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ntensive and Critical Care Nursing (2014) 30, 138—144

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anaging hyperactive delirium and spinalmmobilisation in the intensive care setting:

case study and reflective discussion ofhe literature

aime P. Hyde-Wyatt ∗

ntensive Care Unit, Scunthorpe General Hospital, United Kingdom

Accepted 22 November 2013

KEYWORDSDelirium;Hyperactive delirium;Intensive Care Unit;Nursing;Sedation holds;Spinalimmobilisation;Ventilator carebundle

Summary The management of ventilated patients on intensive care has, at its core, a carebundle; an evidence based group of actions designed to reduce the risk of ventilator-associatedpneumonia. One of these is the daily cessation of sedation medication to expedite weaning fromventilatory support. A reflection-on-action exercise was carried out when a spinally injuredpatient became physically active during a sedation hold. This was attributed to hyperactivedelirium. The concern was the conflict between providing evidence based Intensive Care Unit(ICU) therapy care and maintaining spinal immobility.

Reflection on this incident led to a literature search for guidance on the likelihood of deliriumcausing secondary spinal injury in patients with unstable fractures. There was plentiful researchon delirium and its consequences but very little examining the link between spinal injury anddelirium. In order to be able to provide evidence-based care to future trauma patients theresearch supporting spinal immobilisation was also examined.

The research showed that compliance with ventilator care bundles reduced the risks ofacquiring ventilator-associated pneumonia. Research surrounding spinal immobilisation wasconflicting and there were no studies linking the consequences of immobilised patients experi-

encing hyperactive delirium.

Through a case study approach the research was reviewed in relation to a particular patient

and although literature was lacking some implications for practice could be identified to pro- mote the best possible outcomes.

Sedation cessation episodes are an essential part of patient care on intensive care. For spinallyinjured patients’ these may need to be modified to sedation reductions to prevent sudden

∗ Correspondence to: Morton Road, Laughton, Gainsborough, Lincolnshire DN21 3PS, United Kingdom. Tel.: +44 01427628438.E-mail address: J Hyde1979@yahoo.co.uk

964-3397/$ — see front matter © 2013 Elsevier Ltd. All rights reserved.ttp://dx.doi.org/10.1016/j.iccn.2013.11.004

Managing hyperactive delirium and spinal immobilisation 139

wakening and uncontrolled movement should the patient be experiencing hyperactive delirium.This case study clearly highlights the need for further research in this area as the consequencesof both ventilator associated pneumonia and extending spinal injuries is costly for both patients

and hospitals.© 2013 Elsevier Ltd. All rights reserved.

Implications for Clinical Practice

• More research into the specific area of secondary spinal cord injury due to delirium is required.• Education of nursing staff to be aware of the risk factors associated with delirium.• Support for nursing staff to be able to remain at the bedside to provide reassurance to delirious patients and to

reduce risk factors where able.• Training in the use of a validated delirium assessment tool to enable early recognition of delirium.• Modifying sedation holds into slow sedation reduction to allow the patient to be assessed for signs of delirium before

any hyperactive incidents lead to uncontrolled patient movement that could exacerbate a spinal cord injury.

Introduction

The standard treatment of ventilated patients on the Inten-sive Care Unit (ICU) in the United Kingdom (UK) is basedaround a ventilator ‘care bundle’ (Department of Health,2007; Westwell, 2008). This evidence-based tool is aimed atreducing the incidence of ventilator-associated pneumonia(VAP). This particular nosocomial infection affects approx-imately 12% of ICU patients (Bercault and Boulain, 2001;Orgeas et al., 2008). Mechanical ventilation was linked with83% of nosocomial pneumonias in ICU patients (Richardset al., 2000). The development of nosocomial pneumonia hasbeen attributed to an increased mortality rate and length ofICU stay (Bercault and Boulain, 2001).

The implementation of a ventilator ‘care bundle’ hasbeen found to reduce the development of VAP in ICU patients(Al-Tawfiq and Abed, 2010; Marra et al., 2009; Morris et al.,2011). This group of interventions includes a daily sedationhold (cessation of all sedative medication), to facilitate ven-tilatory weaning and assess neurological function along withreducing the harmful effects of over sedation. Usually theclinical treatment of a patient’s condition is compatible withthis care bundle. A situation arose on the ICU where theauthor works which highlighted an instance where compli-ance with the ventilator care bundle was not possible dueto the nature of a patient’s orthopaedic injuries.

A man was admitted requiring spinal immobilisation fol-lowing a road traffic collision (RTC). During a sedation holdthe patient exhibited signs of hyperactive delirium resultingin vigorous, non-purposeful movement. Delirium has beendefined as an acute, fluctuating change in mental functionthat is characterised by inattention and disorganised think-ing (Bourne, 2008; Devlin et al., 2008; National Institute ofClinical Excellence (NICE) 2010). Daily sedation holds werestopped due to fear of potential secondary spinal traumacaused by further uncontrolled movement. The use of seda-tive medication is associated with numerous risks including

Concern over whether or not this patient received opti-mal care during his critical illness led to reflection on histreatment. A literature search was carried out to discoverif it was possible to co-ordinate his ICU care with the man-agement of his unstable spinal injury. What follows is anexamination of the evidence gathered, with the aim of link-ing theory to practice in this area. This case study illustratedthat there was a knowledge deficit when it came to man-aging the combination of the patient’s spinal injury anddelirium. A literature review was carried out to enable bestpractice to be provided to other patients presenting withsimilar complex problems in the future.

Reflective practice is a useful learning tool in health careas it enables the individual to learn from experience and usethat knowledge to benefit others in the future (FitzGeraldand Chapman, 2000; Jasper, 2003). A case study approachwas used to present the findings of this reflection-on-actionprocess. The clinical details of the case are written in italicsto separate them from the discussion of the literature.

Literature review

Keywords used in the literature search were: log roll, spinalimmobilisation, delirium, hyperactive delirium, ICU, inten-sive care, lumbar fractures, nursing, ventilator-associatedpneumonia and ventilator care bundles. These words wereused singly and in combination i.e. spinal immobilisationand hyperactive delirium, spinal immobilisation and nursing.Databases searched were Athens, Google Scholar, Depart-ment of Health and the Cochrane Database. The search waslimited by the year of publication (2002-2013). Most of theliterature found related to spinal immobilisation in the acci-dent and emergency and pre-hospital setting.

There was a dearth of information available relatedto hyperactive delirium combined with spinal immobilisa-tion; and on continued spinal immobilisation in hospitalafter spinal injury. In order to locate literature on lum-

the development of delirium (Thompson and Ocampo, 2011;Van Rompaey et al., 2009). During his stay on ICU the patientsuffered a number of adverse events resulting in continuoussedation for several weeks.

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ar fractures and immobilisation the limitation of yearf publication was removed. The literature was reviewedegarding the effects of delirium, concentrating on hyperac-ive delirium and the importance of spinal immobilisation.

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he lack of official guidance on limiting spinal mobility inhe delirious patient was disappointing. There was minimalvidence demonstrating episodes of delirium exacerbatedpinal injury.

After reviewing the literature it was apparent that thereas little, if any specific guidance on how to manage spinal

ractures in the delirious patient. It became obvious, thatny recommendations for practice would have to be basedpon an amalgamation of the pertinent points found in theisparate studies reviewed.

ase study

45-year-old man, whose name has been changed toaintain confidentiality in accordance with Nursing andidwifery Council (NMC) guidelines (2008), was admitted to

he ICU following a RTC. Max was previously fit and well witho significant medical history, he was a social drinker and aon-smoker. Max was conscious on admission to hospital andis cervical spine was cleared both radiographically and clin-cally but he was found to have a burst fracture of his fifthumbar vertebrae. He also had a closed comminuted frac-ure of his left femoral shaft. When placed under a generalnaesthetic for fixation of his fractured femur his conditioneteriorated. He was admitted to the ICU sedated and venti-ated with the instruction to maintain spinal immobilisationithout cervical spine control. This entailed being nursedn a solid foam mattress and log rolled when movement wasequired.

Road traffic collisions are the most common cause ofpinal injury and due to the high velocities involved mul-iple injuries usually occur (Adam and Osborne, 2005; Jain,007; Sell, 2011). Spinal injury is acknowledged to dramati-ally affect the quality of life of patients and their familiesKwan et al., 2001); therefore reducing the risk of secondarypinal cord damage is a priority of hospital treatment.

The search found that most literature concentrated onpinal immobilisation only up to the point of clearing theervical spine and did not consider other spinal injuries.ach study concluded by recommending either: (1) clearinghe cervical spine and mobilising the patient or (2) surgicaltabilisation of the injury prior to mobilisation. However,ax’s case illustrates that either clearing or surgically sta-ilising the spine is not always possible. Harrison and Cairns2008) stated that full spinal precautions should continuentil the patient was able to report any pain or neurologi-al symptoms. This can be problematic for patients on theCU as they are often unconscious for prolonged periods,specially if they have multiple medical and orthopaedicroblems. Bernhard et al. (2005) revealed that 25% of spinalord damage might occur after the initial injury, althoughhey admitted that this evidence was historical and not sup-orted by research. Despite this, Bernhard et al. (2005)trongly advocated immobilisation to reduce the possibilityf exacerbating spinal injury. From examining this study oneay conclude that all potentially spinally injured patients

hould be fully immobilised to prevent secondary injury to

he spinal cord.

Kang and Lehman (2011) argued that the practice ofmmobilising spinally injured patients immediately afternjury was not supported by evidence. Kwan et al. (2001)

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J.P. Hyde-Wyatt

oncurred with this view. The implications of this are that ifpinal precautions immediately post injury are unnecessaryhere would be little point in starting or continuing themnce the patient has been admitted to hospital. If this werehe case then Max was subjected to the considerable risks ofedation and immobilisation for no reason. Further researchould be required on this matter but is unlikely to be car-

ied out due to the potential catastrophic consequences tohe patient of a negative outcome.

Despite the fact that approximately 60% of all spinalnjuries are thoracolumbar (McNee et al., 2011) there is ahortage of literature on the management of these frac-ures. In Max’s case, guidance was sought from the localpecialist neurosurgery centre, whose advice was to con-inue spinal precautions without cervical spine control forix weeks. Following this he could begin to mobilise once

lumbar brace had been fitted. Surgical stabilisation wasonsidered unnecessary. The purpose of carrying out spinalmmobilisation was to restrict the movement of the spinalolumn in order to prevent secondary neurological traumaDel Rossi et al., 2003; Wirasinghe et al., 2011).

Research by Jones et al. (1987) concluded that 6-8 weeksf bed rest followed by mobilisation with continued spinalupport using an external orthosis (brace) gave patients aood outcome. This study recommended a shift from non-urgical treatment that involved immobility in bed for upo six months to earlier mobilisation with a brace. Theseuthors claimed that to allow the patient to mobilise with-ut external support led to deformity at the site of fractureeading to aesthetic and functional problems. This is an oldtudy but is cited in modern research and, as evidenced byhe advice given regarding Max’s fracture management, is aractice still in use today.

The British Orthopaedic Association Standards for Traumatated that spinal immobilisation was not recommended forore than 48 hours (BOAST, 2008) due to the complications

ssociated with immobility. They did not offer an alterna-ive method of spinal stabilisation for the conservativelyanaged patient.Some of the side effects of immobilisation are: increased

ikelihood of chest infection, increased risk of developingenous thromboembolism (incidence of up to 80% in traumaatients according to Wilson-MacDonald and James (2011)),uscle atrophy, joint stiffness, loss of bone density, periph-

ral nerve injury, increased risk of urinary tract infection,educed gut motility, constipation and pressure damageDonnelly et al., 2008; Field, 2005; Hennessy et al., 2010).ome studies have also found an increased risk of deliriumssociated with immobility (Goodwin et al., 2012; Takahirot al., 2009).

Any of these complications could greatly effect patientutcomes and influence length of stay on the ICU and inospital. For the polytrauma patient pressure damage is aignificant problem as regular repositioning is difficult dueo the risk of secondary spinal cord damage. Max had a par-icularly high risk of developing pressure ulcers as he wasritically unwell, immobilised, had sustained a spinal injury,as faecally incontinent, had a reduced level of conscious-

ess and was also subject to the side effects associated withasoactive medication (NICE, 2005). Max was log rolled everyour to six hours to reduce the risk of pressure damage whilerying to minimise the risk of secondary spinal cord damage.

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Managing hyperactive delirium and spinal immobilisation

He did not develop any pressure sores during his intensivecare stay.

In summary, the literature advocated early clearanceof the spine and discouraged unnecessary immobilisation.However, in practice if the spine cannot be cleared andtreatment is conservative, immobilisation is routine despitelimited supporting evidence. In Max’s case the potential sideeffects of immobilisation were reduced where possible (e.g.venous thromboembolism (VTE) prophylaxis, pressure relief)and it was decided that the risks associated with the cessa-tion of spinal precautions outweighed the possible harmfuleffects of immobility.

Max’s sedation was stopped the day after surgery in orderto wean his ventilatory support and assess his neurologicalfunction. During the sedation hold Max became very agitatedand was thrashing around the bed. He was moving all hislimbs and twisting his trunk, he was not able to comply withadvice to lie still. He was re-sedated and remained so forseveral weeks.

Max’s uncontrollable behaviour was attributed to delir-ium, which has been found to occur in up to 80% ofICU patients (Dun and Ely, 2007; Girard et al., 2008;Morandi et al., 2009). In practice delirium is greatly under-diagnosed. Dun and Ely (2007) believed that this was becausethe most prevalent form is hypoactive delirium, whichcauses the patient to appear withdrawn and apathetic(Borthwick et al., 2006). Mixed delirium is the second mostcommon type (where the patient’s cognitive state fluctuatesbetween hypo and hyperactive delirium) with pure hyper-active delirium being relatively rare but characterised byrestlessness and agitation (Bourne, 2008; Dun and Ely, 2007;Girard et al., 2008) which can result in removal of invasivelines and endotracheal tubes leading to an increased hospi-tal stay and increased mortality (Dun and Ely, 2007; Morandiet al., 2009).

Experiencing delirium can have a negative impact onpatients during the period of critical illness and for yearsafter their ICU admission (Dun and Ely, 2007; Morandi et al.,2009; Van den Boogaard et al., 2010). For the purposesof this reflective study the effect of hyperactive deliriumon the spinally injured trauma patient has been examinedalthough the general issue of delirium and its prevention onthe ICU is relevant to all patients.

Hyperactive delirium shares some features with post-traumatic stress disorder (PTSD) in that vivid delusions andhallucinations can occur which often involve paranoid ideas(Jackson et al., 2009). Carrying out sedation holds enablespatients to form factual memories that could help to reducethe incidence of PTSD (Jackson et al., 2009). As already dis-cussed Max was not given daily sedation holds due to fear ofagitation resulting in damage to his spinal cord.

Despite the lack of consensus as to the cause of deliriummany risk factors have been identified, some of which aredebated in the literature. Peterson et al. (2006) found thatdelirium was more common in patients aged 65 years andolder. Van Rompaey et al. (2009) identified four risk areas:two that were impossible to modify (patient characteris-tics and chronic pathology) and two that could be adjusted

(patient environment and acute illness). The authors didnot find any link between age and the incidence of delir-ium. Abuse of alcohol and addiction to nicotine did increasethe likelihood of developing delirium. Under the heading

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f chronic pathology only pre-existing cognitive impairmentas a risk factor. Length of ICU stay was shown to be rel-vant in the development of delirium as was the numberf infusions, the use of benzodiazepines and intubation.nvironmental factors that increased the risk of developingelirium were: use of physical restraints, patient isolation,nability to see daylight and a lack of visitors. These modifi-ble environmental risk factors were found to be responsibleor 53% of delirium. Pandharipande et al. (2008) establishedhat benzodiazepine use was a statistically significant riskactor in the development of delirium. The authors did notnd that baseline demographic information; admission diag-osis or severity of illness indicated a patient group moreikely to experience delirium. This study concluded by sug-esting that sedative and analgesic medications should bearefully considered in light of the results.

The modification, where possible, of these risk factorsould result in a reduced incidence of delirium in the criticalare setting. There were very few articles related to delir-um in the spinally injured patient and those that there wereealt with postoperative delirium following spinal surgeryhere mobilisation of the patient was not problematic.

Takahiro et al. (2009) stated that episodes of deliriumight result in trauma to the spine and spinal cord. This

mall study was carried out to establish the incidence andisk factors of postoperative delirium in patients undergo-ng cervical spine surgery. The authors found that deliriumccurred more frequently in older patients, patients withearing deficit, those treated with methylprednisoloneused to reduce swelling of the spinal cord during surgery)nd immobilised patients. They produced a protocol whereteroid use was reduced and early mobilisation was encour-ged. The authors stated that these alterations to treatmentnabled the circadian rhythm to be normalised and thus thencidence of delirium reduced, thereby also linking sleepisturbance to delirium.

There was no evidence in any of the literature reviewedf an effective treatment for delirium or any interven-ion that improved long-term outcomes for patients. Thenus was on reducing the risk factors and carrying outon-pharmacological measures prior to treatment with med-cation. Nurses were identified as being ideally placed tossess for and treat delirium through modification of theatient environment (NICE, 2010; Van Rompaey et al., 2009),romotion of normal sleep patterns (Pandharipande et al.,008) and reassurance and reorientation of the patient toime and place (NICE, 2010).

None of the articles discussed relate directly to Max’situation, however the potential risks of hyperactive delir-um have been established. After reviewing the research itas clear that episodes of pure hyperactive delirium are

elatively rare. Neither of the two research papers linkingpinal surgery and delirium mentioned any specific prob-ems to the spinally injured patient caused by experiencingelirium, although the delirium occurred post-operatively inll patients (Gao et al., 2008; Takahiro et al., 2009). Bear-ng this information in mind it would need to be decidedhether the risk of causing secondary spinal cord injury was

reater than the risks associated with prolonged unneces-ary sedation.

After four weeks Max’s sedation was stopped again.e had suffered multiple complications in this time:

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e developed acute respiratory distress syndrome (ARDS)hat required high frequency oscillation ventilation, whichnvolves deep sedation and muscle paralysis. This treat-ent, unfortunately, led to a pneumothorax that required

hest drain insertion. During this procedure an intercostalrtery was severed requiring emergency transfer to anotherospital for thoracic surgery. Max was transferred backo the original ICU after five days. When his conditionad stabilised and he was on regular ventilation, sedationolds were once again carried out. He was compliant withreatment and neurologically intact. He was able to obeyommands and continued to be immobilised until a braceas fitted six weeks after his initial injury. He later revealed

hat he experienced terrifying hallucinations and dreamshilst a patient on ICU. After hospital discharge Max con-

inued to visit the ICU and attended the follow up clinic toelp with the psychological consequences of his admission.

onclusion

rom examining the literature it can be ascertained thathere is no research to inform the best practice in managinghe patient with a spinal injury and hyperactive delirium.eflection-on-practice indicates that Max was managed in aay that, although not in accordance with best practice forentilated patients, did take into account the risks posedy his other injuries. The considerable side effects associ-ted with prolonged sedation and ventilation were reducedoth by medical and nursing intervention. The conclusionseached are based on the evidence found and related toax’s situation. From these conclusions recommendationsave been made that may benefit patients with similarnjuries in the future.

It has been noted that skilled nursing care is neces-ary to achieve good outcomes for the poly-trauma patientMorris, 2009). Gallagher (2005) highlighted the impact nurs-ng procedures can have on patient outcomes, specificallyheir future disabilities. These should include screening forelirium using an established tool as many patients go undi-gnosed and suffer the long-term cognitive consequences ofypoactive delirium (Peterson et al., 2006). Implementingurse led non-pharmacological interventions could reducehe risk of patients developing delirium. Keeping ventilatedatients conscious involves a higher degree of nursing inputnd excellent communication skills (Karlsson et al., 2012).urses spend the most time with the patient and so areerfectly placed to assess for delirium and ensure that itsisk factors are minimised. Education of nursing staff in theecognition and prevention of delirium could reduce the inci-ence of patients extending their spinal injury while in angitated state.

Early mobilisation was found to be a key factor in improv-ng patient outcomes as regards lumbar fractures (Sell, 2011)nd in reducing the risk of delirium (Takahiro et al., 2009). Inax’s situation mobilisation was impossible due to the con-

ervative management of his spinal fracture and his other

njuries. It would be useful to investigate whether lumbarraces could be applied during sedation holds to provide pro-ection to the spine if delirium occurred. A literature reviewxamining the effectiveness of using braces in patients with

B

J.P. Hyde-Wyatt

horacolumbar fractures was unable to determine their effi-acy (Giele et al., 2009).

Ideally all mechanically ventilated ICU patients shouldeceive daily sedation holds to reduce morbidity and mor-ality, and the long-term psychological and cognitive effectsf critical illness. If the risks of delirium can be reducedn the spinally injured patient through environmental mod-fications, safe sedation holds should be possible in moreatients. Perhaps in the spinally injured patient sedationolds should be carried out gradually and more cautiouslyhan in other patients, allowing for rapid diagnosis of hyper-ctive delirium and titration of sedation to ensure that theatient is compliant with treatment while being as lightlyedated as possible.

ecommendations for practice

rom the literature reviewed the following recommenda-ions for practice were developed.

Further research into the topic of managing spinal stabil-ty in the delirious critically ill patient is necessary. It woulde helpful to establish if there was any evidence to suggesthat patients did sustain secondary spinal cord injury due toyperactive delirium. Possible methods of injury preventionould then be investigated.

The importance of assessing for delirium in all ICUatients has been clearly highlighted. Nurses are ideallylaced to carry out assessments and instigate non-harmacological treatment for delirium.

Awareness of predisposing risk factors could allowatients who are more likely to suffer from delirium to haveheir environment and medications altered prior to stoppingedation.

The importance of psychological support for the ICUatient must be emphasised. In order to prevent agitationncreased nursing presence at the bedside offering comfortnd reassurance has been found to be effective.

Modifying sedation holds to prevent rapid wakening inhis patient group would enable assessment of the patient’sental state before any uncontrolled movements could

ause harm.Carrying out these nursing procedures should enable

pinally injured patients to receive the best care both forheir injury and for their critical illness, thereby improvingong-term physical and psychological health.

cknowledgement

hanks to Julie Santi-Tomlinson for expert guidance.

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