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Being Fully Conscious

Breathing tube, bladder catheter, intravenous infusions: no one enjoys lying in an intensive care unit. But if it does come to that, strong sedatives appear to make the stay more bearable. Professor Dr. Hartmut Bürkle, Medical Director of the Department of Anesthesiology and Critical Care at the Medical Center - University of Freiburg, and Dr. Johannes Kalbhenn, explain why they nevertheless prefer to keep their intensive care patients fully conscious.

- Why would I as a patient want to consciously experience my stay in your intensive care unit?

The more alert you are, the less time you are with us, as a rule. You don't need to be ventilated as long, you have fewer bed sores, and the risk of serious complications such as pneumonia decreases. Still, you have to endure a lot of unpleasantness. Isn't that quite stressful?

Certainly. But long-term sedation with strong medication is no less stressful. Even a sedated patient wakes almost completely if he suffers from thirst, pain, or anxiety. Only he can't express those needs. Many sedated intensive care patients remember such moments, and a third of them have to struggle later with posttraumatic stress disorder (PTSD).

- And alert patients are less stressed?

The advantage that patients free of sedatives have is that they can express their wishes, and we can help them. If you are in pain, you will receive exactly the right painkillers. If you are afraid, you can talk to therapists or pastoralists and get anxiety-reducing drugs. To date, no cases of PTSD have been seen in fully conscious intensive care patients.

In addition, alert patients can actively contribute to their recovery. Even if they're attached to a breathing tube or require circulation-supporting medication, they can strengthen their pulmonary and circulatory function with early mobilization and physiotherapy.

- Since the beginning of 2013, you have largely renounced sedatives and are thus performing pioneering work in Germany. How difficult was the changeover?

The processes in the intensive care unit have changed completely. In the beginning there was often the fear that alert patients would mean more work. This is not necessarily the case. On the contrary, an alert patient can often quench his own thirst, use a painkiller pump, lie down, cover or uncover himself. However, workflows are less predictable. The nursing staff is particularly affected by this change. So it is only possible to realize a concept like this through teamwork.

We go to a great deal of effort to meet the needs of our patients. Massage, active physiotherapy with bed bicycles and vibrating boards, occupational therapy as well as psychological care and spiritual assistance, all help with the recovery.

- How are things now different for you personally as a result of the changeover?

Relations with the patients are much more intense. One of the most impressive examples for us all was a patient with acute respiratory distress. Although her life depended on a machine that oxygenated her blood outside the body, she celebrated her birthday with her daughter in our unit. She later thanked us for the high degree of autonomy she could experience in this extreme situation.

- And where are the boundaries for the alert intensive care unit?

Obviously, at cases whose clinical pictures can only be treated with seditives, as with traumatic brain injury. Yet low-sedation intensive care does not mean that everyone is a little sedated, but instead depending on need, most not at all and some even fully sedated.

- Professor Bürkle, you have participated in creating the guidelines for the German Society of Anaesthesiology and Intensive Care Medicine, which recommend less sedation in intensive care medicine. What motivates you to be this involved?

While working on the guidelines, we evaluated data from numerous studies and were able to disprove widespread errors. Thus, the sleep of sedated patients is less restful than believed, in fact the drugs actually hinder normal sleep phases. And elderly patients in particular, after deep sedation, suffer more frequently and severely from confusion, so-called delirium. Sedatives cannot mitigate these brain function disturbances, they only conceal them. Without sedation, the delirium becomes visible - and thus treatable. The more alert patients we care for, the more knowledge we acquire about optimal treatment of severely ill patients.