Adrenal insufficiency: the link between low apolipoprotein A-I levels and poor outcome in the critically ill?

To the Editor: I commend the Society of Critical Care Medicine’s task force (1) for addressing an important issue: the use of restraining therapies in the intensive care unit. However, I am concerned that the proposed guidelines may promote the use of restraints as “protective devices” and, therefore, inadvertently produce the behaviors they are intended to prevent. In addition, several important publications of data-based evidence regarding the relative harms of restraining therapies were not included in the task force report. For example, Atkins et al. (2) conducted a retrospective case control study of 50 adult patients who had self-extubated and two matched controls who had not selfextubated. Use of physical restraints was identified as a primary risk factor for unplanned extubation (p .001). A second case control study identified that patients who self-extubated, including those who were not agitated, were more likely to have received benzodiazepines (p .05) (3). ICU survivors have recounted the physical restraint experience as stressful, uncomfortable, causing feelings of vulnerability, and a primary discomfort and worry (4). Moreover, animal models ( 400 studies) show significant harmful effects from physical restraint use on heart rate, cortisol levels, blood pressure, gastric mucosal integrity, immune system functioning, and short-term memory (5). The task force should be applauded for recommending studies to test the hypothesis that ICU staffing patterns affect the need for and use of restraining therapies. Expert critical care nurses tell me that physical restraint use would be greatly reduced if nurses could visualize and continuously “be with” high-risk patients. Studies of ICU staffing patterns and restraining therapies should be carefully designed to assure that the work process, location, and continuity of ICU caregivers is measured in addition to the nurse/patient ratio. It does not matter how many staff are assigned to a unit or shift if they are not observing and physically present with unrestrained high-risk patients. Importantly, studies that showed an increase in unplanned extubation when physical restraints were removed demonstrate that restraints cannot be removed without some alternative interventions to prevent unplanned extubation (or “treatment interference”). In addition to investigating the physiologic effects of physical restraint use and testing alternative interventions, research and practice improvements must focus on improving agitation-sedation assessment and treatment. Because randomized controlled trials may be impractical and in some cases ethically challenging, well-designed, carefully conducted case control and phase lag designs should be considered. I enthusiastically support the task force’s recommendation regarding the need for clinicians to maximize communication with nonspeaking, intubated patients. Unfortunately, wrist restraints prevent the use of nonvocal communication (hand gesture, writing, electronic augmentative communication devices) and restrict patients to yes/no response (head nods, eye blinks) or facial expressions. Behavioral control via physical restraint then becomes control of the content and process of patient communication.