October CE Article

OCTOBER CPE Article

ICU Recovery Challenges

Authors: Ariana N.Chambers, PY4 Pharm.D candidate 2021 and Jimmi Hatton Kolpek, Pharm.D. The authors declare that there are no financial relationships that could be perceived as real or apparent conflicts of interest.

Universal Activity # 0143-0000-20-010-H05-P &T 1.0 Contact Hours (0.1 CEU) Expires 10/30/23 Learning Objectives: At the conclusion of this Knowledge-based article, the reader should be able to: Pharmacist Objectives: 1. 2.

Define Post-ICU Syndrome

Identify the components of the ABCDEF bundle

Recognize the role of a pharmacist during and post-ICU stay in both in-patient and community or ambulatory settings

Obtain/access resources that can be given to patients possibly suffering from PICS Pharmacy Technician Objectives: 1.

Define Post-ICU Syndrome

Identify the components of the ABCDEF bundle

Recognize possible signs of PICS in your patient population that can be referred to the pharmacist for additional resources

We all know someone who has been in a severe cal illness. Symptoms include ICU-acquired weakcar accident, suffered from a stroke or heart attack, ness, cognitive or brain dysfunction such as had post-operative complications, pneumonia, memory problems, inability to organize thoughts coronavirus, and the list of emergency situations or complete tasks, sleep disturbances, anxiety and that could lead to an intensive care unit visit con- posttraumatic stress disorder (PTSD) [3]. PICS can tinues. According to the Society of Critical Care occur within 2 days to weeks or months following Medicine (SCCM), there are approximately 5 million an ICU stay. No definitive timeline for onset or duindividuals admitted to the ICU yearly in the United ration has been reported, although most ICU reStates. Unfortunately, around one-third of these covery clinics evaluate patients within three patients will be placed on mechanical ventilation months of ICU discharge and follow them up to [1]. However, did you know that anywhere from 30 one year. to 70% of these 5 million individuals will go on to develop a new syndrome because of their ICU stay? [2] When patients are in the ICU, it is important to manage risk factors associated with developing PICS. They can be separated into ICU-related risk What is Post-Intensive Care Unit Syndrome? factors such as delirium, immobility, failed commuPost-Intensive Care Unit Syndrome (PICS) was first defined by the Society of Critical Care Medicine in 2010. It presents as a change or worsening of cognition, physical or psychological function after critinication, systemic corticosteroids, sepsis, acute respiratory distress syndrome, renal replacement therapy, sedative use, and prolonged mechanical ventilation greater than seven days [2,4]. As stated

previously, one-third of ICU patients require me- during the time of the trial. Additionally, it is imchanical ventilation which then exponentially in- portant to note that the use of a patient’s native creases their risk for the development of PICS. Ad- language during breathing and awakening trials is ditionally, there are some unmodifiable patient- an important and often under-utilized facet that specific risk factors to consider as well including can help orient the patient. patient personality, life experiences, previous medical history (alcoholism, prior stroke, COPD, etc.), ability of the patient to handle ICU stress, baseline impairments, depression, anxiety, PTSD, lower educational level, and female sex [2,4]. The third component of the ABCDEF bundle is choice of analgesia and sedation as well as coordinated communication and care. This component goes hand-in-hand with the “A” component of the bundle. Pharmacy can play a role here as recomGiven the wide range of risk factors at play, it is cru- mendations for desired level of sedation can be cial that the patient’s interdisciplinary team dele- made to the team. For example, pharmacy could gates team members to assess patient progression recommend dexmedetomidine or benzodiazepines each day. Fortunately, a few studies have occurred for lighter sedation if a breathing trial is anticipated in the past few years to assess how to best do so. to be attempted soon versus the use of propofol or The prominent model is the ABCDEF or ICU Libera- a combination of sedatives if deeper sedation is detion bundle per the SCCM (Table 1). One prospec- sired. Pharmacy can also play a role in analgesia tive, cohort study found that the ABCDEF bundle here in terms of patient home medications. If the “showed significant and clinically meaningful im- patient is taking a medication for pain or neuropaprovements in outcomes including survival, me- thy at home, pharmacy could suggest restarting chanical ventilation use, coma and delirium, re- this medication and has the expertise to review straint-free care, ICU readmissions, and post-ICU medications for dual use while in-patient. Additiondischarge disposition [5].” Thus, let us delve into ally, coordinated communication and care is vital each component further to assess the role of the for ICU patients and their families. Regarding the pharmacist particularly in the in-patient critical patient, updates on their progression once stable care setting and then in the community or ambula- and candid conversation about their journey, if retory setting as well. quested, can help the patient begin to process What are the components of the ABCDEF Liberation Bundle? what they are experiencing, improve memory, and understand nightmares and terrors as a result of their ICU stay particularly if the patient keeps a ICU The first component of the ABCDEF bundle is as- diary or journal [7]. The family component of coordisess, prevent, and manage pain per SCCM [6]. Other nated care will be mentioned later. models list the first component as airway management. As a clinical pharmacist in the critical care inpatient setting, recommending IV opioids and nonopioid analgesics and assessing pain via speaking with nursing staff, family, and reviewing documentation can be helpful. This component can be difficult to assess given the likelihood that the patient will be sedated and/or intubated, so team communication is vital. Due to the high probability that these patients are going to need intubation, the airway management component will likely already have been assessed and implemented prior to pharmacist involvement with the team. The fourth component of the ABCDEF bundle is assess, prevent, and manage delirium. Unfortunately, the cause of delirium in many ICU patients is an anomaly. Per DSM-IV, delirium can be defined as a disturbance of consciousness or change in cognition that develops over a short period of time and caused by the direct physiological consequences of a general medical condition [8]. Symptoms of delirium can vary based on the type of delirium the patient is experiencing. First, hyperactive delirium includes symptoms of irritability, anger, nightmares, and easy startling. Secondly, hypoactive delirium symptoms include depression, slurred speech, anoThe next component of the ABCDEF bundle is rexia, and altered sleep patterns. Lastly, mixed delirspontaneous awakening and spontaneous breath- ium includes symptoms of both hyperactive and ing trials [6]. This component is essential for evalu- hypoactive as listed above. Delirium has been ating the patient’s respiratory function at sched- found to be an independent predictor of higher 6uled intervals to potentially wean the patient from month mortality and longer hospital stay especially mechanical ventilation as early as possible. As we in mechanically ventilated patients [9]. have learned, prolonged ventilation use places a patient at increased risk of developing PICS. Pharmacist are not likely to have a direct impact during these breathing and awakening trials. However, pharmacist can always assess patient home medications for inhalants as these may be useful to have Pharmacist intervention could be made for the delirium component when assessing patient medications that could lead to its development. These medications could include anticholinergics, stimulants, dopamine agonists, high-dose benzodiazepines, corticosteroids, and sedatives as examples. |22| Kentucky Pharmacists Association | September/October 2020

Also, pharmacists can help interpret and trend the It is important to note that family can also experipatient’s Confusion Assessment Method in the ICU ence changes in mood, depression, fatigue, anxiety, (CAM-ICU) scores and assess electrolyte changes or and PTSD from seeing their loved-one’s experience imbalances which could lead to total parenteral nu- in the ICU. Thus, family members can experience trition (TPN) or enteral feeding adjustments. Lastly, PICS-family (PICS-F) and should seek help from someone from the team should speak with the pa- their primary care physician to be referred for aptient’s family to assess their normal routine and propriate care as needed [4]. There are also peer needs for improved sensory stimulation. These non- support groups available online for patients and pharmacologic interventions include obtaining pa- families to connect with others who have had an tient glasses or hearing aids, opening and closing ICU experience as an individual or a family member. the patient’s blinds in the room at certain times One easily accessible resource is each morning and evening, and having family pre- https://sccm.org/MyICUCare/THRIVE/Patient-andsent during the day [10]. Family-Resources via SCCM and can be given to paThe fifth component of the ABCDEF bundle is early mobility and exercise. The team should consult tients and family members or caregivers who would like additional information about PICS [3]. physical and occupational therapist as soon as the What are ICU Recovery Clinics? patient is medically stable and able to ambulate. Early movement shows improvement in both cognitive and psychiatric symptoms [4]. As a clinical pharmacist, the focus of this component would likely include assessing the in-patient medications for sedative/drowsiness side effects and attempting to adjust order times that are going to best coincide with the patient’s physical therapy to allow the patient to have optimal performance. Intensive care unit recovery clinics are slowly emerging across the United States. These centers are designed to improve the patient’s quality of life after a stay in the ICU and assist patients with any adjustments to their “new normal” as they recover. Many patients will need individualized care after their ICU stay and an ICU recovery center usually has an interdisciplinary team that may include a physician, nurse practitioner, pharmacist, physical The final component of the ABCDEF bundle is fami- therapist, dietitian, occupational therapist, and/or ly engagement and empowerment and prove to be social worker [11]. Each of these professionals can a vital piece of the recovery process for the patient. assist in a patient’s recovery in specific areas which Family can be utilized in many ways including ob- will ultimately provide optimal patient care. Vantaining baseline information such as medication derbilt’s ICU recovery clinic “identified a high prevahistory, allergies, mental status, and outpatient lence of cognitive impairment, anxiety, depression, pharmacy information. Clinical pharmacists can physical debility, lifestyle changes, and medicationprovide clarity and comfort to the family by updat- related problems warranting intervention [11].” As ing them on medication changes and answering data continues to be collected regarding the utility questions related to medications as they arise each of ICU recovery centers, hopefully this will lead to day. Additionally, reviewing medication discharge expansion of these services to millions of patients instructions and changes that were made with the who are suffering from PICS. patient and their family is an essential duty of the pharmacist as several changes may have been made due to the patient’s ICU stay. In the setting of an ICU recovery clinic, pharmacist can play several roles. For starters, pharmacists are trained to assess patient medications for adverse Furthermore, patient families are likely going to effects, drug-drug interactions, safety and efficacy. identify or notice changes in the patient post- In a small study, it was found that the median numdischarge and can be extremely helpful in as- ber of pharmacy interventions at an ICU recovery sessing if the patient needs to be seen for PICS. clinic was 4 per patient [12]. These pharmacy interNew symptoms that would indicate the possibility ventions led to the treatment of many medicationof PICS in a post-ICU patient could include new on- related problems as well as the recommendation set confusion, poor sleep patterns, nightmares, for preventive measures such as immunizations. mood changes, and increased difficulty completing Pharmacist can also be useful in recommending activities of daily living [3]. Once again, there is not a medications for newly developed PICS symptoms definitive timeline of when and how symptoms will as treatment of PICS is complex and individualized appear in patients, so logging of changes by family based upon the patient’s symptomology. Accordcan be great tool for the patient’s follow-up ap- ingly, pharmacists can be utilized as an essential pointments. Inevitably, patient recovery is going to member as ICU recovery clinics continue to grow. be a journey that will depend on several factors, but the support of family can certainly improve both outcomes and motivation.

Currently, the only ICU recovery clinic in Kentucky is the pharmacy. In these instances, technicians can located at the University of Kentucky in Lexington. inform the pharmacist in order to provide the paPatients who are admitted to the University of Ken- tient or family with additional resources regarding tucky’s medical intensive care unit (MICU) are PICS, if requested. screened by the ICU recovery team for risk factors of PICS. If a patient is at risk, a member of the team meets with the patient and family to determine if they are interested in scheduling a follow-up appointment in the ICU recovery clinic [13]. This clinic is also open to referrals from other ICU teams within the University of Kentucky hospital system. At the clinic, the patient is seen by a physician, nurse practitioner, pharmacist, and physical and occupational therapist to assess for PICS and address any concerns that may have arisen since the patient’s ICU discharge. Due to the rarity of ICU recovery clinics at this time despite the number of affected individuals by PICS, patients and their families can be directed to the Society of Critical Care Medicine Patients and Family portal at sccm.org/myicucare/home. As previously stated, this resource will allow them to connect with a support group. Additionally, there is a guide available to help them understand PICS and their ICU stay [3, 4]. Lastly, the site offers a glossary of terms and a patient communicator app to document PICS symptoms, medications and responses [4]. Hopefully, more resources and ICU recovery In a community or ambulatory setting, similar inter- clinics will continue to be made available. ventions can be made through medication assisted therapy interventions when an ICU recovery center is not feasible for the patient. In these situations, it may be more difficult to ascertain the patient’s recent ICU stay, but the introduction of new medication or short fills for some could help the pharmacist in determining that the patient had a recent hospital stay. Also, technicians can be utilized in the community or ambulatory setting. Many times, patients are familiar with the technicians when picking up medications. They may be more willing to speak candidly with technicians about their recent hospital stay especially if the patient is a regular at In conclusion, anyone can be affected by PICS as no one anticipates a stay in the ICU. Fortunately, PICS is a defined syndrome and can be mitigated through assessing patients for risk factors and the utilization of the ABCDEF bundle. Patients and their families can be directed to the SCCM website for additional resources at any time. Additionally, there are several books, podcasts, and videos available online to learn about personal journeys of those affected by this syndrome (Table 2). Finally, pharmacists across the United States can make an impact on identifying and serving patients affected by PICS in a variety of patient-care settings. Table 2: ICU Recovery Resources Institution/Organization Society of Critical Care Medicine

University of Kentucky ICU Recovery Clinic Lexington, KY Contact information https://sccm.org/MyICUCare/THRIVE/Post-intensive-CareSyndrome https://ukhealthcare.uky.edu/wellness-community/blog/ critically-ill-patient-finds-heroes-icu

Vanderbilt University Medical Center ICU Recovery Center Nashville, TN Phone Number: 859-323-9555 https://www.icudelirium.org/the-icu-recovery-center-atvanderbilt

Eskenazi Health Critical Care Recovery Center Indianapolis, IN Phone Number: 615-322-2386 https://www.eskenazihealth.edu/health-services/recoverycenter

Pharmacy to Dose: The Critical Care Podcast (available on Apple Music, Spotify, and online)

YouTube Phone Number: 317-880-2224 PICS – Aired January 15, 2020 Life After the ICU: A Personal Experience – Aired January 28, 2020 After the ICU: Nancy Andrews at TEDxDirigo Generate

Books Recovering from the ICU: A Survivor's Story In Shock: My Journey from Death to Recovery and the Redemptive Power of Hope by Rana Awdish

Table 1: Summary of ABCDEF Liberation Bundle Components

Component

A

B

C

D

E

F Management

Assess, prevent, and manage pain; airway

Spontaneous awakening and breathing trials

Choice of analgesia and sedation

Assess, prevent, and manage delirium

Early mobility and exercise

Family Engagement and Empowerment

Potential Medication Considerations What type of analgesia should be used? Ex: IV opioids such as hydromorphone, fentanyl, morphine or nonopioid analgesics such as APAP, NSAIDs What medications could aid in helping the patient successfully complete the trials? Consider patient home inhaler(s) or nebulization treatments What is the desired level of sedation and which agents could help? Ex: Dexmedetomidine, propofol plus component A medications What medications could be contributing to patient delirium? Ex: anticholinergics, stimulants, dopamine agonists, high-dose benzodiazepines, corticosteroids, sedatives Evaluate pain control and medications that could increase fall risk. Ex: antihistamines, sedatives, benzodiazepines, opioids, antihypertensives Is family available to provide: allergies, medication history, mental status, pharmacy information? Other Considerations

Is the patient being managed for pain in the outpatient setting?

Review medications, dosing schedule, and labs (phosphorus, calcium, metabolic alkalosis) that may compromise patient breathing effort What is the patient’s native language?

What is the desired duration of sedation? Will the patient need surgery? Is an awakening of breathing trial coming up?

Non-pharmacologic interventions: patient glasses or hearing aids, opening and closing patient blinds at appropriate times of day, monitor noise levels and visual stimuli such as television, visitations with family

When will the patient be extubated? Is the patient willing and able to begin to walk?

What is the dynamic of the family communication? Is team communication with the family effective, clear, and concise? Evaluate family coping and support needs