Treatment in intensive care can be stressful and memories of

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1 The Journal of TRAUMA Injury, Infection, and Critical Care Outcome After Injury: Memories, Health-Related Quality of Life, Anxiety, and Symtoms of Deression After Intensive Care Mona Ringdal, MSc, Kaety Plos, PhD, Dag Lundberg, PhD, Lotta Johansson, MSc, and Ingegerd Bergbom, PhD Background: To examine the relationshi between delusional memories from the Intensive Care Unit (ICU) stay, health related quality of life (HRQoL), anxiety, and symtoms of deression in atients with hysical trauma, 6 months to 18 months after their ICU stay. Methods: Multicenter study in five combined medical and surgical ICUs (n 239). A questionnaire comrising the Medical outcome Short Form 36, the Hosital Anxiety and Deression scale, and the Intensive Care Unit Memory tool was sent to the atients with trauma 6 months to 18 months after their discharge from the ICU. Clinical data were drawn from atient records in retrosect. A matched reference samle (n 159) was randomly drawn from the Swedish Short Form 36 norm database (n 8,930). Results: Patients with trauma had significantly lower HRQoL than the reference samle. One or more delusional memories such as hallucinations, nightmares, dreams, or sensations of eole trying to hurt them in the ICU were exerienced by 26%. These atients were significantly younger, had a longer ICU stay, relied more on mechanical ventilation, and had higher Injury Severity Score and Sequential Organ Failure Assessment scores. They also reorted a significantly oorer HRQoL and a higher robability of exeriencing anxiety (51% vs. 29%) and symtoms of deression (48% vs. 26%) comared with atients without such memories. Conclusions: Our results highlight the imortance of treating the delusional memories exerienced by ICU atients with a trauma diagnosis as a ostinjury factor with a otential to create anxiety and symtoms of deression and which may affect HRQoL after discharge. Key Words: Health-related quality of life, Critical care, Delusional memories, Trauma. J Trauma. 2009;66: Submitted for ublication October 29, Acceted for ublication May 30, Coyright 2009 by Liincott Williams & Wilkins From the Institute of Health and Care Sciences, The Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden. Suorted by the Cancer Traffic Injury Foundation. Address for rerints: Mona Ringdal, MSc, Institute of Health and Care Sciences, The Sahlgrenska Academy at Gothenburg University, Box 457, S Gothenburg, Sweden; mona.ringdal@fhs.gu.se. DOI: /TA.0b013e318181b8e3 Treatment in intensive care can be stressful and memories of dreams, hallucinations, nightmares, and aranoia or so called delusional memories are a well-known roblem. 1 3 These memories can be an early symtom of an intensive care unit (ICU) delirium, but may not be recognized. 4,5 Studies show that 21% to 75% of ICU atients recall delusional memories. 6 9 The cause of this troublesome henomenon are not clear but surgery in connection to the trauma, intravenous medication with roofol and oioids, high temerature, rolonged length of stay in ICU, and mechanical ventilation are factors that may contribute to the develoment of disturbed memories. 3 Desite of an increasing body of knowledge, little is known about ossible health consequences of these memories. Patients with hysical trauma sometimes have amnesia because of the injury and exerience roblems because of the fact that they have fragmentary memories of the ICU and those with delusional memories can have unexlained feelings of anic after the ICU discharge. 3 Patients with trauma are admitted to the ICU as a result of acute, often lifethreatening, injury. These atients are usually healthy before the trauma but their health related quality of life (HRQoL) often dros substantially after the trauma. 10,11 In contrast to the rest of the ICU atients who seem to recover to their re-icu HRQoL, 12 trauma atients do not follow this attern and robably have a reduced HRQoL for a much longer time. 13 Patients with trauma constitute about 12% of all ICU admissions in Sweden 14 and these atients often require extensive medical treatment and nursing care in the ICU. Preinjury factors such as age, 13,15 gender, 16 and reexisting disease 17 have been shown to have a significant imact on HRQoL. Also, the severity of injury 10 and the ostinjury hase, e.g., failure of vital organs, 18 mechanical ventilation, 19 and length of stay, 15,20 have an influence on the atients outcome and HRQoL after an ICU stay. Another roblem is symtoms of osttraumatic stress disorder which also may affect the HRQoL. 21 These symtoms may occur from sychological roblems after an ICU treatment. 22,23 However, little is known about the influence of delusional memories from the ICU eriod on HRQoL and sychological health. The aim of the study was to examine the relationshi between delusional memories from the ICU stay, HRQoL, anxiety, and symtoms of deression for atients with hysical trauma 6 months to 18 months after their ICU stay. PATIENTS AND METHODS Settings An exlorative multicenter study design was used. Five hositals in an area serving a oulation of 1,500,000 inhab Aril 2009

2 Outcome After Injury itants in Sweden articiated in the study; one university hosital, two county hositals, and two districts hositals. All the hositals have ICUs which treat emergency atients with trauma. The ICUs have between 4 and 14 beds for ICU atients in each ICU with two atients in every room, 50% to 60% of the staff members are ICU registered nurses, and one nurse is always at the bedside, thus atients are never left unattended. Nor are atients ever hysically restrained, and eole who are well-known to the atients, such as close family and friends, are free to visit them at any time. The trauma care is similar at the hositals in this region and atients are sometimes moving from one ICU in the county or district hositals to the ICU in the university hosital. 483 Patients with trauma 440 Included atients with trauma 344 Patients received questionnaire 4424 Admissions to five Intensive Care Units 1 Setember August Patients 18 yr 66 No rely 239 Final study grou 96 Excluded atients: 45 Non survivors 37 Unknown address 7 Suicide attemt 5 Intellectual imairment 2 Not resident in Sweden 39 Declined articiation 178 Patients without delusional memories 61 Patients with delusional memories Fig. 1. Inclusion and exclusion criteria, the final study grou and atients with and without delusional memories. Recruitment Strategy and Samle The articiating units were requested to identify atients who were over 18 and who had been admitted to the ICU for a consecutive eriod of 1 year because of trauma (Setember 2001 to August 2002). All atients were checked with the Swedish registrar s office. Exclusion criteria were trauma with attemted suicide, nonsurvivors, not resident in Sweden, intellectual imairment, and unknown address uon follow-u (Fig. 1). All identified atients who were eligible for the study received a letter inviting them to articiate. The letter was sent 6 months to 18 months after discharge from the ICU, and included information about the study and the need for informed consent. A self-administered questionnaire and a reaid addressed enveloe were enclosed. Nonresonders were telehoned after one written reminder. The study was aroved by the Ethics Committee at the Medical Faculty of the University. Data Collection Data were collected from two sources; one source consisting of a questionnaire answered by the atients and one from the atient records. The questionnaire included three instruments, namely the Intensive Care Unit Memory tool (ICUM tool), 24 the Medical Outcome Short Form 36 (SF-36), 25 and the Hosital Anxiety and Deression Scale (HAD). 26 The ICUM tool 24 is a self-administered test comrising 14 items. The questions concern the amount and tye of memories before, during, and after the ICU eriod. According to the instrument, atients have delusional memories if they exerience any hallucination, nightmare, dream, or sensation of eole trying to hurt them. Emotional memories exerienced by the atients were characterized by ain, anic, fear, feeling down, confused, or uncomfortable. Factual memories were ward rounds, suctioning, breathing tube, lights, alarms, darkness, clock, tube in your nose, faces, voices, and family. 24 The instrument has been rimarily tested and validated on ICU atients in England and Italy. 8,24 Cronbach s alha was 0.86 for the full instrument 24 and the delusional memories aeared to be the most ersistent variable over time with a kaa value It has been translated into Swedish and then translated back into English and validated with good agreement between instrument and interview in cross grous in a Swedish ilot study. 27 As an outcome measure for HRQoL, the Swedish version of the SF-36 health survey questionnaire 28 was emloyed. The 36 items form a quality of life instrument which is widely used and it is scored based on eight domains, each with a range of values from 0 to 100 (100 is otimal). It is a generic tool recommended for assessing the HRQoL exerienced by trauma survivors. 29 For the resent study, an age and gendermatched reference samle (n 159) was randomly drawn from the Swedish SF-36 norm database (n 8,930) (Health Care Research Unit, Sahlgrenska University Hosital, Gothenburg, Sweden) and comared with the scores from the study trauma grou. The HAD scale 26 was emloyed to measure sychological outcome. This instrument hels showing anxiety and symtoms of deression for atients without sychiatric disorders and it has 14 items dealing with sychological health, 7 with anxiety (HAD-A), and 7 with symtoms of deression (HAD-D). The score ranges between 1 and 21, and scores 8 indicate robable or definite anxiety or symtoms of deression. The validity of the HAD scale was found to be satisfactory for assessing the severity of anxiety and symtoms of deression in somatic care atients. Cronbach s alha for the HAD-A was 0.83 and for the HAD-D When evaluated on a Swedish oulation, the Swedish version of the HAD seems to be bidimensional as is in the original instrument. 31 Patients also stated their age, gender, and home circumstances in the questionnaire. Volume 66 Number

3 The Journal of TRAUMA Injury, Infection, and Critical Care Clinical data were drawn in retrosect from atient records and it comrised ICU stay in days, reexisting disease, mechanism of injury, and the general severity of illness described with the Acute Physiological, and Chronic Health Evaluation (APACHE II). 32 Severity of injury was measured with the Injury Severity Score (ISS) which is an anatomic descrition of injury. 33 It is a score from 0 to 75 where 75 is lethal, and a score above 15 indicates severe trauma. ISS was calculated in retrosect by one of the authors (MR) in cooeration with a trauma nurse coordinator. Head injury was examined with a comuted tomograhy scan of the head showing intracranial hemorrhage uon arrival at the hosital. Number of days of mechanical ventilation and descrition of the usual regimes for analgesia and sedation were also recorded. Failure of vital organs were measured by the Sequential Organ Failure Assessment Score (SOFA score). 34 Six different organ systems were evaluated: resiratory (PaO 2 / FIO 2 ), cardiovascular (blood ressure, vasoactive drugs), renal (creatinine, urine outut), heatic (bilirubin), neurologic (Glasgow Coma Score), and hematologic (latelet count). The maximum score for each system was assessed in retrosect from medical records on one occasion by one of the authors (MR) and the total SOFA score was defined as the highest total score recorded during the ICU stay. Statistical Methods The statistical analysis was erformed using the Statistical Package for the Social Sciences version 12.0 (SPSS, Chicago, IL). Descritive statistics on injury mechanism and memories were used to illustrate the results. Fisher s exact test was used for categorical data and the Student s t test for continuous data when comaring grous. Pitman s test 35 was used for the correlation between on one hand the eight domains of the SF-36 and HAD and on the other hand gender, delusional memories, head injury, mechanical ventilation, reexisting disease, age, ICU-stay in days, ISS, APACHE II, and total SOFA score. For the multivariate analysis with all significant correlations from Pitman s test, forward multile linear regression analysis was used for SF-36 and forward logistic regression for HAD. Indeendent variables were delusional memories, head injury, mechanical ventilation, reexisting disease, age, ICUstay in days, ISS, APACHE II and total SOFA score and deendent variables were HRQoL with the eight domains of SF-36 and HAD. Statistical significance was defined as a value 0.05 in all analyses. 36 RESULTS Eleven ercent of all the 4,424 atients in the five ICUs were atients with the diagnose of trauma. The final grou of this study consisted of 239 atients (Fig. 1), which constituted 70% of the total grou of eligible atients. The only significant difference in available data between articiants and nonresonders was that the latter had a shorter ICU stay (Table 1). Table 1 Demograhic Data of ICU Admitted Trauma Patients in the Study and the No Resonder Patient Included, n 239 No Resonder, n 105 Male 178 (75%) 88 (84%) Mechanical ventilation 60 (25%) 18 (17%) Age LoS (ICU d) Fisher s exact test, Student s t test, Continuous data are resented as mean SD and categorical data as n (%). APACHE, Acute Physiological and Chronic Health Evaluation; ISS, injury severity score; LoS, length of stay; SOFA, sequential organ failure assessment. More than half of the atients had been in traffic injuries. The second largest grou consisted of injuries because of a fall, the majority was male, and 32% lived alone. The mean ISS was 10.8 and 38.5% had ISS 9, 33% had ISS 9, and 28.5% had ISS 15. Ninety of the atients (38%) had surgery. Sixty atients had been on mechanical ventilation. Of these, 28% were mechanically ventilated for 1 day, 52% for 2 days to 6 days, and 20% for 7 or more days. Of the 78 atients with reexisting diseases 6 were related to sychiatric history, and 72 to somatic history. The mean age was 44.7 year (range, 19 87) (Table 2). Sedation routines for atients on mechanical ventilation consisted of continuous intravenous infusion of roofol, on average 2,000 mg/d and 45% of the atients received benzodiazeines. Muscle relaxants or hysical restraints were never used. Oioids were used as ain treatment for all atients. Table 2 Demograhic and Clinical Data of the Study Grou n 239 Mechanism of injury Traffic injuries 133 (55%) Fall injuries 46 (19%) Recreational injuries 19 (8%) Intentional injuries 16 (7%) Occuational injuries 16 (7%) Other 9 (4%) Male 178 (75%) Delusional memories 61 (26%) Head injury 60 (25%) Mechanical ventilation 60 (25%) Preexisting disease 78 (33%) Age (yrs) LoS (ICU d) ISS APACHE II Total SOFA score Continuous data are resented as mean SD and categorical data as n (%). APACHE, Acute Physiological and Chronic Health Evaluation; ISS, injury severity score; LoS, length of stay; SOFA, sequential organ failure assessment Aril 2009

4 Outcome After Injury Patients Memories Twenty-six ercent of all the atients described delusional memories from the ICU, such as hallucinations, nightmares, dreams, or sensations of eole trying to hurt them. With the excetion of 6 atients with emotional and delusional memories, all the other 55 atients had delusional and factual memories of, for examle, a family visit. Patients with delusional memories were significantly younger, had a longer ICU stay, were more often on mechanical ventilation, had higher ISS and SOFA scores, than those without such memories. Three of the atients who had delusional memories also had reexisting diseases related to sychiatric history (Table 3). Patients with delusional memories received significantly more roofol/d than atients without such memories (919 mg/d vs. 319 mg/d, 0.003). Seventy-four ercent of the Table 3 Differences Between Patients With and Without Delusional Memories Delusional Memories, n 61 No Delusional Memories, n 178 Male 48 (79%) 130 (73%) Head injury 18 (30%) 42 (24%) Mechanical ventilation 26 (43%) 34 (19%) Preexisting disease 23 (38%) 55 (31%) Psychiatric history 3 (5%) 3 (2%) 0.302a Age (yrs) LoS (ICU d) ISS APACHE II Total SOFA score Fisher s exact test, Students t test, a 2 Continuous data are resented as mean SD and categorical data as n (%). APACHE, Acute Physiological and Chronic Health Evaluation; ISS, injury severity score; LoS, length of stay; SOFA, sequential organ failure assessment. atients had no delusional memories, of these a minority, 27 atients, had exerienced amnesia related to their time in the ICU. Factual or emotional memories or both were exerienced by all other atients. Of the 60 atients on mechanical ventilation, 43% described delusional memories comared with 19% of the atients without mechanical ventilation. Fifty-six ercent of the atients reorted that they had discussed their ICU stay with their family, 8% had talked to hysicians or nurses, 14% had soken to both family and hosital staff, whereas 22% had not talked about their ICU stay at all. Reference Samle When comaring the atients with trauma with a healthy grou matched for age and gender, the atients with trauma scored significantly lower in all eight SF-36 domains ( 0.001). Patients with delusional memories scored even lower (Fig. 2). HRQoL Patients with delusional memories and atients with reexisting diseases had significant correlation with all eight domains of SF-36. Higher age, longer ICU-stay, higher ISS, APACHE II, and total SOFA score had significant correlation with the lower hysical functioning and lower role hysical domains. Patients on mechanical ventilation had significant correlation with five domains: hysical functioning, role hysical, vitality, social functioning, and mental health. Moreover, atients with head injury had a significant correlation with the mental health and social functioning domains (Table 4). The second ste was to comare all significant variables from the univariate analysis in a multivariate analysis. Patients with delusional memories had a significantly lower Reference samle from norm oulation n=159 No delusional memories n=178 Delusional memories n= PF RP BP GH VT SF RE MH Fig. 2. Health related quality of life in reference grou and atients with and without delusional memories. PF, hysical function; RP, role limitations due to hysical function; BP, bodily ain; GH, general health; VT, vitality; SF, social function; RE, role limitations due to emotional roblems; MH, mental health. Volume 66 Number

5 The Journal of TRAUMA Injury, Infection, and Critical Care Table 4 Univariate Analysis With Correlation Between Different s and Health Related Quality of Life, Anxiety, and Symtom of Deression Physical Function, Role Physical, Bodily Pain, General Health, Vitality Social Function, Role Emotional, Mental Health, Gender Delusional memories Head injury Mechanical ventilation Preexisting disease Age LoS (ICU) ISS APACHE II Total SOFA score Pitmans test. APACHE, Acute Physiological and Chronic Health Evaluation; HADA, Hosital anxiety and deression scale anxiety; HADD, Hosital anxiety and deression scale deression; ISS, injury severity score; LoS, length of stay; SOFA, sequential organ failure assessment. HADA, HADD, score in all eight domains of HRQoL. If atients exerienced delusional memories they scored 14 to 24 units below in all domains comared with those who did not have these exeriences. If atients had reexisting diseases they also had significantly lower scores, 8 to 18 units below in all domains. APACHE II had an influence on hysical function, and if APACHE II increased by one unit, hysical function decreased by 1.3 units. The total SOFA score had an influence on role because of hysical function; if the total SOFA score increased by one unit, role because of hysical function decreased by 2.7 units. Head injury had an effect on social function and mental health with 8 to 9 units below (Table 5). This influence from the variables on HRQoL was indeendent of each other. Anxiety and Symtoms of Deression Of all the trauma atients, 39% exerienced anxiety (Hosital anxiety and deression scale anxiety 8) and 31% had symtoms of deression (Hosital anxiety and deression scale deression 8). The univariate analysis showed a significant correlation between delusional memories and both anxiety ( ) and symtoms of deression ( ). Moreover, atients with head injury had a significant correlation with anxiety ( 0.017). In the second ste with a multivariate analysis, atients with delusional memories (OR: 2.5, CI: 1.4, 4.7, ) and those with head injury (OR: 2.1, CI: 1.1, 3.6, 0.017) still had a significant correlation with anxiety. The robability of atients exeriencing anxiety when having had delusional memories was 51% and with delusional memories and head injury it was 69%. Without these memories and head injury the robability for anxiety was 29%. Patients with delusional memories also had significant correlation with symtoms of deression (OR: 2.7, CI: 1.5, 5.0, ). The robability of symtoms of deression when atients had delusional memories was 48% and without these memories it was 26%. The number of delusional memories (1 to 4) had no imact on the atients anxiety or symtoms of deression. Patients (22%) who had not talked to anybody about their ICU exeriences had significantly more symtoms of deression than those who had discussed this toic with someone (52% vs. 26%, 0.001). DISCUSSION Our results highlight the imortance of recognizing delusional memories as a ostinjury factor that may create otential anxiety, symtoms of deression and affecting HRQoL after discharge from the ICU. In this study, a rather small art of the atients exerienced delusional memories comared with other studies. 6 9 This can be because of the fact that in the resent study not all atients were on mechanical ventilation whereas in most studies only atients on mechanical ventilation were included. When comaring only the mechanically ventilated atients in our study to other studies the figures are more comarable. 7 8 The level of anxiety and symtoms of deression in atients with delusional memories was rather high. The robability of exeriencing the described anxiety or symtoms of deression was 51% and 48% resectively, which indicates that these atients did not enjoy good sychological health. Some exlanations for this could be; first, these atients were assessed as having more severe injuries, more vital organ failure lus being on mechanical ventilation, thus they may have feared that they would not recover; second, they may have had sychological roblems before the trauma, even if no sychiatric history was detected in the records; third, their anxiety and symtoms of deression may have been exacerbated as a result of the delusional memories. Other studies also show a high level of sychological disabilities after trauma 13,37 and for ICU atients in general. 6,22,38 Furthermore, head injury was associated with a higher level of anxiety, head injury has been reorted as an imortant risk factor for develoing sychological distress Aril 2009

6 Outcome After Injury Table 5 Multivariate Regression Analysis With Significant s From the Univariate Analysis and Health Related Quality of Life Physical Function Role Physical Bodily Pain General Health B CI R 2 B CI R 2 B CI R 2 B CI R 2 Delusional memories , , , , Head injury Mechanical ventilation NS NS Preexisting disease , , , , Age NS NS LoS (ICU) NS NS ISS NS NS APACHE II , NS Total SOFA NS , Constant Vitality Social Function Role Emotional Mental Health B CI R 2 B CI R 2 B CI R 2 B CI R 2 Delusional memories , , , , Head injury , , Mechanical ventilation NS NS NS Preexisting disease , , , , Age LoS (ICU) ISS APACHE II NS NS Total SOFA Constant Multile linear regression, CI 95% confidence interval. NS, non significant The variable has a significant imortance univariate, but in a multivariate model it has no significant imortance beyond the other variables; APACHE, Acute Physiological and Chronic Health Evaluation; B, unstandardized coefficient; ISS, injury severity score; LOS, length of stay; R 2, the variance in the deendent variables which is exlained by all the significant indeendent variables; SOFA, sequential organ failure assessment. Volume 66 Number

7 The Journal of TRAUMA Injury, Infection, and Critical Care In comarison to a norm oulation we found, as anticiated, that atients with trauma had a lower HRQoL after discharge from the ICU. However, we also found that the HRQoL of atients with delusional memories was even lower. The question is if this difference among atients with trauma and delusional memories from their ICU stay is ermanent or if it may disaear after the first 2 years after the trauma? The minority of atients, those who did not talk about their exeriences with anyone, reorted more symtoms of deression. Patients with deression do not always have the strength to talk about their exeriences. Our result shows that atients who seak with someone about their memories of critical illness had fewer deressive symtoms after the trauma. For atients well-being it is desirable if nurses and hysicians could give some time and sace for existential conversations about the critical illness while the atient is still in the hosital. It is also essential to stress the need to inform relatives and atients about the imortance of exressing memories and exeriences from the ICU stay with each other and robably also for nurses to give atients social suort and rovide caring conversations about their exeriences during and after the ICU stay. 40 Patients exeriencing anxiety and symtoms of deression should be offered some follow-u from the hosital, as has been mentioned earlier. 13,41 Diaries and hoto diaries from the ICU have been shown to hel atients deal with their exeriences. 42 At first, the HRQoL seemed to be affected by several of the variables, esecially the hysical functioning and role limitation because of hysical incaacity, findings which were similar to those of other studies. 13,43 Patients with head injuries had lower scores in two HRQoL domains; social functioning and mental health. This was in accordance with earlier findings which had shown that severe head injury could be a redictor of oor HRQoL in such atients. 37,43 In the multivariate analysis delusional memories and reexisting disease were the only variables that significantly affected all SF-36 domains indeendently of each other. The effect of reexisting diseases on HRQoL is in accordance with Orwelius et al., 17 but in her study only a small grou consisted of atients with trauma. One study of general ICU atients has shown that dreams and nightmares during the ICU stay may disturb the atients everyday life, thus leading to a lower HRQoL. 44 In our study the delusional memories imair not only the HRQoL in all domains but also cause hysiologic distress in terms of anxiety and symtoms of deression. Often general health and overall satisfaction with recovery are deendent on sychological health outcome. 37,39 Although revious studies have revealed that women are at greater risk of oor sychological outcome after trauma, 16,45 no such gender difference was observed in the resent study. Methodical Consideration Some limitations have to be considered. First, the data were collected on a single occasion after discharge and we have a droout rate of 30%. Certainly, a dro-out rate of 30%, as in this study, can be accetable, 46 but it nevertheless adds some uncertainty to the findings. Second, the assessment of delusional memories by means of the ICUM Tool has some limitations, as it is a rather new instrument and there may therefore be some difficulties in the interretation of the data. The questionnaire in the resent study was self-administered. This may constitute a weakness, because of the fact that some atients may have misunderstood the questions. On the other hand, there can be no bias introduced by an interviewer. The retrosective art of the study based on the atients recall of their memories from the trauma and the ICU stay by means of the ICUM tool might add some uncertainly. However, atients often remember these memories for a long time. 2 Third, the gender and age matched reference grou which was randomly drawn from the norm database only constituted 159 ersons because of the fact that 2 older male atients ( 85 year) in our study were difficult to match in the norm database. Hence, the minimum ratio was three atients to two referents (0.667). This ratio was then used to determine the number of atients to draw in the other sex-age categories. Fourth, only a small art of the atients was seriously injured with ISS 15. However, our intention was to involve all atients who arrive to the ICU with a diagnosis of trauma. We think that also atients with smaller traumas and relatively low ISS scores may have these delusional memories. At last the study has mainly the character of an exlorative study of this reason no ower analysis is included but in future studies it would be a strength to include that. Desite these weaknesses, this study addresses some imortant outcome issues in a atient oulation difficult to take care of. We hoe that follow-u visits taking lace at the ICU and including caring conversations about memories and exeriences from the ICU stay, will be routinely arranged for survivors and their relatives after trauma. CONCLUSION Patients with trauma are a rather small subgrou (11%) of all ICU atients and only a small art are heavily injured (ISS %) but for all traumatized atients the trauma itself is an alarming event and the ICU stay may also affect them. One of four atients with trauma exerienced delusional memories in the ICU and these atients had a significantly lower HRQoL and a higher level of anxiety and symtoms of deression 6 month to 18 month after the ICU stay comared with atients without these memories. Patients who had not talked to anyone about their ICU stay had more symtoms of deression. ACKNOWLEDGMENTS We thank Professor Anders Odén and Helena Johansson for statistical consultation. REFERENCES 1. Mendelson JH, Foley JM. An abnormality of mental function affecting atients with oliomyelitis in a tank-tye resirator. Trans Am Neurol Assoc. 1956; ; 81st Meeting Aril 2009

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