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EDITORIAL
Physical restraint in the ICU: does it prevent
device removal? A critical appraisal
S. JAROSCH 1, C. LEHMANN
1Department of Anesthesia and Intensive Care Medicine, SANA Klinikum Lichtenberg, Berlin, Germany; 2Department
of Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, NS, Canada
P hysical restraint of different intensity has
become integral part of ICU patient’s re-
covery and weaning process after a certain peri-
od of ventilation under analgosedation.1, 2 And,
to be honest, we assume that this serious en-
croachment upon the personal freedom is nec-
essary and for the patient’s benefit. But what do
we really know about the frequency and kind
of restraint? On which scientific basis do we,
that we always claim to practice evidence based
medicine, apply a method that is far much
more invasive than inserting a respiratory tube
or giving any drug?
In the last decades, the character of rela-
tionship between physicians and pa­tients has
changed. While a long time doctors were re-
garded as having the natu­ral right to intrude in
the patient’s body and privacy, it became evi-
dent that both parties have to be equal partners
in a treatment contract.3, 4 Nowadays, informed
consent is the prerequisite for every medical
procedure.
However, informed consent requires an alert
patient who is able to anticipate the conse-
quences of agreement or disagreement in cer-
tain procedures.5
or other proprietary information of the Publisher.
In the ICU setting, physicians are faced with
two problems: Patients in the wean­ing pro-
cess have to be released from analgosedation.
In the same time, these pa­tients often aren’t
able to realize the need for certain procedures
like intravascu­lar catheters, feeding tubes or
Comment on p. 1086.
Vol. 81 - No. 10 MINERVA ANESTESIOLOGICA 1053
2
endotracheal tubes to maintain a necessary
and life-supporting treatment. Refusal of this
treatment or removal of essential de­vices would
threaten the healing process or even their
physical integrity or life.6, 7
In this issue of Minerva Anestesiologica, Per-
ren et al. studied the question: “Physical re-
straint in the ICU - does it prevent device re-
moval?”.8 Not surpris­ingly and consistent with
common experiences and in accordance with
other tri­als 9, 10 they found that physical re-
straint in the ICU is frequently used to “treat”
non-cooperative patients that are regarded to
be threatened by device removal. The authors
showed that at least for the less sedated and
therefore agitated patients a temporarily fixa-
tion can have a protective meaning. Although
the three included ICUs belong to the “simi-
lar cultural and professional back­ground”,8 in
their survey the frequency and kind of restraint
was variable. Taking this seriously means that
we have to think about how local and historical
derived habits influence our daily work in par-
ticular on fields that don’t provide hard facts as
evidence. We must accept that we have to ques-
tion methods and procedures that “were done
like this all the time.”
While the survey answers very important
questions, it raises other questions, too. The
authors only assessed the immediate effect and
possible benefit of re­straint, there remains the
question of long-term consequences of this
serious interference potentially causing even
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JAROSCH PHYSICAL RESTRAINT IN THE ICU
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
post-traumatic distress syndrome. We know
that ICU-patients suffer from this syndrome in
different degrees,11, 12 but we know little about
the reasons. Physical restraint may be one of
the causes and should be the target for further
studies.
Can we just accept the fact, that reduction in
the amount of sedative drugs is positively asso-
ciated with physical restraint? Or shouldn’t we
rather think about our practice of drug with-
drawal to prevent situations that make restraint
neces­sary? Since it seems that severe agitation
occurs more often following propofol sedation,
do we have to re-assess this practice? Maybe the
availability of newer drugs like the α2-agonist
dexmedetomidine 13 or short acting benzodi-
azepines like the now available i.v. lormetaze-
pam 14 will play a substantial role in the wean-
ing process and have to be assessed regarding
their potential to prevent patients from side-
effects of weaning.15
Perren et al. discuss their findings of a less
intensive restraint in the study ICUs in part as
a result of a lower patient to nurse ratio. For
everyone who is responsi­ble for ICU staffing,
this is an additional argument to demand a suf-
ficient number of well-trained nurses adapted
to the local patient population since no method
and no technical equipment can substitute the
presence of qualified and moti­vated nurses. As
we know about the association of understaffed
ICUs and the spread of infections, we should
assess this as a reason for delirium and agitation
with its consequences.16, 17
One last point to mention is that sometimes
we might be focused too much on the agitated
sub-population of the patients in the ICU. As
the survey indicates, the apparently calm and
quiet patients are those that are most endan-
gered by device removal and the potential con-
sequences because they easily escape from our
or other proprietary information of the Publisher.
attention. This leads to the area of yet insuffi-
cient diagnostic of delirium that includes the
detection of not only the easy to find hyper-
active delirium, but the maybe more severe
hypoactive delirium, too.18
We appreciate the work by Perren et al. since
it once again drives our focus to the very im-
portant period of the patient’s recovery in the
1054 MINERVA ANESTESIOLOGICA October 2015
ICU. The process of wean­ ing and recovery
deserves the same attention like the phase of
curative treat­ment of the underlying disease.
Actually, it is an essential part of it. The survey
contributes to the always-required reflections
about our daily work in the ICU and will hope-
fully initiate more research in this field.
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means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is

PHYSICAL RESTRAINT IN THE ICU JAROSCH

This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other

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Conflict of interest.—The author certifies that there is no conflict of interest with any financial organization regarding the material discussed
in the manuscript.
Received on December 1, 2014. - Accepted for publication on December 11, 2014. - Epub ahead of print on December 12, 2014.
Corresponding author: S. Jarosch, Department of Anesthesia and Intensive Care Medicine, SANA Klinikum Lichtenberg, Fanninger
Strasse 32, 10365 Berlin, Germany. E-mail: st.jarosch@berlin.de
or other proprietary information of the Publisher.

Vol. 81 - No. 10 MINERVA ANESTESIOLOGICA 1055