Patients discharged from critical care who go on to be discharged home are offered the chance to return to the critical care environment for their psychological rehabilitation. Better understanding their journey of care helps some to contextualise the often disturbing memories they have of their care experience. For others, it is simply an opportunity for them to thank staff and bring closure to a part of their lives they would rather forget.
At a recent conference I was listening to one patients experience which really brought home for me the importance of communicating with your sedated or unconscious patient, particularly when they are first sedated in the ED. This experience is by no means uncommon and I hear similar stories time and time again when patients visit us in critical care.
Bob (not his real name of course) recalls vividly the sounds of the emergency department and even a conversation had between his wife and the consultant at the end of his bed. Before the opiates completely flooded his body, Bob recounts the moment when his crying wife was told that he may not survive his injuries and that she should prepare for the worst but hope for the best. How often do you and your team discuss the patient within their ear shot or even worse, right over their head? After a few days of sedation, Bobs memories become more muddled and confused but his story of bedside alarms and beeps is terrifying. Bob dreams repeatedly of lying, tied to a train track hearing the distant ringing and rumbles of a train rolling towards him, the alarms of the ventilator become the high pitched peel of the trains warning sounds but Bob is helpless to get out of its way and over and over again he fights and panics until the alarm is switched off and he waits until the ordeal starts all over again.
Why do we sedate? RSI.
In the emergency department patients will be sedated for a number of reasons including decreased consciousness or respiratory failure requiring mechanical ventilation. Whatever the clinical decision making process, sedation suppresses the patient’s awareness of their environment to a greater or lesser degree, dependant on dose, sedation type and end goal of that sedation. Most often you will be assisting with a Rapid Sequence Induction (RSI), a procedure designed to take control of the airway quickly and with minimal risk of regurgitation of abdominal contents [1]. To perform this procedure, the anaesthetist will need to paralyse the patient making it vital that you monitor their levels of sedation. If using Suxamethonium, the duration of action may be only up to 10 minutes, but 10 minutes can be an eternity if your patient is not adequately sedated. Watch this space, EDeducates very own @ashleighlowther will be bringing you all up to date in current RSI practice in the near future.
Conscious sedation.
More and more departments are choosing to use conscious sedation for minor procedures such as limb manipulations or cardioversion. Conscious sedation is a process whereby a sedative and an anaesthetic are administered to help the patient relax and block pain [2]. Easiest thing to monitor in any sedation scenario are the basics and as most induction agents such as Propofol, Fentanyl and Midazolam cause hypotension it is safe to assume that if your sedated patient has been anaesthetised, a marked increase in BP or HR could indicate awareness and/or pain. To combat the potential for cardiovascular suppression, some departments may only administer Ketamine, an anaesthetic agent which induces sedation, analgesia and perhaps more importantly, memory loss. A common side effect of Ketamine is hypertension and patients may experience transient agitation once the sedation wears off [3]. The important nursing point here is to know what agent is being administered and how to monitor during and after sedation.
Just to be clear, I am not talking about monitoring the brain injured patient when writing about monitoring sedation. Brain injuries will require a number of different tools to monitor the progress of the secondary damage. Glasgow Coma Scale (GCS) is the most well known scoring system in this arena but has become the ‘go to’ chart for anyone experiencing sedation, chemically or otherwise. If GCS is the only tool you use to assess consciousness, remember to record where the sedation has limited the patient’s ability to gain a higher score [4]. For example; for verbal ability you would need to mark them down with either a T for endotracheal tube or tracheostomy or document that their confused or absent speech is a result of a sedation bolus. All elements of eyes, verbal and motor may be excluded when sedated and ventilated making a sedation score like the Richmond Agitation Scale (RASS example below) a useful tool, try it next time you have a sedated patient. Once paralysing agents have worn off, most units will aim to sedate to a RASS of -2 as it is well recognised that over sedation results in longer patient stays and increased ventilatory support [5]. What is most important is consistency and it is recommended that whatever tool you use, when handing over, you perform the chosen assessment with the receiving nurse.
The unconscious or sedated patient is vulnerable and completely reliant on the nursing care that you provide them. Remember at university when the tutors banged on about the activities of daily living or the patient’s hierarchy of needs (see Roper, Logan & Tierney model or Maslow’s hierarchy of needs on Wikipedia if you have forgotten) and you switched off? You thought bla bla bla; wake me when we get to the cool stuff like defibrillation! Perhaps that was just me…anyway, it’s important, your patient will thank you for remembering. I know your ED is busy but take some time to provide mouth and eye care. Nothing too elaborate, just suction the patients mouth, wet some mouth care swabs and moisten the patients tongue and gums. With eye care, make sure the patients eyes are closed, naturally is best but they may need to be taped shut gently to protect them. I choose to soak gauze with sterile 0.9% saline and lay these pieces of gauze over the closed eyes, a bit like you would with cucumber pieces at the beauty salon. After a short time of the eyelid moistening I wipe the eye gently from the inner aspect out to the outer edge to remove any debris. See the handy Nursing Times [6] piece in the reference list for additional advice on instilling eye drops if needed. Above all, make sure you communicate what you are doing to your patient. If you still don’t believe it’s important to talk to your unconscious patient, try this little experiment: next time your partner is just dropping off to sleep, stick your finger in their open mouth and see what happens (disclaimer; it is not recommended that you really put your finger in your partners mouth as there is a real risk that you might lose it and the author will not be held responsible for any loss of digits).
The jury remains out regards the science of sedated patients hearing and processing speech, sounds and memories. The phenomenon of critical care patients reporting scarily accurate memories is distinct from accidental awareness during anaesthesia, a subject you can find out more about on the Association of Anaesthetists of Great Britain and Ireland website (aagbi.org). When families ask, I always say that their relatives can hear them, they just may not remember that they can. I have witnessed seemingly deeply sedated patients have increases in heart rate and blood pressure when their loved ones speak to them, I don’t need science to prove that communicating with patients, sedated or otherwise, is beneficial for everyone invested in their care. Between the lines, whether they are tidy or tangled is a patient; nursing is a team sport.
Holly : )
The Richmond Agitation and Sedation Scale taken from https://pbrainmd.wordpress.com/2015/03/23/rass-scale/comment-page-1/
RCN Competency Framework L1 & L2:
CD 2.5 The unconscious patient.
CD1 3.2.2 Undertake a neurological assessment.
[1] Sinclair, R., and Luxton, M. (2005) ‘Rapid Sequence Induction’, Continuing Education in Anaesthesia, Critical Care and Pain, Vol 5, Iss 2 [online]. Available at: https://academic.oup.com/bjaed/article/5/2/45/422107
[2] Royal College of Emergency Medicine. (2012) ‘Safe Sedation of Adults in the Emergency Department’ [PDF online]. Available at: https://www.rcem.ac.uk/docs/College%20Guidelines/5z7.%20Safe%20Sedation%20in%20the%20Emergency%20Department%20-%20Report%20and%20Recommendations.pdf
[3] National Institute for Health and Care Excellence, British National Formulary. (2018) Ketamine [online]. Available at https://bnf.nice.org.uk/drug/ketamine.html
[4] Fairley, D., and Timothy, J. (2005) ‘Using a Coma Scale to Assess Patients Conscious Level’, Nursing Times, Vol 101, Iss 25 [online]. Available at: https://www.nursingtimes.net/using-a-coma-scale-to-assess-patient-consciousness-levels/203819.article
[5] Rowe, K. (2008) ‘Sedation in the Intensive Care Unit’, Continuing Education in Anaesthesia, Critical Care and Pain, Vol 8, Iss 2 [online]. Available at: https://academic.oup.com/bjaed/article/8/2/50/338650
[6] Mooney, G. (2007) ‘Eye Care’, Nursing Times Online [online]. Available at: https://www.nursingtimes.net/clinical-archive/assessment-skills/eye-care/199389.article