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Recollection (2004)

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Logistic regression analysis of determinants of recollection of discomfort confirmed that factual recollection was indeed an independent factor in predicting recollection of discomfort. The calculated OR was 1. This implies that the risk for recalling discomfort was 1.

Age also was a determinant of recollection of discomfort. The calculated OR was 0. This implies that the risk for recalling discomfort was lower by a factor of 0. The duration of intubation appeared not to be independently related to recollection of discomfort. Factual recollection appears to be inversely related to age. Analysis of the relationship between factual recollection score and age in the ICU group revealed that the correlation coefficient was Figure 1 Scatterplot of factual recollection by age in intensive care unit ICU patients and the reference group Control.

Finally, recollection of pain appeared to be related to age OR 0. This implies that younger patients reported more recollection of discomfort in the form of pain. The presence of an endotracheal tube, medical interventions, noise and experiences of hallucination were among the sources of discomfort most frequently reported. To our knowledge, this study is the first to evaluate the association between recollection of discomfort and intact factual recollection.

In the present study we found the degree of factual recollection to be an important determinant of discomfort, in the sense that more discomfort was reported by those with better factual recollection.

Each item of factual recollection that was scored correctly increased slightly the risk for recollection of discomfort. Factual recollection and recollection of discomfort therefore appeared to be related. In an ICU many factors contribute to impairment in memory: Jones and coworkers [ 10 ] described many causes of amnesia during severe illness, including large dosages of sedative medication and withdrawal syndromes.

Because levels of sedation strongly influence the function of memory, a weak point in our study is that no sedation score was recorded to enable us to evaluate the effects of sedatives on patient recollection.

It should also be noted that we did not look for objective signs of postdischarge psychological distress or examine their relationship to memories of stressful events, either real or perceived. We merely wished to improve our understanding of discomfort by taking into account the confounding role of memory. The presence of an endotracheal tube, medical activities, and noise and bustle were the sources of discomfort remembered most frequently Table 2.

This finding is comparable with those of other studies. The reason for discomfort relating to the endotracheal tube may be endotracheal suctioning. While intubated, patients are regularly suctioned via the endotracheal tube in order to maintain airway patency.

The strong mechanical stimuli resulting from endotracheal suctioning may explain why the endotracheal tube is remembered as a prominent source of discomfort. In a previous study [ 12 ], we investigated recollection of endotracheal suctioning with two methods of suctioning: In the case of routine endotracheal suctioning, a 49 cm suction catheter was passed into the lower airways.

With minimally invasive airway suctioning the suction catheter did not enter the lower airways and suctioning was limited to the endotracheal tube.

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Our findings show that discomfort resulting from the endotracheal tube and its handling can be reduced by changing the procedure. Hallucinations were another source of discomfort. In a more recent study, Ely and colleagues [ 13 ] found that Delirium was an important variable, contributing as an independent predictor to higher 6-month mortality and longer hospital stay. Clearly, the presence of delirium by this definition does not imply the presence of hallucinations.

The exact percentage of patients who recalled hallucinations was not stated in the report by Ely and coworkers.

In studies conducted by Puntillo [ 14 ] and Holland and coworkers [ 2 ], pain was reported as a source of discomfort as well. Differences in type of sedation and pain medication, number of patients, inclusion criteria and type of questionnaire used are possible explanations for the low recollection of pain in the present study as compared with previous ones.

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A standardized score to assess recollection in this type of patient was lacking at the time our study was performed. We developed a factual recollection questionnaire that may represent a reliable new tool for acquiring information regarding recollection of facts in post-ICU patients.

These findings are hardly surprising in view of the considerable differences between groups in severity of illness and consumption of hypnotics and sedatives. Further studies are needed to determine the validity and reliability of this instrument.

Jones and coworkers [ 15 ] have since proposed a similar tool Intensive Care Unit Memory tool , which has been validated in a number of settings [ 4 , 16 ].

Both good factual recollection and younger age increased the risk for discomfort. Factual recollection and age were inversely associated with each other, but this association was weak.

The association of increasing age with reduction in memory function is widely recognized [ 17 , 18 ]. Although factual recollection and recollection of discomfort appear to be related, increasing the level of sedation is not necessarily the best way to prevent discomfort. Not only will deep sedation lead to increased length of stay in the ICU and prolonged ventilator dependency [ 19 ] but it may also have an adverse effect on the rate of post-traumatic stress disorder experienced by patients after their discharge from the ICU [ 10 ].

It has been proposed by various authors that factual recollection helps to offset the emotional impact of delusional memories [ 10 , 19 ] and may actually help to avoid adverse psychological outcomes in this type of patient. The development of drugs that can eliminate the emotional impact of stressful events in the ICU, while preserving mental clarity and memory, might offer the best way to avoid long-term psychological distress. Meticulous treatment of delusional states will also contribute to this end.

The most frequent sources of discomfort cited were presence of an endotracheal tube, hallucinations and medical interventions. The median factual recollection score for ICU patients was significantly lower than the median factual recollection score for ward patients who had not been in an ICU environment. Younger patients were at greater risk for remembering pain as source of discomfort.

Patients with better factual recollection had greater recollection of discomfort. Factual recollection and age were inversely related, but this relationship was weak. Discomfort thus appears to be a serious problem for patients in an ICU environment. Its prevalence is probably underestimated because retrospective assessment of the degree of discomfort when the patient has been discharged from the ICU is seriously handicapped by global or partial amnesia, caused by critical illness, delusional states and the use of drugs.

However, the fact that discomfort is not always remembered does not imply that the patient has not suffered during his or her stay in the ICU.

Reduction in discomfort should remain a focus of attention for both researchers and clinicians caring for critically ill patients. Endotracheal tube, hallucinations and medical interventions were cited as sources of discomfort. Patients with a higher factual recollection have greater recollection of discomfort. Notes The author s declare that they have no competing interests. Incidence of recall, nightmare, and hallucination during analgosedation in intensive care.

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