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Abstract |
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• Objectives To determine and describe the remembered experiences of critical care patients who were given neuromuscular blocking agents and sedatives and/or analgesics to facilitate mechanical ventilation, improve hemodynamic stability, and improve oxygenation.
• Methods A phenomenological approach with in-depth interviews with 11 patients was used. Data were analyzed by using the constant comparative approach.
• Results A total of 4 themes and 3 subthemes were identified. The first theme was back and forth between reality and the unreal, between life and death; the subtheme was having weird dreams. The second theme was loss of control; the 2 subthemes were (1) fighting or being tied down and (2) being scared. The third theme was almost dying, and the fourth theme was feeling cared for.
• Conclusions Patients can remember having both negative and positive experiences during neuromuscular blockade. Steps to improve the experiences of patients receiving neuromuscular blockers include improving assessment parameters, developing and using sedation/analgesia guidelines, and investing in quality improvement programs to provide assessment of awareness during therapeutic paralysis and follow-up and referral as necessary. Ways to decrease the use of neuromuscular blockers would also be useful.
Notice to CE enrollees:A closed-book, multiple-choice examination following this article tests your understanding of the following objectives:
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| Some patients have awareness and recall of events and discomfort during therapeutic paralysis, despite high doses of sedatives/analgesics.
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Several indications exist for the use of therapeutic paralysis in the care of critically ill patients. NMBAs are often administered to optimize mechanical ventilation in patients with critical pulmonary illness such as status asthmaticus or adult respiratory distress syndrome because the agents promote ventilator synchrony, diminish peak inspiratory pressure, and enhance oxygenation, all of which reduce the work of breathing.4 Patients with complex multisystem trauma also may benefit from NMBAs and ablation of muscle activity. Long-term use of NMBAs enhances positive-pressure ventilation, controls movement in instances in which activity could be life threatening, and diminishes oxygen utilization. Although administration of NMBAs to patients with neurological injuries is controversial because of the resultant inability to conduct a good neurological examination, use of NMBAs in these patients can decrease activity-induced intracranial pressure.5–7
Use of NMBAs began in 1942 with the use of curare as a complement to anesthesia.4,5 NMBAs can be classified as depolarizing or nondepolarizing. Depolarizing agents cause momentary muscle depolarization and contraction before the onset of dose-related flaccid paralysis. Nondepolarizing agents produce a dose-related onset of flaccid paralysis that is not preceded by muscle depolarization and contraction. The only depolarizing drug available in the United States is succinylcholine, which is used for muscle relaxation during intraoperative anesthesia.4 The most common agents used in the ICU are the nondepolarizing drugs pancuronium (Pavulon), vecuronium (Norcuron), atracurium (Tracrium), doxacurium (Nuromax), and cisatracurium (Nimbex).7,8 These agents cause paralysis but have no sedative or analgesic effects, leaving patients fully conscious, able to experience pain, all other sensory stimuli, and anxiety.
| Use of neuromuscular blocking agents is ethically and therapeutically contraindicated in patients who have not received adequate sedation and analgesia.
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Use of NMBAs is ethically and therapeutically contraindicated in patients who have not received satisfactory amounts of sedatives and analgesics.9,10 Sedatives and analgesics are necessary to reduce awareness, relieve fear, produce comfort, decrease anxiety, induce unconsciousness, and minimize possible complications such as posttraumatic stress syndrome.2,5,8 Benzodiazepines and opioids are the medications most often used to provide sedation and analgesia.10 Analgesic and sedative protocols for paralyzed patients vary, and no consensus exists on the pharmacological agents to use. However, agreement exists that the best method of delivery is continuous infusion to avoid peaks, and especially troughs, in the level of sedation or analgesia.11 According to Berger and Waldhorn,10(p171) "Paralyzed patients who are not given sedation are able to recall some aspects of their ventilated period and report that it is a terrifying experience."
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Background |
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Assessment of adequate sedation and analgesia during neuromuscular blockade is challenging. Indications of an increase in the activity of the sympathetic nervous system, such as tachycardia, hypertension, lacrimation, or diaphoresis, may be used, but these parameters are not totally trustworthy because they can be affected by multiple factors, including fluid balance and an unstable hemodynamic status.11 Neuromuscular blockade must be reversed (an impractical as well as potentially unsafe intervention) in order to assess for sufficient levels of sedation and analgesia.14,15
The depth of neuromuscular blockade is commonly assessed by using the train-of-4 method.16 This method is a mode of nerve stimulation in which a peripheral nerve stimulator is used to deliver 4 supramaximal stimuli (measured in milliamperes) every 0.5 second. When the nerve is stimulated with enough intensity, the normal response (in the absence of an NMBA) is 4 muscle twitches. Each set of stimuli (train of 4) may be repeated every 10 seconds. After administration of an NMBA, the response of the muscle decreases in parallel with the number of fibers blocked.17 The dosage of the NMBA is adjusted on the basis of the patient’s clinical status and the response to the train-of-4 stimuli.
The train-of-4 method has limitations, including interference by edema or moist skin, poor electrode contact with the skin, incorrect electrode placement, the unreliability of observers’ interpretation of the twitch response, and impaired nerve function, that could lead to overestimation of the level of blockade.7,8,18 With this method, only the nerve and muscle that are being stimulated can be assessed, a situation that may not reflect neuromuscular block in other muscles; the response can be zero twitches, but muscle movement may still be observed.8
Extensive research has been done on the experience of paralysis during anesthesia, and the incidence of awareness during anesthesia has become the subject of concern in the United States. The Joint Commission on Accreditation of Healthcare Organizations has published a Sentinel Event Alert on awareness during anesthesia.19 The frequency of awareness during anesthesia ranges from 0.1% to 0.2% of patients given general anesthetics, or 20 000 to 40 000 cases per year.20–23 Posttraumatic stress disorder (PTSD) develops in as many as 50% of these patients; they have associated symptoms of auditory recollections, flashbacks in which they relive the pain, panic attacks, anxiety, difficulty concentrating, sleep disturbances, and nightmares.24–26 According to Montgomery,26(p297) PTSD is "a pathological response to the experience of a traumatic event. The traumatic event is persistently reexperienced with flashbacks, intrusive thoughts, recurrent distressing recollections, dreams or the feeling that the traumatic event is reoccurring" and can lead to chronic anxiety, detachment, fear of death, and interference with normal daily functioning.
This disorder is likely to occur with any serious threat to life or personal integrity and is a threat to patients who experience awareness during anesthesia, particularly patients who have compromised cardiopulmonary and vascular functioning or compromised hemodynamic status and patients who have increased anesthetic requirements because of previous intravenous drug use, chronic alcohol ingestion, or opioid use for premorbid conditions.25,27 The Joint Commission on Accreditation of Healthcare Organizations therefore recommends education of staff about awareness during anesthesia, effective anesthesia monitoring techniques, follow-up of all patients who have undergone anesthesia, management of patients who have experienced awareness during anesthesia, and counseling for those who are experiencing PTSD. Healthcare providers must remain steadfastly aware that analgesics do not necessarily reduce recall of traumatic events and that sedatives have no effect on pain.
Long-term follow-up studies of ICU patients who received only analgesics and sedatives (without NMBAs) suggest that quality of life can be affected, with subsequent development of PTSD.28 For example, Rundshagen et al24 interviewed 289 patients after discharge from the ICU who had been sedated and treated with mechanical ventilation during the ICU stay. A total of 187 patients (65%) had no recall of the experience. A total of 49 (17%) remembered either having a tracheal tube in place, receiving mechanical ventilation, or being extubated. Those who recalled the extubation reported it as an unpleasant experience. In addition, 61 patients (21%) remembered dreams; among these, 9.3% recalled nightmares, and 6.6% reported hallucinations and delusions. The patients who remembered dreams were hesitant to talk and seemed anxious when being reminded of events. The longer the patients were in the ICU, the higher was the risk of recall or dreams.
The experiences and recollections of patients undergoing neuromuscular blockade during critical care have not garnered the same degree of research scrutiny as has awareness during anesthesia. The reports have primarily been single case studies. The most-cited single case in the literature involved a patient who was an ICU nurse who received pancuronium, diazepam, and morphine.3 She reported having visual and auditory hallucinations and delusions and of being aware of her environment. In one study,28 6 patients paralyzed with pancuronium experienced feelings of being buried alive, panic, and hallucinations. Wagner et al1 studied the experiences of 11 patients who had undergone therapeutic paralysis. Of these, 4 patients could recall a negative experience. One patient could remember being unable to move and experiencing discomfort. Another felt shaky and unable to take full breaths. The third patient experienced pain and felt uncomfortable during tracheal suctioning and reported that a nurse had been rough with him. All the patients who had recollection of the episode experienced fear, anxiety, and sleeplessness and are at high risk for PTSD.
More recently, Johnson et al2 conducted a qualitative study of 11 trauma patients who had therapeutic paralysis and the patients’ families to determine the 2 groups’ recollections of the paralysis. The patients remembered the experience with vagueness, as if they were sleeping. They had difficulty separating dreams from reality and in distinguishing whether details they recalled were memories of real events or of dreams. They could not remember being paralyzed or any procedures that they underwent, but they had recollections of people being present, usually their nurses or mothers. The patients recalled hearing voices but did not remember being treated with mechanical ventilation or experiencing any pain. Some patients offered suggestions to improve their nursing care2(p496): "Don’t tape my hands" and "Don’t tie the hands down so tight."
The patients’ families understood the purpose of neuromuscular blockade, recalled that they were told that the patient could still hear, and were encouraged to talk with and touch their loved one. When asked about what the nurse could do to make it better for them, the family members spoke about keeping them informed, having continuity of nursing care, and being told about "shaking" that the patient would experience when use of the NMBAs was discontinued. Overall, the experiences of the patients and their families were not described in the negative terms that had been reported previously.
Because considerable time has elapsed since the study by Johnson et al,2 we wished to examine patients’ experiences of therapeutic paralysis in patients in another locale and in patients with various diagnoses who had different NMBAs administered. We sought to understand the patients’ recollections and to determine whether they experienced pain, anxiety, or negative or positive recollections of care despite the administration of sedatives and/or analgesics.
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Methods |
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A phenomenological method was used to understand the remembered experiences of patients who were given NMBAs and sedatives and/or analgesics to facilitate mechanical ventilation, improve hemodynamic status, and improve oxygenation while in the ICU. Phenomenology is concerned with describing and understanding the subjective and objective lived experience of a person as expressed through dialogue. The focus is on the participant as subject, rather than object, and involves interpretation that arises from the participant’s emic (insider’s) perspective.
Setting and Sample
The study was approved by the appropriate institutional review board and human rights and research committee. The risks and benefits for the patients in the study were explicitly identified in the research proposal. Anticipated possible risks included further loss of privacy, a sense of insecurity associated with sharing what may be deeply personal and painful memories, and feelings of loss of control. In order to protect privacy, each patient was interviewed in private, and all field notes, tapes, transcripts, and analyses were/are kept locked in a secure file. Each patient was approached respectfully and gently, given the opportunity to stop the interview at any time, and verbally supported during times of emotional distress. Advance preparation was made for pastoral care and psychiatric referral as needed. The benefits of participation were also delineated: the opportunity for expression and catharsis, acknowledgment of the reality of the lived event, and contribution to improvement in critical care nursing.
Purposive sampling was used to select participants. Patients 18 years or older who had received an NMBA via continuous infusion for a minimum of 6 hours were included in the sample. Patients with head injury, previous dementia, or confusion and those who did not speak English were excluded. Patients were cared for in 7 critical care areas within 3 suburban hospitals, and the level of paralysis was assessed by using clinical observation and the train-of-4 method.
Participants were contacted 48 to 72 hours after extubation, because the window of opportunity for accurate recall might be narrow,23 and this time frame coincided with the previously cited research and the patients’ ability to regain the use of their vocal cords after extubation.
Data Collection
The nursing faculty member on the research team (L. R.), who has a doctoral degree, provided a review for the other members of the team on the form and process of qualitative research methods. Informed consent was acquired verbally and in writing. Each patient was interviewed in private at his or her bedside, either in the critical care unit or another unit within the hospital, and the interview was recorded on audiotape. An unstructured open-ended interview technique was used. The main questions asked of each participant were, What do you remember about the time when you were on the breathing machine and unable to move? and What events or conversations do you remember? Follow-up and clarifying probes (eg, What was that like for you?) were used to elicit further meaning. The interviews were transcribed verbatim, and confidentiality was ensured by labeling each interview with a fictitious name. A member of the research team of 5 nurses compared all transcribed data with the audiotape recordings to ensure accuracy. Data saturation, when no new additional information was forthcoming, occurred by the time 11 patients had been interviewed.
Data Analysis
Data analysis began with bracketing. Assumptions about the phenomenon, patients, and researchers were stated and recorded in an effort to set aside bias. This activity was important because the nurse researchers were familiar with the care of patients treated with NMBAs. The interview transcripts were analyzed by using the constant comparative method.30–32 The team began with cross-case intuitive analysis, moved on to individual case analysis, and progressed again to cross-case analysis. Reading and analyzing the answers to common questions from all of the interviews were done first, with constant comparisons of different perspectives on the central issues. Then each interview was analyzed by comparing, integrating, and refining categories from the previous interviews. In this way, categories elicited from the data were constantly compared with data obtained earlier in the data collection process. Logical construction of meaningful patterns resulted from this process. The system of identifying, coding, and categorizing the primary themes in the data ensued after multiple readings, continuous refinement, and the discovery of relationships between and among the various concepts, themes, and subthemes.
Trustworthiness of Data
Credibility is the criterion for establishing confidence in the truth of qualitative data.33 Credibility was enhanced by spending as much time as needed with each patient, from 45 to 90 minutes. Periods of silence and thinking were embraced to allow the patients to think and express themselves fully. The patients were given full and undivided attention, and multiple expressions of their experience were encouraged. A total of 2 investigators conducted the one-on-one interviews, and 5 researchers analyzed and interpreted the data.
Confirmability refers to the objectivity or neutrality of the data so that the findings can be independently interpreted by others.33 An audit trail was established at the beginning of the research process, and the tapes, transcripts, notes, memos, themes, categories, and other documentation were retained to provide confirmability.
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Results |
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Back and Forth
One major theme was the feeling of going back and forth, which included a sense of being gone and then being there, being dead and then being alive; a vacillation. One participant said, "I remember them giving me medicine. That’s like all I remember. More drugs. Them messing with me. I could hear them talking and then putting more stuff in me." Another likened the experience as remembered fleeting moments, "It’s just, it’s just passing moments you remember, you know . . . fleeting moments, you know." And another remarked, "Just certain people that come in and out to see me; I feel like I’ve dreamt that they’ve come in but know that I’ve come out of it a little bit to see, and I remember them and then I’d go back to being where I was." This movement back and forth was clearly distressing and disconcerting to those who experienced it.
| Patients described a sense of being gone and then being there, being dead and then being alive.
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Weird Dreams. Part of the sensation of going back and forth was described as a weird dreamlike state with the unreal disembodiment that this state entails. One patient said, "I can’t really tell reality from real." Another patient gave the following example of a weird dream:
And I thought I was in my country and, uh, I left the hospital and I could come back and it was terrible because I wasn’t feeling good and I was on a street and I couldn’t find the hospital and then, uh, the nurse wake me up, she gave me medicine then I find out . . . It wasn’t good experience, I feel that something was inside. I thought they had did, a trache, uh, trachtomy I thought.
Loss of Control
The second major theme was loss of control; patients had a general sense of being out of control with every facet of existence. Patients expressed feeling a loss of control over time, money, and life. One patient said, "I was in a paralyzed state, I couldn’t do anything." This feeling extended to the inability to process information:
Well, no, I was not quite under enough. Not to not know anything. I was under it just enough that I knew some things. Well, I guess I remember them going in and out of my mouth, changing the tubes, telling me that they were changing the tubes. They told me what they were doing. They did explain all of that. But they didn’t explain it in a sense that I understood. See that’s where I think the communication factor was bad then. They didn’t know that I wasn’t being receptive to what they were doing.
Fighting or Being Tied Down. Although being out of control was a general theme, fighting or being tied down was a subtheme. Many of the patients talked about attempting to regain control at one time or another during their experience by fighting, especially when restrained or being told that restraints might be necessary. Chewing through intravenous tubing and struggling against restraints were experiences fraught with anxiety. One patient said, "I recall fighting them while the tube was still in there. I remember fighting them, telling ’em no, or trying to say no . . . and I could remember them saying ‘We’ve got to keep these in or we’ll have to tie you down.’ "
| Chewing through intravenous tubing and struggling against restraints were experiences fraught with anxiety.
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Being Scared. Another subtheme of loss of control was being scared. The negative experience of being frightened and distressed was evident in the interviews in implicit as well as explicit ways. Patients were slow and hesitant to talk about their experiences and used the word scared repeatedly. One patient said, "I was drugged up. I couldn’t . . . like I was in a paralyzed state. I couldn’t do anything. . . . I was so scared, I felt violated. I felt scared to be alone."
| "I was so scared, I felt violated. I felt scared to be alone."
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Almost Dying
The third major theme was almost dying. The words dying and alive were juxtaposed in the interviews with the acknowledgment that death was close or had happened a number of times during the paralytic episode. One patient related, "I felt like I was already dead inside. . . . I thought I wasn’t ever gonna wake up. I thought I was in the process of dying. . . . Yeah, I felt like I could see me and I was dying and there was nothing I could do."
| "I felt like I was already dead inside.... I thought I wasn’t ever going to wake up."
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Feeling Cared For
The fourth major theme was feeling cared for. Despite the fear, loss of control, and experience of almost dying, the patients had a sense of being cared for. One patient stated, "[The nurses] took excellent care of me. They did just what they needed to do to get me well from the time I came through the door." One patient explained it as follows:
There were others. You know, others what I thought were angels or people, you know, in the background but you couldn’t see exactly who they were, but you could hear them. . . . It ah, seemed like I had been at a place where they were not looking over me and then the moment I came here, they started looking over me.
The fact that nurses "told me what they were doing" seemed very important to the patients. Nurses were remembered as important because of their holistic approach, which contributed to the patients’ personal integrity. One patient said, "There were some nurses that meant a lot more to me than others that I remember. And we brought them cards and breakfast and stuff. . . . They meant more to me, they took care of me, they talked to me, they spent time with me and stuff. And they were just nice." Another said, "One of the things that made me feel the best was when the nurse came in and, uh, she washed my hands, she washed my face, she washed my feet, she held me." Attention to the sensory elements of hearing and touch seemed important to patients so critically ill, fading in and out of awareness.
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Discussion |
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The interviewers sensed that more existed within the memory of the patients that lingered on the fringes of perfect narrative recall, that most of the patients could not put into words everything that they experienced. This phenomenon could be due to lack of direct access to implicit memory, the level of memory in which there is no conscious or intentional recollection.34–36 Patients were hesitant to relive the fear of their experience; some left sentences unfinished and allowed their thoughts to trail off. Although the patients were generally open and candid, recall itself seemed to be traumatic and distressing. The patients used metaphorical expressions to allude to the reality of death—being in a movie, being in the cold, drowning, ringing the bell—that revealed the experience as more frightening than they were able to explicitly remember. Of interest, avoidance is also part of the phenomenon of PTSD,37 and the narrative formation of traumatic memories occurs over time after the actual traumatic event.38
According to Levine,29 the process of adaptation results in conservation. Levine’s concept of conservation lends itself well to the experiences voiced by the patients in this study. The patients were reconstructing their lives; they had lived through a life-threatening and life-altering experience. Modification of the stress response most likely helped them survive, because "the continued stress response is pathologic and can increase mortality from prolonged illness."39(p952) Patients talked of now living beyond the "ringing bell," of having to care for themselves in new and different ways, of preserving the self and treading tentatively in a new world.
The experience of going back and forth may reflect an unintended variation in analgesia/sedation. Clinical practice guidelines11 call for adequate analgesia and sedation before administration of NMBAs in accordance with clinical judgment. Nurses’ vigilance in maintaining a consistent, steady state of both analgesia and sedation is important because the steady state preserves and enhances the ability of the body to adapt to the stress of being paralyzed. This steady state in turn leads to improved outcomes. Such nursing vigilance is reinforced by our findings.
The fact that patients may remember elements of their care while being paralyzed should be a concern of nurses. First of all, our findings suggest the need for better assessment tools for monitoring the response of all patients, even though individual sensitivities to medications must be taken into account.9,10,12,40 Nurses should seek out more reliable assessment tools, because physiological indicators such as elevated pulse rate and lacrimation are not necessarily good barometers of pain level. Because nurses respect the vulnerabilities of patients who are paralyzed, attention should be directed to research into the use of available alternative methods of assessing awareness, such as electroencephalography, auditory evoked response, ocular microtremor, and the patient state analyzer index.27 Bispectral index monitoring is another assessment tool that is increasingly used to monitor sedation and arousal states in the ICU.18,27 Beyond assessment, the care of patients receiving NMBAs requires adequate administration of analgesics and sedation to the level of unresponsiveness for all patients, with attention to the administration of continuous infusion during paralysis.
| Better assessment tools for monitoring patients’ responses are needed.
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Nurses wish to help patients conserve energy, personal integrity, and social integrity, in addition to structural integrity. Helping patients minimize the experiences of weird dreams, a feeling of loss of control, and a feeling of dying is a challenge to nurses. It seems ethically appropriate to capitalize on the importance of presence, voice, and touch while caring for ICU patients, particularly patients who have no way of responding to their internal or external environments. The voice of unfamiliar persons "in the background" can be either reassuring or distressing. The lack of touch and a feeling of loss of control are stressors. Nurses can use therapeutic touch, give information, and provide reassurance so each patient knows that he or she is being cared for.
| The use of presence, voice, and touch is especially important in therapeutically paralyzed patients.
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Notably absent in the interviews were discussions about technology and the alarms and noises that accompany intensive therapies. Also missing were specific references to pain. Of interest, 4 of the 11 patients did not receive any analgesic while undergoing neuromuscular blockade, yet none of the patients recalled experiencing pain despite being specifically asked about discomforts.
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Conclusions |
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Nurses can develop research designed to test various methods of assessment for levels of sedation and evaluate the efficacy of analgesia and sedation. Nurses can also intervene to prevent some of the adverse effects of awareness by being proactive, using voice, touch, and presence to provide support, encouragement, and life affirmation. Including patients’ family members in these interventions is also recommended. Quality improvement programs can be instituted to assess for awareness during therapeutic paralysis and provide follow-up and referral as needed because when repeated discussion, explanation, and psychological support are provided to patients who experience awareness, neurotic symptoms can disappear within 3 weeks.23
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ACKNOWLEDGMENTS |
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Commentary by Mary Jo Grap (see shaded boxes).
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REFERENCES |
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This article has been cited by other articles:
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  L. Corso Train-of-Four Results and Observed Muscle Movement in Children During Continuous Neuromuscular Blockade Crit. Care Nurse, June 1, 2008; 28(3): 30 - 38. [Full Text] [PDF]
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
