: randomized trial. Lancey(London, UK), 375(9713), 475-480.(09) 62072-9

13. Brook, A.D., Ahrens, T.S., Schiff, R., Prentice, D., Sherman, G., Shannon, W.,&Hollef, M.H.(1999). The influence of sedation program implemented by nursing on the duration of mechanical ventilation. “Critical Care Medicine”, 27(12), 2609-2615.

14. Basin lamp(2019). ABCDEF bundle therapy for critically ill patients: the results of ICU liberation cooperation on more than 15000 adults. Critical Care Medicine, 47(1), 3-14.

15. Davidow, D.S., Gifford, J.M., Desai, S.V., Needham, D.M., and Bienvenu, O.J.(2008). Posttraumatic stress disorder among survivors in the general intensive care unit: a systematic summary. Psychiatry, General Hospital, 30(5), 421-434.

16. Nelson, B.J., Wetival, C.R., Bury, C.L., Marinelli, W.A., and Gross, C.R.(2000). Critical Care Medicine, 28(11), 3626-3630.

17. Wilcox, M.E., Brummel, N.E., Archer, K., Ely, E.W, Jackson, J.C., Hopkins, R.O.(2013). Cognitive dysfunction in ICU patients: risk factors, predictive factors and rehabilitation intervention. “Critical Care Medicine”, 41(9 Suppl1), S81-S98.

18. Desai, S.V., Law, T.J.,&Needham, D.M.(2011). Long term complications in the treatment of severe patients. Critical Care Medicine, 39(2), 371-9.

19. Tanaka Light(2014). Early sedation and clinical outcome in mechanically ventilated patients: a prospective multicenter cohort study. Severe patients(London, UK), 18(4), R156.

20. Rawal, G., Yadav, S. and; kumar，R.(2017). Intensive care syndrome: review. Journal of Translational Medicine, 5(2), 90-92.

21. Vanhorebeek，I.，Latronico，N.，& amp；Van den Berghe，G.(2020). ICU is weak the day after tomorrow. Intensive Care Medicine, 46(4), 637-653.

22. Cox, J., Roche, S. and; murphy，V.(2018). Risk factors of stress injury in severe patients: descriptive analysis. Advances in skin and skin research; wound Management, 31(7), 328-334.

23. Nelson, B.J., Wetival, C.R., Bury, C.L., Marinelli, W.A., and Gross, C.R.(2000). Critical Care Medicine, 28(11), 3626-3630.

24. Mart, M., Brummel, N. and; ely，W.(2019). ABCDEF bundle for ventilator therapists. Respiratory management, 64(12).

25. Clark Lamp(2013). Effectiveness of early mobilization program in trauma and burn intensive care unit: a retrospective cohort study. Physical therapy, 92(2).

26. Hunter，A.，Johnson，L.，&amp；Coustasse，A.(2014). Shortening the length of stay in the ICU: early mobilization cases. Health Care Management, 33(2).

27. Azu lamp(2016). Benefits of early initiatives in the medical intensive care unit: a demonstration study. American Journal of Medicine, 129(8).

28. Hshieh et al.(2015). Effectiveness of multi-component non drug fibronectin intervention: a meta-analysis. JAMA Internal Medicine, 175(4).

29. Medical insurance center; medicaid services.(2017). Moving Workgroups: Changing Packages and Suites [white paper]. U. United States Department of Health; human services.

30. Diestriwin; guery，B.(2005). Prevention and treatment of aspiration pneumonia in ICU. Medical treatment of respiratory organs

31. Thornton lamp(2021). The impact of the 2018 Institute of Critical Care Medicine guidelines on pain, excitement/sedation, fibrinoreticulation, floating and sleep on the results of non opioid analgesics after major surgery for severe adults. Exploration of severe patients, 3(10).

32. Brook et al.(1999). The effect of sedation program on the duration of mechanical ventilation. Critical Care Medicine, 27(12).

33. Equivalent(2021). Early rehabilitation can alleviate diaphragm dysfunction caused by long-term mechanical ventilation: a randomized controlled study. BMC Pulmonary Medicine, 21(106).

34. Lipschutz, A., and; gropper，M.(2013) Acquired neuromuscular weakness and early activity in intensive care unit. Anesthesiology, 118(1).

35. Misspelling, etc.(2015). The influence of early mobilization on discharge management of mechanical ventilation patients. Journal of Physical Therapy Science, 27(3).

36. Schujmann et al.(2019). Effects of progressive activity plan on functional status, respiration and muscle system of ICU patients: a randomized controlled trial. Critical care medicine 48(4).

37. Ely，W.(2017). ABCDEF Bundle: the science and philosophy of how to liberate ICUs to serve patients and families. Critical Care Medicine, 45(2).

38. Elmer et al.(2021). Effect of physical therapy on local pulmonary function in critically ill patients. Frontier of Physiology, 12.

39. Strickland Lights(2013). AARC Clinical Practice Guideline Effectiveness of Non drug Airway Clearance Therapy for Inpatients. Respiratory management, 58(12).