Article Review By: Jenna Faiella Posttraumatic Stress Symptoms in ICU patients: An Exploration of Associated Factors1 Rosalind Elliot, Doug Elliot, Mary Fien, Sharon McKinley Article Review By: Jenna Faiella

Purpose To explore demographic, clinical, and psychological factors in the ICU, including self-reported sleep quality and experiences that were associated with posttraumatic stress (PTS) symptoms 6 months after discharge from the hospital  Effects of sleep in ICU during critical illness on subsequent PTS symptoms has not been previously studied

PTS Symptoms “Feelings of anxiety, avoidance, intrusive thoughts, and alterations in reaction to those attributes as a result of exposure to a traumatic event.”

Setting & Inclusion Criteria Adult ICU at a University-affiliated hospital in New South Wales, Australia 18 years or older Treated in ICU for 48 hours or more Assessed as sufficiently recovered by the treating physician to transfer out of the ICU Able to provide informed consent

Exclusion Criteria Known or suspected preexisting sleep disorder Uncorrected vision or hearing impairments Inability to complete the study instruments in English

Method While in the ICU: Completed self-report questionnaires on their sleep prior to admission and during their stay in the ICU 2 months after DC: Reported on sleep over the past month + experiences in the ICU 6 months after DC: Reported on PTS symptoms + depression, anxiety, stress levels + quality of sleep over past month

Measures Age Sex BMI Severity of illness Operative admission or not Clinical & demographic characteristics were collected from healthcare records including: Age Sex BMI Severity of illness Operative admission or not Trauma or not Length of mechanical ventilation LOS in ICU & hospital

Measures Cont’d Sedation level Pain level (Visual Analog Pain Scale) State anxiety (Faces Anxiety Scale) Experience of treatment in ICU (ICEQ) Psychological well-being (DASS-21 & PCL-S) Self-reported quality of sleep (ISI, RCSQ, PSQI) Sedation level (Richmond Sedation-Agitation Scale) Pain level (Visual Analog Pain Scale) State anxiety (Faces Anxiety Scale) Experience of treatment in ICU (Intensive Care Experience Questionnaire) Psychological well-being (DASS-21: Depression, Anxiety, and Stress Scales-21 and PCL-S: Posttraumatic Stress Disorder Checklight-Specific) Self-reported quality of sleep (Insomnia Severity Index, Richards-Campbell Sleep Quesitonnaire, The Pittsburgh Sleep Quality Index)

Patient Demographics & Clinical Characteristics Out of 222 patients: 65% male (mean age: 57 y.o.) Severity of illness: Low Median duration of mechanical ventilation: 0.5 days Median ICU LOS: 3 days Pain intensity: Low (Mean: 2.5) Anxiety Level: Moderately High

Experience of Treatment in ICU 82.7% of the sample remembered their ICU stay 63.8% answered never to “I knew where I was” High frequency of memories evident for “bad dreams” (47% all of the time) and “seeing strange things” (53% all of the time) Only 10.8% felt in control all of the time

Results Symptoms of PTS reported by 1 in 7 (14%)  (Previous studies 13-27%) Depression and anxiety symptoms were demonstrated by 1 in 5 (20%) Note: *Demonstrated in a cohort with a relatively low severity of illness, short durations of mechanical ventilation and ICU length of stay  low level of exposure to critical illness process and treatments that may affect psychological well-being

Factors associated with PTS symptoms at 6 months after DC 1. Higher pain-intensity scores at enrollment 2. Poorer sleep quality at 6 months 3. Lower awareness of ICU 4. More recall of frightening experiences 5. Higher levels of depression, anxiety, & stress

Impact & Implications Continued attempts to maximize sleep quality and comfort are required & appear to be more important during recovery Patients should be provided with access to specialist follow-up and rehab services for psychological screening and treatment

Implications Cont’d Further pain management practices in ICU Assess anxiety regularly using the Faces Anxiety Scale

Implications Cont’d Need to assess, prevent, and treat delirium to reduce the likelihood of patients recalling frightening experiences in ICU* Intensive efforts to provide reassurance and repeating explanations about treatment* Enabling patients to communicate their fears when possible

Conclusion Continuing symptoms of PTS were evident in 14% of the cohort Clinically significant depression and anxiety were demonstrated in 20% of patients Sleep quality proved to be affected at 6 months after DC Screening for delirium is essential Psychological screening and follow-up during recovery would also be beneficial for many patients

References 1. Elliott, Rosalind, Sharon Mckinley, Mary Fien, and Doug Elliott. "Posttraumatic Stress Symptoms in Intensive Care Patients: An Exploration of Associated Factors." Rehabilitation Psychology 61.2 (2016): 141-50. Web.