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Bose S, Groat D, Dinglas VD, Akhlaghi N, Banner-Goodspeed V, Beesley SJ, Greene T, Hopkins RO, Mir-Kasimov M, Sevin CM, Turnbull AE, Jackson JC, Needham DM, Brown SM. Association Between Unmet Nonmedication Needs After Hospital Discharge and Readmission or Death Among Acute Respiratory Failure Survivors: A Multicenter Prospective Cohort Study. Crit Care Med 2023; 51:212-221. [PMID: 36661449 DOI: 10.1097/ccm.0000000000005709] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To characterize early unmet nonmedication discharge needs (UDNs), classified as durable medical equipment (DME), home health services (HHS), and follow-up medical appointments (FUAs) and explore their association with 90-day readmission and mortality among survivors of acute respiratory failure (ARF) who were discharged home. DESIGN Prospective multicenter cohort study. SETTING Six academic medical centers across United States. PARTICIPANTS Adult survivors of ARF who required an ICU stay and were discharged home from hospital. INTERVENTIONS None. Exposure of interest was the proportion of UDN for the following categories: DME, HHS, and FUA ascertained within 7-28 days after hospital discharge. MEASUREMENTS AND MAIN RESULTS Two hundred eligible patients were recruited between January 2019 and August 2020. One-hundred ninety-five patients were included in the analytic cohort: 118 were prescribed DME, 134 were prescribed HHS, and 189 needed at least one FUA according to discharge plans. 98.4% (192/195) had at least one identified nonmedication need at hospital discharge. Median (interquartile range) proportion of unmet needs across three categories were 0 (0-15%) for DME, 0 (0-50%) for HHS, and 0 (0-25%) for FUA, and overall was 0 (0-20%). Fifty-six patients (29%) had 90-day death or readmission. After adjusting for prespecified covariates, having greater than the median level of unmet needs was not associated with an increased risk of readmission or death within 90 days of discharge (risk ratio, 0.89; 0.51-1.57; p = 0.690). Age, hospital length of stay, Acute Physiology and Chronic Health Evaluation II severity of illness score, and Multidimensional Scale Perceived Social Support score were associated with UDN. CONCLUSIONS UDN were common among survivors of ARF but not significantly associated a composite outcome of 90-day readmission or death. Our results highlight the substantial magnitude of UDN and identifies areas especially vulnerable to lapses in healthcare coordination.
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Affiliation(s)
- Somnath Bose
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
- Center for Anesthesia Research Excellence, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Danielle Groat
- Department of Critical Care, Intermountain Medical Center, Salt Lake City, UT
- Center for Humanizing Critical Care, Intermountain Medical Center, Salt Lake City, UT
| | - Victor D Dinglas
- Outcomes After Critical Illness and Surgery (OACIS) Group, and Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Narjes Akhlaghi
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Valerie Banner-Goodspeed
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
- Center for Anesthesia Research Excellence, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Sarah J Beesley
- Department of Critical Care, Intermountain Medical Center, Salt Lake City, UT
- Center for Humanizing Critical Care, Intermountain Medical Center, Salt Lake City, UT
- Division of Pulmonary Medicine, University of Utah, Salt Lake City, UT
| | - Tom Greene
- Department of Biostatistics and Epidemiology, University of Utah, Salt Lake City, UT
| | - Ramona O Hopkins
- Center for Humanizing Critical Care, Intermountain Medical Center, Salt Lake City, UT
- Psychology Department and Neuroscience Center, Brigham Young University, Provo, UT
| | - Mustafa Mir-Kasimov
- Division of Pulmonary Medicine, University of Utah, Salt Lake City, UT
- Section of Pulmonary and Critical Care Medicine, George E Wahlen VA Medical Center, Salt Lake City, UT
| | - Carla M Sevin
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Alison E Turnbull
- Outcomes After Critical Illness and Surgery (OACIS) Group, and Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - James C Jackson
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Dale M Needham
- Outcomes After Critical Illness and Surgery (OACIS) Group, and Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Samuel M Brown
- Department of Critical Care, Intermountain Medical Center, Salt Lake City, UT
- Center for Humanizing Critical Care, Intermountain Medical Center, Salt Lake City, UT
- Division of Pulmonary Medicine, University of Utah, Salt Lake City, UT
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Sayde GE, Stefanescu A, Hammer R. Interdisciplinary Treatment for Survivors of Critical Illness in the Era of COVID-19: Expanding the Post-Intensive Care Recovery Model and Impact on Psychiatric Outcomes. J Acad Consult Liaison Psychiatry 2023; 64:226-235. [PMID: 36720311 PMCID: PMC9884613 DOI: 10.1016/j.jaclp.2023.01.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 01/12/2023] [Accepted: 01/19/2023] [Indexed: 01/31/2023]
Abstract
BACKGROUND Post-intensive care unit recovery programs for survivors of critical illness related to COVID-19 remain limited, ever-evolving, and under active investigation. Mental health professionals have an emerging role within this multidisciplinary care model. OBJECTIVE This article explores the design and implementation of an intensive care unit follow-up clinic in New Orleans during the era of COVID-19. Survivors of a critical illness due to COVID-19 were offered multidisciplinary outpatient treatment and systematic psychological screening up to 6 months after the initial clinic visit. METHODS We implemented a prospective, observational study at a post-intensive care syndrome (PICS) clinic for survivors of a critical illness related to COVID-19 embedded within an academic Veterans Affairs hospital. Our team identified patients at high risk of PICS and offered them a clinic consultation. Patients were provided the following interventions: review of the critical care course, medication reconciliation, primary care, psychopharmacotherapy, psychotherapy, and subspecialty referrals. Patients were followed up at 1- to 3-month intervals. Psychological symptom screening was conducted with Posttraumatic Stress Disorder Checklist for the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition, 9-question Patient Health Questionnaire, and 7-item Generalized Anxiety Disorder assessments. RESULTS Seventy-seven total patients were identified to be at high risk of PICS from March to November 2020, and of this cohort, 44 (57.14%) survived their COVID-19 hospitalizations. Of the surviving 44 patients contacted, 21 patients established care in the PICS clinic and returned for at least 1 follow-up visit. At initial evaluation, 66.7% of patients demonstrated clinically meaningful symptoms of post-traumatic stress disorder. At 3-month follow-up, 9.5% of patients showed significant post-traumatic stress disorder symptoms. Moderate-to-severe symptoms of anxiety were present in 38.1% of patients at initial evaluation and in 4.8% of patients at 3 months. Moderate-to-severe symptoms of depression were present in 33.4% and 4.8% of patients at initial visit and at 3 months, respectively. CONCLUSIONS A PICS clinic opened by dually trained internist-psychiatrists serves as a successful posthospitalization model of care for COVID-19 intensive care unit survivors. This type of health care infrastructure expands the continuum of care for patients enduring the consequences of a critical illness. We identified a high prevalence of post-traumatic stress, anxiety, and depression, along with other post- intensive care unit complications warranting an intervention. The prevalence of distressing psychological symptoms diminished across all domains by 3 months. Our results deserve replication, along with further investigation of the value that PICS clinics can provide for patients and families.
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Affiliation(s)
- George E. Sayde
- Department of Internal Medicine and Psychiatry, Tulane University School of Medicine, New Orleans, LA,Send correspondence and reprint requests to George E. Sayde, MD, MPH, Department of Internal Medicine and Psychiatry, Tulane University School of Medicine, 1440 Canal Street, Suite 1000, New Orleans, LA 70112
| | | | - Rachel Hammer
- Department of Internal Medicine and Psychiatry, Tulane University School of Medicine, New Orleans, LA
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Best A, Harvey C, Minton C. A protocol for exploring patients' and support peoples' experiences after prolonged critical illness. Nurs Crit Care 2023. [PMID: 36626896 DOI: 10.1111/nicc.12872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 11/29/2022] [Accepted: 12/05/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Improved survival of critically ill people has increased the number of patients who experience an extended stay in intensive care units (ICU). Evidence suggests the complexities, vulnerabilities, and traumas created by critical illness are substantial for both patients and their support people with a number experiencing devastating impairments across multiple domains of health and function including physical, mental, cognitive, and social health. However, research on survivors predominantly focuses on those who have experienced a relatively short length of stay; only a limited number of studies seek to explore the experiences of survivors and their support people who have had a prolonged stay in intensive care. AIMS AND OBJECTIVES To describe the experiences of survivors of prolonged critical illness (invasively mechanically ventilated in ICU for ≥eight days) and their support people during the first 12 months following hospital discharge in New Zealand. DESIGN This research will be a multi-centre study recruiting from three intensive care units in New Zealand. A narrative inquiry methodology will be used to interview 6-8 former long stay patients and 6-8 support people of a former long stay patient. Each participant will be interviewed at 3-, 6-, 9-, and 12-months following hospital discharge. METHODS Data will be collected via narrative inquiry interviews. Data analysis will combine two theoretical frameworks: the Clandinin and Connelly narrative inquiry three-dimensional space and the Fairclough situation, discourse and context framework. RESULTS The phenomenon of investigation will be experiences after prolonged critical illness explored longitudinally across the first-year post-hospital discharge. RELEVANCE TO CLINICAL PRACTICE This protocol provides a methodological framework for exploring the lived experiences of survivors of prolonged critical illness and their support people. Data analysis will support understanding of the human journey of ICU survivorship and add to the body of knowledge on how to support post-ICU recovery in this population. The barriers and enablers of survivorship at the micro, meso, and macro levels of the health service will also be illuminated.
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Affiliation(s)
- Amy Best
- School of Nursing, Massey University, Wellington, New Zealand.,Intensive Care Unit, Wellington Regional Hospital, Capital Coast Health, Wellington, New Zealand
| | - Clare Harvey
- Deputy Head of School, School of Nursing, Massey University, Wellington, New Zealand
| | - Claire Minton
- School of Nursing, Massey University, Palmerston North, New Zealand
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Saqib M, Iftikhar M, Neha F, Karishma F, Mumtaz H. Artificial intelligence in critical illness and its impact on patient care: a comprehensive review. Front Med (Lausanne) 2023; 10:1176192. [PMID: 37153088 PMCID: PMC10158493 DOI: 10.3389/fmed.2023.1176192] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 04/04/2023] [Indexed: 05/09/2023] Open
Abstract
Artificial intelligence (AI) has great potential to improve the field of critical care and enhance patient outcomes. This paper provides an overview of current and future applications of AI in critical illness and its impact on patient care, including its use in perceiving disease, predicting changes in pathological processes, and assisting in clinical decision-making. To achieve this, it is important to ensure that the reasoning behind AI-generated recommendations is comprehensible and transparent and that AI systems are designed to be reliable and robust in the care of critically ill patients. These challenges must be addressed through research and the development of quality control measures to ensure that AI is used in a safe and effective manner. In conclusion, this paper highlights the numerous opportunities and potential applications of AI in critical care and provides guidance for future research and development in this field. By enabling the perception of disease, predicting changes in pathological processes, and assisting in the resolution of clinical decisions, AI has the potential to revolutionize patient care for critically ill patients and improve the efficiency of health systems.
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Affiliation(s)
- Muhammad Saqib
- Khyber Medical College, Peshawar, Khyber Pakhtunkhwa, Pakistan
| | | | - Fnu Neha
- Ghulam Muhammad Mahar Medical College, Sukkur, Sindh, Pakistan
| | - Fnu Karishma
- Jinnah Sindh Medical University, Karachi, Sindh, Pakistan
| | - Hassan Mumtaz
- Health Services Academy, Islamabad, Pakistan
- *Correspondence: Hassan Mumtaz,
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Bach C, Hetland B. A Step Forward for Intensive Care Unit Patients: Early Mobility Interventions and Associated Outcome Measures. Crit Care Nurse 2022; 42:13-24. [DOI: 10.4037/ccn2022459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Background
Critical illness survivors have impairments across physical, psychological, and cognitive health domains known as post–intensive care syndrome. Although physical activity can improve outcomes across all health domains, most intensive care unit early mobility studies focus solely on physical outcomes.
Objective
To explore the role of early mobility for adult patients in the intensive care unit by analyzing early mobility intervention studies with physical, psychological, or cognitive outcome measures.
Methods
This integrative review used Whittemore and Knafl’s methodology and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. CINAHL, Embase, PubMed, PsycINFO, and Scopus databases were searched for primary research articles published from 2005 through 2021 on adult intensive care unit early mobility interventions evaluated by physical, cognitive, or psychological outcome measures during or after intervention delivery. Interventions comprising only passive mobility were excluded.
Results
Of 1009 articles screened, 20 were included. Variations in outcome measures, measurement timing, instruments, and control groups made synthesis difficult. No study evaluated an intervention using outcome measures from all 3 health domains. Five studies measured physical and cognitive outcomes; 6 studies measured physical and psychological outcomes.
Conclusion
Early mobility is primarily addressed objectively and unidimensionally, limiting understanding of the implications of early mobility for patients. Post–intensive care syndrome prevention begins in the intensive care unit; early mobility is a promising intervention for targeting multiple risk factors. Studies that measure outcomes in all health domains during or after early mobility are needed to better evaluate the comprehensive effects of early mobility.
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Affiliation(s)
- Christina Bach
- Christina Bach is a PhD student and research assistant at the University of Nebraska Medical Center College of Nursing and a staff nurse and relief lead in the oncology intensive care unit at Nebraska Medicine in Omaha, Nebraska
| | - Breanna Hetland
- Breanna Hetland is an assistant professor at the University of Nebraska Medical Center College of Nursing and a critical nurse scientist at Nebraska Medicine in Omaha
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Clinical Decision-Making in Practice with New Critical Care Ultrasound Methods for Assessing Respiratory Function and Haemodynamics in Critically Ill Patients. Clin Pract 2022; 12:986-1000. [PMID: 36547110 PMCID: PMC9776659 DOI: 10.3390/clinpract12060102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 11/16/2022] [Accepted: 11/17/2022] [Indexed: 11/26/2022] Open
Abstract
Situations often arise in intensive care units (ICUs) for which only sparse primary evidence or guidelines are applicable or to which existing evidence cannot be applied owing to interactions of multiple disease states. To improve and guide intensive care management in complex scenarios, ultrasonography and echocardiography are invaluable. In five clinical scenarios involving acute deterioration, serial ultrasound examinations of the respiratory system, general critical care ultrasound (GCCUS), and non-invasive haemodynamic critical care echocardiography (CCE) were used routinely. Ultrasonographic results were used to guide further management and initiate experimental therapy or transition from curative to supportive care. The process of initiation of ultrasound examinations to clinical decision-making in these complex scenarios is outlined. These case vignettes highlight the utility of ultrasound and echocardiography. When clinical management is not clear, or evidence is not available, the use of ultrasound for the evaluation of the respiratory system, GCCUS, and non-invasive haemodynamic CCE can help to guide management, reveal newly developed pathologies, lead to clinical management changes, and support the decision for employing experimental therapy approaches in a dynamic way of which few other imaging modalities or monitoring tools are currently capable.
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Kazibwe J, Shah HA, Kuwawenaruwa A, Schell CO, Khalid K, Tran PB, Ghosh S, Baker T, Guinness L. Resource use, availability and cost in the provision of critical care in Tanzania: a systematic review. BMJ Open 2022; 12:e060422. [PMID: 36414306 PMCID: PMC9684998 DOI: 10.1136/bmjopen-2021-060422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Critical care is essential in saving lives of critically ill patients, however, provision of critical care across lower resource settings can be costly, fragmented and heterogenous. Despite the urgent need to scale up the provision of critical care, little is known about its availability and cost. Here, we aim to systematically review and identify reported resource use, availability and costs for the provision of critical care and the nature of critical care provision in Tanzania. DESIGN This is a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. DATA SOURCES Medline, Embase and Global Health databases were searched covering the period 2010 to 17 November 2020. ELIGIBILITY CRITERIA We included studies that reported on forms of critical care offered, critical care services offered and/or costs and resources used in the provision of care in Tanzania published from 2010. DATA EXTRACTION AND SYNTHESIS Quality assessment of the articles and data extraction was done by two independent researchers. The Reference Case for Estimating the Costs of Global Health Services and Interventions was used to assess quality of included studies. A narrative synthesis of extracted data was conducted. Costs were adjusted and reported in 2019 US$ and TZS using the World Bank GDP deflators. RESULTS A total 31 studies were found to fulfil the inclusion and exclusion criteria. Critical care identified in Tanzania was categorised into: intensive care unit (ICU) delivered critical care and non-ICU critical care. The availability of ICU delivered critical care was limited to urban settings whereas non-ICU critical care was found in rural and urban settings. Paediatric critical care equipment was more scarce than equipment for adults. 15 studies reported on the costs of services related to critical care yet no study reported an average or unit cost of critical care. Costs of medication, equipment (eg, oxygen, personal protective equipment), services and human resources were identified as inputs to specific critical care services in Tanzania. CONCLUSION There is limited evidence on the resource use, availability and costs of critical care in Tanzania. There is a strong need for further empirical research on critical care resources availability, utilisation and costs across specialties and hospitals of different level in low/middle-income countries like Tanzania to inform planning, priority setting and budgeting for critical care services. PROSPERO REGISTRATION NUMBER CRD42020221923.
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Affiliation(s)
- Joseph Kazibwe
- Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Hiral A Shah
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
- Center for Global Development, Washington, DC, USA
| | - August Kuwawenaruwa
- Health System Impact Evaluation and Policy Unit, Ifakara Health Institute, Ifakara, United Republic of Tanzania
| | - Carl Otto Schell
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden
| | - Karima Khalid
- Department of Anaesthesia and Critical Care, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Phuong Bich Tran
- Department of Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium
| | - Srobana Ghosh
- Global Health Department, Center for Global Development, Washington, DC, USA
| | - Tim Baker
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
- Department of Emergency Medicine, Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania
| | - Lorna Guinness
- Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
- Center for Global Development, Washington, DC, USA
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Results of the 2018 Japan Society for Blood Purification in Critical Care survey: current status and outcomes. RENAL REPLACEMENT THERAPY 2022; 8:58. [PMID: 36407492 PMCID: PMC9660154 DOI: 10.1186/s41100-022-00445-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 10/20/2022] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
The Japan Society for Blood Purification in Critical Care (JSBPCC) has reported survey results on blood purification therapy (BPT) for critically ill patients in 2005, 2009, and 2013. To clarify the current clinical status, including details of the modes used, treated diseases, and survival rate, we conducted this cohort study using data from the nationwide JSBPCC registry in 2018.
Methods
We analyzed data of 2371 patients who underwent BPT in the intensive care units of 43 facilities to investigate patient characteristics, disease severity, modes of BPTs, including the dose of continuous renal replacement therapy (CRRT) and hemofilters, treated diseases, and the survival rate for each disease. Disease severity was assessed using Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) scores.
Results
BPT was performed 2867 times in the 2371 patients. Mean APACHE II and SOFA scores were 23.5 ± 9.4 and 10.0 ± 4.4, respectively. The most frequently used mode of BPT was CRRT (67.4%), followed by intermittent renal replacement therapy (19.1%) and direct hemoperfusion with the polymyxin B-immobilized fiber column (7.3%). The most commonly used anticoagulant was nafamostat mesilate (78.6%). Among all patients, the 28-day survival rate was 61.7%. CRRT was the most commonly used mode for many diseases, including acute kidney injury (AKI), multiple organ failure (MOF), and sepsis. The survival rate decreased according to the severity of AKI (P = 0.001). The survival rate was significantly lower in patients with multiple organ failure (MOF) (34.6%) compared with acute lung injury (ALI) (48.0%) and sepsis (58.0%). Multivariate logistic regression analysis revealed that sepsis, ALI, acute liver failure, cardiovascular hypotension, central nervous system disorders, and higher APACHE II scores were significant predictors of higher 28-day mortality.
Conclusion
This large-scale cohort study revealed the current status of BPT in Japan. It was found that CRRT was the most frequently used mode for critically ill patients in Japan and that 28-day survival was lower in those with MOF or sepsis. Further investigations are required to clarify the efficacy of BPT for critically ill patients.
Trial Registration: UMIN000027678.
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Outpatient Mental Health Follow-up and Recurrent Self-harm and Suicide Among Patients Admitted to the ICU for Self-harm: A Population-based Cohort Study. Chest 2022; 163:815-825. [PMID: 36445799 DOI: 10.1016/j.chest.2022.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 10/16/2022] [Accepted: 10/23/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Patients surviving an ICU admission for deliberate self-harm are at high risk of recurrent self-harm or suicide after discharge. It is unknown whether mental health follow-up after discharge (with either a family physician or psychiatrist) reduces this risk. RESEARCH QUESTION What is the association between mental health follow-up after discharge and recurrent self-harm among patients admitted to the ICU for intentional self-harm? STUDY DESIGN AND METHODS Population-based cohort study of consecutive adults (≥ 18 years of age) from Ontario, Canada, who were admitted to ICU because of intentional self-harm between 2009 and 2017. We categorized patients according to follow-up, with 'early follow-up' indicating 1 to 21 days after discharge, 'late follow-up' indicating 22 to 60 days after discharge, and 'no follow-up' indicating no follow-up within 60 days of discharge. We conducted analyses using a cause-specific extended Cox regression model to account for varying time for mental health follow-up relative to the outcomes of interest. The primary outcome was recurrent ICU admission for self-harm within 1 year of discharge. RESULTS We included 9,569 consecutive adults admitted to the ICU for deliberate self-harm. Compared with receiving no mental health follow-up, both early follow-up (hazard ratio [HR], 1.37; 95% CI, 1.07-1.75) and late follow-up (HR, 1.69; 95% CI, 1.22-2.35) were associated with increased risk in recurrent ICU admission for self-harm. As compared with no follow-up, neither early follow-up (HR, 1.10; 95% CI, 0.70-1.73) nor late follow-up (HR, 1.54; 95% CI, 0.84-2.83) were associated with increased risk of death by suicide. INTERPREATION Among adults admitted to the ICU for deliberate self-harm, mental health follow-up after discharge was not associated with reduced risk of recurrent ICU admission for self-harm or death resulting from suicide, and patients seeking outpatient follow-up may be those at highest risk of these outcomes. Future research should focus on additional and novel methods of risk mitigation in this vulnerable population.
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Holod AF, Choi J, Tate J. Optimizing Recovery Following Critical Illness: A Systematic Review of Home-Based Interventions. HOME HEALTH CARE MANAGEMENT AND PRACTICE 2022. [DOI: 10.1177/10848223221127440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Around 5 million Americans are treated in an intensive care unit (ICU) annually. Upon discharge, it is not uncommon for ICU survivors to experience psychological, physical, or cognitive symptoms related to their ICU stay. Home-based interventions have been touted as a potential treatment modality for post-ICU sequelae. However, limited evidence exists regarding the effectiveness of home-based interventions for patients in the post-ICU recovery period. As such, the purpose of this review was to aggregate and summarize the findings of studies focused on post-ICU rehabilitation, following critical illness, delivered in the home setting. A literature search was performed in MEDLINE, CINAHL, EMBASE, APA PsycINFO, and Google Scholar. Studies were included if they: used a RCT or quasi-experimental study design; included participants aged ≥18 years discharged home from an ICU; examined the effectiveness of a home-based, post-ICU intervention; were published in English after the year 2010; and were peer-reviewed. Nine studies met inclusion criteria. Sample sizes ranged from 21 to 386, with most participants receiving mechanical ventilation. Target outcomes included: physical function, psychological well-being, cognitive function, quality of life, and healthcare utilization. Interventions included face-to-face, web-based, telephone, or self-directed activities. Findings of included studies were mixed or inconclusive. Limitations of this review include: inclusion of only adult ICU survivors, exclusion of Post-Intensive Care Syndrome as a search term, and search restricted to pre-pandemic studies. Findings suggest a need for more rigorous research to develop and test home-based interventions.
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Affiliation(s)
- Alicia F. Holod
- The Ohio State University College of Nursing, Columbus, OH, USA
| | - JiYeon Choi
- Yonsei University College of Nursing, Seoul, South Korea
| | - Judith Tate
- The Ohio State University College of Nursing, Columbus, OH, USA
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Lee CC, Kuo G, Chan MJ, Fan PC, Chen JJ, Yen CL, Tsai TY, Chen YC, Tian YC, Chang CH. Characteristics of and Outcomes After Dialysis-Treated Acute Kidney Injury, 2009-2018: A Taiwanese Multicenter Study. Am J Kidney Dis 2022; 81:665-674.e1. [PMID: 36252882 DOI: 10.1053/j.ajkd.2022.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 08/17/2022] [Indexed: 11/06/2022]
Abstract
RATIONALE & OBJECTIVE Dialysis-treated acute kidney injury (AKI) is increasingly common in intensive care units (ICUs) and is associated with poor outcomes. Few studies have explored the temporal trends in severity of acute illness at dialysis initiation, indications for dialysis, and their association with patient outcomes. STUDY DESIGN Multicenter retrospective cohort study. SETTING & PARTICIPANTS 9,535 adult patients admitted to the ICU who received their first dialysis treatment from Chang Gung Memorial Hospital system in Taiwan from 2009 through 2018. EXPOSURE Calendar year. OUTCOMES ICU mortality and dialysis treatment at discharge among hospital survivors. ANALYTICAL APPROACH The temporal trends during the study period were investigated using test statistics suited for continuous or categorical data. The association between the study year and the risk of mortality was analyzed using multivariable Cox regression with adjustment for relevant clinical variables, including the severity of acute illness, defined by Sequential Organ Failure Assessment (SOFA) score. RESULTS The mean SOFA score at dialysis initiation decreased slightly from 14.0 in 2009 to 13.6 in 2018. There was no significant trend in the number of indications for dialysis initiation that were fulfilled over time. Observed ICU mortality decreased over time, and the curve appeared to be reverse J-shaped, with a substantial decrease from 56.1% in 2009 to 46.3% in 2015 and a slight increase afterward. The risk of mortality was significantly reduced from 2013 to 2018 compared with 2009 in adjusted models. The decreasing trend in ICU mortality over time remained significant. There was an increase in dialysis treatment at discharge among survivors, mainly in patients with estimated glomerular filtration rate<60mL/min/1.73m2, from 36.8% in 2009 to 43.9% in 2018. LIMITATIONS Residual confounding from unmeasured factors over time such as severity of comorbidities, detailed medication interventions, and delivered dialysis dose. CONCLUSIONS We observed reductions in mortality among ICU patients with dialysis-treated acute kidney injury between 2009 and 2018, even after adjusting for dialysis indication and severity of illness at dialysis initiation. However, dialysis treatment at discharge among survivors has increased over time, mainly in patients with preexisting kidney disease.
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Affiliation(s)
- Cheng-Chia Lee
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - George Kuo
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ming-Jen Chan
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Pei-Chun Fan
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jia-Jin Chen
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chieh-Li Yen
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Tsung-Yu Tsai
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yung-Chang Chen
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ya-Chung Tian
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chih-Hsiang Chang
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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The Next Frontier in Neurocritical Care in Resource-Constrained Settings. Crit Care Clin 2022; 38:721-745. [PMID: 36162907 DOI: 10.1016/j.ccc.2022.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Neurocritical care (NCC) is an emerging field within critical care medicine, reflecting the widespread prevalence of neurologic injury in critically ill patients. Morbidity and mortality from neurocritical illness (NCI) have been reduced substantially in resource-rich settings (RRS), owing to the development of advanced technologies, neuro-specific units, and subspecialized medical training. Despite shouldering much of the burden of NCI worldwide, resource-limited settings (RLS) face immense hurdles when implementing guidelines generated in RRS. This review summarizes the current epidemiology, management, and outcomes of the most common NCIs in RLS and offers commentary on future directions in NCC practiced in RLS.
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Precision Medicine in Sepsis and Septic Shock. J Clin Med 2022; 11:jcm11185332. [PMID: 36142979 PMCID: PMC9501229 DOI: 10.3390/jcm11185332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 09/07/2022] [Indexed: 11/17/2022] Open
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Arbov E, Tayara A, Wu S, Rich TC, Wagener BM. COVID-19 and Long-Term Outcomes: Lessons from Other Critical Care Illnesses and Potential Mechanisms. Am J Respir Cell Mol Biol 2022; 67:275-283. [PMID: 35348443 PMCID: PMC9447134 DOI: 10.1165/rcmb.2021-0374ps] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 03/28/2022] [Indexed: 01/08/2023] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel coronavirus that is currently causing a pandemic and has been termed coronavirus disease (COVID-19). The elderly or those with preexisting conditions like diabetes, hypertension, coronary heart disease, chronic obstructive pulmonary disease, cerebrovascular disease, or kidney dysfunction are more likely to develop severe cases when infected. Patients with COVID-19 admitted to the ICU have higher mortality than non-ICU patients. Critical illness has consistently posed a challenge not only in terms of mortality but also in regard to long-term outcomes of survivors. Patients who survive acute critical illness including, but not limited to, pulmonary and systemic insults associated with acute respiratory distress syndrome, pneumonia, systemic inflammation, and mechanical ventilation, will likely suffer from post-ICU syndrome, a phenomenon of cognitive, psychiatric, and/or physical disability after treatment in the ICU. Post-ICU morbidity and mortality continue to be a cause for concern when considering large-scale studies showing 12-month mortality risks of 11.8-21%. Previous studies have demonstrated that multiple mechanisms, including cytokine release, mitochondrial dysfunction, and even amyloids, may lead to end-organ dysfunction in patients. We hypothesize that COVID-19 infection will lead to post-ICU syndrome via potentially similar mechanisms as other chronic critical illnesses and cause long-term morbidity and mortality in patients. We consider a variety of mechanisms and questions that not only consider the short-term impact of the COVID-19 pandemic but its long-term effects that may not yet be imagined.
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Affiliation(s)
- Eli Arbov
- Morehouse School of Medicine, Atlanta, Georgia
| | - Alia Tayara
- Department of Biomedical Sciences
- Honors College
| | - Songwei Wu
- Divisions of Molecular and Translational Biomedicine and
| | - Thomas C. Rich
- Department of Pharmacology, and
- Center for Lung Biology, University of South Alabama, Mobile, Alabama; and
| | - Brant M. Wagener
- Divisions of Molecular and Translational Biomedicine and
- Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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Chen J, Gao X, Shen S, Xu J, Sun Z, Lin R, Dai Z, Su L, Christiani DC, Chen F, Zhang R, Wei Y. Association of longitudinal platelet count trajectory with ICU mortality: A multi-cohort study. Front Immunol 2022; 13:936662. [PMID: 36059447 PMCID: PMC9437551 DOI: 10.3389/fimmu.2022.936662] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 07/15/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectivePlatelet (PLT) engages in immune and inflammatory responses, all of which are related to the prognosis of critically ill patients. Although thrombocytopenia at ICU admission contributes to in-hospital mortality, PLT is repeatedly measured during ICU hospitalization and the role of longitudinal PLT trajectory remains unclear. We aimed to identify dynamic PLT trajectory patterns and evaluate their relationships with mortality risk and thrombocytopenia.MethodsWe adopted a three-phase, multi-cohort study strategy. Firstly, longitudinal PLT trajectory patterns within the first four ICU days and their associations with 28-day survival were tested in the eICU Collaborative Research Database (eICU-CRD) and independently validated in the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. Secondly, the relationships among PLT trajectory patterns, thrombocytopenia, and 28-day mortality were explored and validated. Finally, a Mortality GRade system for ICU dynamically monitoring patients (Mortality-GRID) was developed to quantify the mortality risk based on longitudinal PLT, which was further validated in the Molecular Epidemiology of Acute Respiratory Distress Syndrome (MEARDS) cohort.ResultsA total of 35,332 ICU patients were included from three cohorts. Trajectory analysis clustered patients into ascending (AS), stable (ST), or descending (DS) PLT patterns. DS patients with high baseline PLT decline quickly, resulting in poor prognosis. AS patients have low baseline PLT but recover quickly, favoring a better prognosis. ST patients maintain low PLT, having a moderate prognosis in between (HRSTvsAS = 1.26, 95% CI: 1.14–1.38, P = 6.15 × 10−6; HRDSvsAS = 1.58, 95% CI: 1.40–1.79, P = 1.41 × 10−13). The associations remained significant in patients without thrombocytopenia during the entire ICU hospitalization and were robust in sensitivity analyses and stratification analyses. Further, the trajectory pattern was a warning sign of thrombocytopenia, which mediated 27.2% of the effects of the PLT trajectory on 28-day mortality (HRindirect = 1.11, 95% CI: 1.06–1.17, P = 9.80 × 10−6). Mortality-GRID well predicts mortality risk, which is in high consistency with that directly estimated in MEARDS (r = 0.98, P = 1.30 × 10−23).ConclusionLongitudinal PLT trajectory is a complementary predictor to baseline PLT for patient survival, even in patients without risk of thrombocytopenia. Mortality-GRID could identify patients at high mortality risk.
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Affiliation(s)
- Jiajin Chen
- Department of Biostatistics, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Xi Gao
- Department of Immunology, School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Sipeng Shen
- Department of Biostatistics, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Jingyuan Xu
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Zhe Sun
- Department of Biostatistics, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Ruilang Lin
- Department of Biostatistics, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Zhixiang Dai
- Department of Biostatistics, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Li Su
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Pulmonary and Critical Care Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - David C. Christiani
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Pulmonary and Critical Care Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Feng Chen
- Department of Biostatistics, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Ruyang Zhang
- Department of Biostatistics, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China
- *Correspondence: Ruyang Zhang, ; Yongyue Wei,
| | - Yongyue Wei
- Department of Biostatistics, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China
- *Correspondence: Ruyang Zhang, ; Yongyue Wei,
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Fazzini B, Battaglini D, Carenzo L, Pelosi P, Cecconi M, Puthucheary Z. Physical and psychological impairment in survivors with acute respiratory distress syndrome: a systematic review and meta-analysis. Br J Anaesth 2022; 129:801-814. [DOI: 10.1016/j.bja.2022.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 08/11/2022] [Accepted: 08/18/2022] [Indexed: 11/26/2022] Open
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Eya J, Ejikem M, Ogamba C. Admission and Mortality Patterns in Intensive Care Delivery at Enugu State University of Science and Technology Teaching Hospital: A Three-Year Retrospective Study. Cureus 2022; 14:e27195. [PMID: 36039263 PMCID: PMC9395759 DOI: 10.7759/cureus.27195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2022] [Indexed: 11/25/2022] Open
Abstract
Background The intensive care unit (ICU) provides critical care to high-risk patients to prevent morbidity and mortality. This requires closer monitoring and better management than the care provided to patients in normal admission wards and non-critical care units. Mortality rates in ICUs in developing countries are remarkably high compared to rates in more developed countries. Evaluating outcomes of treatment is a way to improve the quality of care. Therefore, this study was conducted to review the pattern of admission and outcome in the ICU of Enugu State University of Science and Technology Teaching Hospital (ESUT-TH). Methodology This study was a three-year retrospective, descriptive review of all patients admitted to the ICU of ESUT-TH between January 1, 2019, and December 21, 2021. Data were collected from admissions and discharge registers of the ICU ward. Data were analyzed and expressed as frequencies and percentages. Categorical parameters were compared using the chi-squared test, and the significance level was set at p < 0.05. Results A total of 179 patients were admitted in the three-year period. Of them, 49.2% were postoperative patients while 21.2% were admitted from the accident and emergency unit. There were a total of 74 (41.3%) medical cases and 81 (45.3%) surgical cases, and the rest were unspecified. Among surgical cases, 19% were from the general surgery department followed by obstetrics and gynecology (18.4%) and neurosurgery (16.8%). Cerebrovascular accidents and traumatic brain injury were the most common specific diagnoses recorded among ICU admitted patients. The most common reason for admission was close monitoring of high-risk patients. The mortality rate during the studied period was 34.1%, and this was significantly associated with patient age and type of illness at presentation (p < 0.05). Stratified by year of admission, the highest rate of mortality was noted in the year 2020 (46.7%). Conclusion There is a high level of mortality among ICU admissions in our center. This calls for the improvement of intensive care delivery in the healthcare facility, including training and retraining of manpower and provision of essential facilities for high-quality healthcare delivery.
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Jain A, Sankar J, Kabra SK, Jat KR, Jana M, Lodha R. Evaluation of Changes in Quadriceps Femoris Muscle in Critically III Children Using Ultrasonography. Indian J Pediatr 2022; 90:541-547. [PMID: 35834126 DOI: 10.1007/s12098-022-04220-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 03/07/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To measure changes in muscle thickness and echogenicity, reflecting muscle bulk and quality, respectively, of quadriceps femoris (QF), in critically ill children. METHODS This study was done on 58 children aged 1-18 y requiring mechanical ventilation, admitted in a pediatric intensive care unit (PICU) of a tertiary care hospital from January 2018 to June 2019. QF thickness was measured twice in longitudinal plane and twice in transverse plane, and an average of these four measurements was used. Muscle quality was assessed using ImageJ software to determine the mean echogenicity, and was calculated separately for vastus intermedius and rectus femoris. These observations were repeated on day 3 and day 7 of the ICU stay. RESULTS The median muscle thickness of QF was 1.58 cm, and vastus intermedius and rectus femoris echogenicity was 35.5 and 25.88 units, respectively in the present cohort, with median age of 6 y. Only 36 of the 58 patients underwent day 7 ultrasonography, as the remainder were either extubated or died. There was no significant change in the muscle thickness over 7 d. Rectus femoris echogenicity increased significantly over 7 d by 16.1% (p = 0.03). Baseline vastus intermedius echogenicity was significantly higher in patients who subsequently died during the course of their illness (p = 0.026). CONCLUSION There was a significant change in rectus femoris echogenicity, but not in QF thickness. Echogenicity rather than muscle thickness may be a more sensitive marker for changes in muscle properties.
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Affiliation(s)
- Agam Jain
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India.
| | - Jhuma Sankar
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Sushil K Kabra
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Kana Ram Jat
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Manisha Jana
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Lodha
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
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Safety and Feasibility Assessment of Repetitive Vascular Occlusion Stimulus (RVOS) Application to Multi-Organ Failure Critically Ill Patients: A Pilot Randomised Controlled Trial. J Clin Med 2022; 11:jcm11143938. [PMID: 35887701 PMCID: PMC9316533 DOI: 10.3390/jcm11143938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 06/30/2022] [Accepted: 07/01/2022] [Indexed: 11/17/2022] Open
Abstract
Muscle wasting is implicated in the pathogenesis of intensive care unit acquired weakness (ICU-AW), affecting 40% of patients and causing long-term physical disability. A repetitive vascular occlusion stimulus (RVOS) limits muscle atrophy in healthy and orthopaedic subjects, thus, we explored its application to ICU patients. Adult multi-organ failure patients received standard care +/- twice daily RVOS {4 cycles of 5 min tourniquet inflation to 50 mmHg supra-systolic blood pressure, and 5 min complete deflation} for 10 days. Serious adverse events (SAEs), tolerability, feasibility, acceptability, and exploratory outcomes of the rectus femoris cross-sectional area (RFCSA), echogenicity, clinical outcomes, and blood biomarkers were assessed. Only 12 of the intended 32 participants were recruited. RVOS sessions (76.1%) were delivered to five participants and two could not tolerate it. No SAEs occurred; 75% of participants and 82% of clinical staff strongly agreed or agreed that RVOS is an acceptable treatment. RFCSA fell significantly and echogenicity increased in controls (n = 5) and intervention subjects (n = 4). The intervention group was associated with less frequent acute kidney injury (AKI), a greater decrease in the total sequential organ failure assessment score (SOFA) score, and increased insulin-like growth factor-1 (IGF-1), and reduced syndecan-1, interleukin-4 (IL-4) and Tumor necrosis factor receptor type II (TNF-RII) levels. RVOS application appears safe and acceptable, but protocol modifications are required to improve tolerability and recruitment. There were signals of possible clinical benefit relating to RVOS application.
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O'Shea AM, Reisinger HS, Panos R, Goede M, Fortis S. Association of interactions between Tele-critical care and bedside with length of stay and mortality. J Telemed Telecare 2022:1357633X221107993. [PMID: 35770292 DOI: 10.1177/1357633x221107993] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Substantial variation exists in telemedicine critical care (Tele-CC) effectiveness, which may be explained by heterogeneity in Tele-CC implementation and utilization. METHODS We studied inpatient intensive care unit (ICU) admissions within the Veterans Health Administration from January 2005 to September 2018. Tele-CC affiliation was based on a facility's Tele-CC go-live date. Tele-CC interaction was quantified as the monthly number of video activations, recorded in the eCaremanager® (Phillips) system, per patient days. Tele-CC affiliated facilities were propensity-score matched to facilities without Tele-CC by hospital volume and average modified APACHE scores. We examined the effect of Tele-CC affiliation and the quantity of video interactions between Tele-CC and bedside on hospital outcomes. RESULTS Comparing Tele-CC affiliated and control facilities, affiliated patients were, on average, younger (66.8 years vs 67.8 years; p < 0.001) and more likely to be rural residents (11.3% vs 6.5%; p < 0.001). Stratifying the Tele-CC affiliated facilities, facilities with frequent interactions care for more rural and sicker patients relative to facilities with infrequent interactions. Adjusting for patient demographics, facilities in the top tertile of interactions and propensity score matched control facilities were assessed; patients in ICU's with Tele-CC access experienced shorter ICU-specific lengths of stay (RR = 0.39; 95% CI = [0.23, 0.65]). However, when facilities in the bottom tertile and propensity score matched control facilities were assessed, no significant differences were noted in ICU length of stay. DISCUSSION Tele-CC interactions may occur more frequently for higher acuity patients. Increased Tele-CC interactions may improve health outcomes for the most acute and complex ICU cases.
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Affiliation(s)
- Amy Mj O'Shea
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA, USA
- Department of Internal Medicine, Division of General Internal Medicine, 12243University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Heather S Reisinger
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA, USA
- Department of Internal Medicine, Division of General Internal Medicine, 12243University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Ralph Panos
- Pulmonary, Critical Care, and Sleep Division and Cincinnati Tele-CC, Cincinnati VAMC, Cincinnati, OH, USA
- Pulmonary, Critical Care, and Sleep Division, 12303University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Matt Goede
- VA Tele-Critical. Care West, 20040Minneapolis VA Health Care System, Minneapolis, MN, USA
- Department of Surgery, Division of Acute Care Surgery, 12284University of Nebraska Medical Center, Omaha, NE, USA
| | - Spyridon Fortis
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA, USA
- VA Tele-Critical. Care West, 20040Minneapolis VA Health Care System, Minneapolis, MN, USA
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Occupational Medicine, 12243University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
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Tang H, Jin Z, Deng J, She Y, Zhong Y, Sun W, Ren Y, Cao N, Chen C. Development and validation of a deep learning model to predict the survival of patients in ICU. J Am Med Inform Assoc 2022; 29:1567-1576. [PMID: 35751440 DOI: 10.1093/jamia/ocac098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 05/23/2022] [Accepted: 06/06/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Patients in the intensive care unit (ICU) are often in critical condition and have a high mortality rate. Accurately predicting the survival probability of ICU patients is beneficial to timely care and prioritizing medical resources to improve the overall patient population survival. Models developed by deep learning (DL) algorithms show good performance on many models. However, few DL algorithms have been validated in the dimension of survival time or compared with traditional algorithms. METHODS Variables from the Early Warning Score, Sequential Organ Failure Assessment Score, Simplified Acute Physiology Score II, Acute Physiology and Chronic Health Evaluation (APACHE) II, and APACHE IV models were selected for model development. The Cox regression, random survival forest (RSF), and DL methods were used to develop prediction models for the survival probability of ICU patients. The prediction performance was independently evaluated in the MIMIC-III Clinical Database (MIMIC-III), the eICU Collaborative Research Database (eICU), and Shanghai Pulmonary Hospital Database (SPH). RESULTS Forty variables were collected in total for model development. 83 943 participants from 3 databases were included in the study. The New-DL model accurately stratified patients into different survival probability groups with a C-index of >0.7 in the MIMIC-III, eICU, and SPH, performing better than the other models. The calibration curves of the models at 3 and 10 days indicated that the prediction performance was good. A user-friendly interface was developed to enable the model's convenience. CONCLUSIONS Compared with traditional algorithms, DL algorithms are more accurate in predicting the survival probability during ICU hospitalization. This novel model can provide reliable, individualized survival probability prediction.
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Affiliation(s)
- Hai Tang
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China.,Shanghai Engineering Research Center of Lung Transplantation, Shanghai, China
| | - Zhuochen Jin
- College of Design and Innovation, Tongji University, Shanghai, China
| | - Jiajun Deng
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China.,Shanghai Engineering Research Center of Lung Transplantation, Shanghai, China
| | - Yunlang She
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China.,Shanghai Engineering Research Center of Lung Transplantation, Shanghai, China
| | - Yifan Zhong
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China.,Shanghai Engineering Research Center of Lung Transplantation, Shanghai, China
| | - Weiyan Sun
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China.,Shanghai Engineering Research Center of Lung Transplantation, Shanghai, China
| | - Yijiu Ren
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China.,Shanghai Engineering Research Center of Lung Transplantation, Shanghai, China
| | - Nan Cao
- College of Design and Innovation, Tongji University, Shanghai, China
| | - Chang Chen
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China.,Shanghai Engineering Research Center of Lung Transplantation, Shanghai, China
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Crescioli E, Krejberg KU, Klitgaard TL, Mølgaard Nielsen F, Barbateskovic M, Skrubbeltrang C, Møller MH, Schjørring OL, Rasmussen BS. Long-term effects of lower versus higher oxygenation levels in adult ICU patients - a systematic review. Acta Anaesthesiol Scand 2022; 66:910-922. [PMID: 35749059 PMCID: PMC9540426 DOI: 10.1111/aas.14107] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 06/01/2022] [Accepted: 06/16/2022] [Indexed: 11/28/2022]
Abstract
Background Oxygen therapy is a common treatment in the intensive care unit (ICU) with both potentially desirable and undesirable long‐term effects. This systematic review aimed to assess the long‐term outcomes of lower versus higher oxygenation strategies in adult ICU survivors. Methods We included randomised clinical trials (RCTs) comparing lower versus higher oxygen supplementation or oxygenation strategies in adults admitted to the ICU. We searched major electronic databases and trial registers. We included all non‐mortality long‐term outcomes. Prespecified co‐primary outcomes were the long‐term cognitive function measures, the overall score of any valid health‐related quality of life (HRQoL) evaluation, standardised 6‐min walk test, and lung diffusion capacity. The protocol was published and prospectively registered in the PROSPERO database (CRD42021223630). Results The review included 17 RCTs comprising 6592 patients, and six trials with 825 randomised patients reported one or more outcomes of interest. We observed no difference in cognitive evaluation via Telephone Interview for Cognitive Status (one trial, 409 patients) (mean score: 30.6 ± 4.5 in the lower oxygenation group vs. 30.4 ± 4.3 in the higher oxygenation group). The trial was judged at overall high risk of bias and the certainty of evidence was very low. Any difference was neither observed in HRQoL measured via EuroQol 5 dimensions 5 level questionnaire and EQ Visual Analogue Score (one trial, 499 patients) (mean score: 70.1 ± 22 in the lower oxygenation group vs. 67.6 ± 22.4 in the higher oxygenation group). The trial was judged as having high risk of bias, the certainty of evidence was very low. No trial reported neither the standardised 6‐min walk test nor lung diffusion test. Conclusion The evidence is very uncertain about the effect of a lower versus a higher oxygenation strategy on both the cognitive function and HRQoL. A lower versus a higher oxygenation strategy may have a little to no effect on both outcomes but the certainty of evidence is very low. No evidence was found for the effects on the standardised 6‐min walking test and diffusion capacity test.
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Affiliation(s)
- Elena Crescioli
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | - Thomas Lass Klitgaard
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Frederik Mølgaard Nielsen
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Marija Barbateskovic
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Capital Region of Denmark, Denmark
| | | | - Morten Hylander Møller
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Olav Lilleholt Schjørring
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Bodil Steen Rasmussen
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Baig SH, Vaid U, Yoo EJ. The Impact of Chronic Medical Conditions on Mortality in Acute Respiratory Distress Syndrome. J Intensive Care Med 2022; 38:78-85. [PMID: 35722731 DOI: 10.1177/08850666221108079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To examine the impact of chronic comorbidities on mortality in Acute Respiratory Distress Syndrome (ARDS). MATERIALS AND METHODS Retrospective cohort study of adults with ARDS (ICD-10-CM code J80) from the National Inpatient Sample between January, 2016 and December, 2018. For the primary outcome of mortality, we conducted weighted logistic regression adjusting for factors identified on univariate analysis as potentially significant or differing between the two groups at baseline. We used negative binomial regression adjusting for the same comorbidities to identify risk factors for longer length of stay (LOS) among ARDS survivors. RESULTS After exclusions, 1046 records were analyzed (3355 ARDS survivors and 1875 non-survivors.) The comorbidities examined included hypertension, diabetes mellitus, obesity, hypothyroidism, alcohol and drug use, chronic kidney disease (CKD), cardiovascular disease, chronic liver disease, chronic pulmonary disease and malignancy. In multivariate analysis, we found that malignancy (OR 2.26, 95% CI 1.84-2.78, p < 0.001), cardiovascular disease (OR 1.54, 95% CI 1.23-1.92, p < 0.001), and CKD (OR 1.75, 95% CI 1.22-2.50, p = 0.002) increased the risk of death. In interaction analyses, cardiovascular disease combined with either malignancy or CKD conferred higher odds of death compared to either risk factor alone. CONCLUSIONS The comorbidity of malignancy confers the most reliable risk of poor outcomes in ARDS with higher odds of hospital death and a simultaneous association with longer hospital LOS among survivors.
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Affiliation(s)
- Saqib H Baig
- Division of Pulmonary, Allergy and Critical Care Medicine, Jane and Leonard Korman Respiratory Institute, 12313Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Urvashi Vaid
- Division of Pulmonary, Allergy and Critical Care Medicine, Jane and Leonard Korman Respiratory Institute, 12313Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Erika J Yoo
- Division of Pulmonary, Allergy and Critical Care Medicine, Jane and Leonard Korman Respiratory Institute, 12313Thomas Jefferson University, Philadelphia, PA 19107, USA
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74
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Ahmad SR, Tarabochia AD, Budahn L, Lemahieu AM, Anderson B, Vashistha K, Karnatovskaia L, Gajic O. Feasibility of Extracting Meaningful Patient Centered Outcomes From the Electronic Health Record Following Critical Illness in the Elderly. Front Med (Lausanne) 2022; 9:826169. [PMID: 35733861 PMCID: PMC9207323 DOI: 10.3389/fmed.2022.826169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 05/11/2022] [Indexed: 12/04/2022] Open
Abstract
Background Meaningful patient centered outcomes of critical illness such as functional status, cognition and mental health are studied using validated measurement tools that may often be impractical outside the research setting. The Electronic health record (EHR) contains a plethora of information pertaining to these domains. We sought to determine how feasible and reliable it is to assess meaningful patient centered outcomes from the EHR. Methods Two independent investigators reviewed EHR of a random sample of ICU patients looking at documented assessments of trajectory of functional status, cognition, and mental health. Cohen's kappa was used to measure agreement between 2 reviewers. Post ICU health in these domains 12 month after admission was compared to pre- ICU health in the 12 months prior to assess qualitatively whether a patient's condition was “better,” “unchanged” or “worse.” Days alive and out of hospital/health care facility was a secondary outcome. Results Thirty six of the 41 randomly selected patients (88%) survived critical illness. EHR contained sufficient information to determine the difference in health status before and after critical illness in most survivors (86%). Decline in functional status (36%), cognition (11%), and mental health (11%) following ICU admission was observed compared to premorbid baseline. Agreement between reviewers was excellent (kappa ranging from 0.966 to 1). Eighteen patients (44%) remained home after discharge from hospital and rehabilitation during the 12- month follow up. Conclusion We demonstrated the feasibility and reliability of assessing the trajectory of changes in functional status, cognition, and selected mental health outcomes from EHR of critically ill patients. If validated in a larger, representative sample, these outcomes could be used alongside survival in quality improvement studies and pragmatic clinical trials.
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Affiliation(s)
- Sumera R. Ahmad
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, United States
- *Correspondence: Sumera R. Ahmad
| | - Alex D. Tarabochia
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, United States
| | - Luann Budahn
- Anesthesia and Critical Care Research Unit, Mayo Clinic, Rochester, MN, United States
| | - Allison M. Lemahieu
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, United States
| | - Brenda Anderson
- Anesthesia and Critical Care Research Unit, Mayo Clinic, Rochester, MN, United States
| | - Kirtivardhan Vashistha
- Department of Infectious Disease, Multi-disciplinary Epidemiology and Translational Research in Intensive Care Research Group, Mayo Clinic, Rochester, MN, United States
| | | | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, United States
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75
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Van Dyck L, Güiza F, Derese I, Pauwels L, Casaer MP, Hermans G, Wouters PJ, Van den Berghe G, Vanhorebeek I. DNA methylation alterations in muscle of critically ill patients. J Cachexia Sarcopenia Muscle 2022; 13:1731-1740. [PMID: 35274472 PMCID: PMC9178166 DOI: 10.1002/jcsm.12970] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 09/15/2021] [Accepted: 02/21/2022] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Intensive care unit (ICU)-acquired weakness can persist beyond ICU stay and has been associated with long-term functional impairment of ICU survivors. Recently, DNA methylation alterations were found in the blood of ICU patients, partially explaining long-term developmental impairment of critically ill children. As illness-induced aberrant DNA methylation theoretically could also be involved in long-term weakness, we investigated whether the DNA methylation signature in muscle of adult critically ill patients differs from that in muscle of healthy controls. METHODS Genome-wide methylation was determined (Infinium® HumanMethylationEPIC BeadChips) in DNA extracted from skeletal muscle biopsies that had been collected on Day 8 ± 1 in ICU from 172 EPaNIC-trial patients [66% male sex, median age 62.7 years, median body mass index (BMI) 25.9 kg/m2 ] and 20 matched healthy controls (70% male sex, median age 58.0 years, median BMI 24.4 kg/m2 ). Methylation status of individual cytosine-phosphate-guanine (CpG) sites of patients and controls was compared with F-tests, using the Benjamini-Hochberg false discovery rate to correct for multiple comparisons. Differential methylation of DNA regions was assessed with bump hunting, with 1000 permutations assessing uncertainty, expressed as family-wise error rate. Gene expression was investigated for 10 representative affected genes. RESULTS In DNA from ICU patients, 565 CpG sites, associated with 400 unique genes, were differentially methylated as compared with controls (average difference 3.2 ± 0.1% ranging up to 16.9%, P < 0.00005). Many of the associated genes appeared highly relevant for muscle structure and function/weakness, including genes involved in myogenesis, muscle regeneration, nerve/muscle membrane excitability, muscle denervation/re-innervation, axon guidance/myelination/degeneration/regeneration, synapse function, ion channelling with especially calcium signalling, metabolism (glucose, protein, and fat), insulin signalling, neuroendocrine hormone regulation, mitochondrial function, autophagy, apoptosis, oxidative stress, Wnt signalling, transcription regulation, muscle fat infiltration during regeneration, and fibrosis. In patients as compared with controls, we also identified two hypomethylated regions, spanning 18 and 3 CpG sites in the promoters of the HIC1 and NADK2 genes, respectively (average differences 5.8 ± 0.01% and 12.1 ± 0.04%, family-wise error rate <0.05). HIC1 and NADK2 play important roles in muscle regeneration and postsynaptic acetylcholine receptors and in mitochondrial processes, respectively. Nine of 10 investigated genes containing DNA methylation alterations were differentially expressed in patients as compared with controls (P ≤ 0.03). CONCLUSIONS Critically ill patients present with a different DNA methylation signature in skeletal muscle as compared with healthy controls, which in theory could provide a biological basis for long-term persistence of weakness in ICU survivors. TRIAL REGISTRATION ClinicalTrials.gov: NCT00512122, registered on 31 July 2007.
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Affiliation(s)
- Lisa Van Dyck
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Fabian Güiza
- Clinical Division of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Inge Derese
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Lies Pauwels
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Michaël P Casaer
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium.,Clinical Division of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Greet Hermans
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium.,Medical Intensive Care Unit, Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Pieter J Wouters
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium.,Clinical Division of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Greet Van den Berghe
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium.,Clinical Division of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Ilse Vanhorebeek
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
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76
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Pallanch O, Ortalda A, Pelosi P, Latronico N, Sartini C, Lombardi G, Marchetti C, Maimeri N, Zangrillo A, Cabrini L. Effects on health-related quality of life of interventions affecting survival in critically ill patients: a systematic review. Crit Care 2022; 26:126. [PMID: 35524315 PMCID: PMC9075706 DOI: 10.1186/s13054-022-03993-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 04/24/2022] [Indexed: 12/12/2022] Open
Abstract
Survival has been considered the cornerstone for clinical outcome evaluation in critically ill patients admitted to intensive care unit (ICU). There is evidence that ICU survivors commonly show impairments in long-term outcomes such as quality of life (QoL) considering them as the most relevant ones. In the last years, the concept of patient-important outcomes has been introduced and increasingly reported in peer-reviewed publications. In the present systematic review, we evaluated how many randomized controlled trials (RCTs) were conducted on critically ill patients and reporting a benefit on survival reported also data on QoL. All RCTs investigating nonsurgical interventions that significantly reduced mortality in critically ill patients were searched on MEDLINE/PubMed, Scopus and Embase from inception until August 2021. In a second stage, for all the included studies, the outcome QoL was investigated. The primary outcome was to evaluate how many RCTs analyzing interventions reducing mortality reported also data on QoL. The secondary endpoint was to investigate if QoL resulted improved, worsened or not modified. Data on QoL were reported as evaluated outcome in 7 of the 239 studies (2.9%). The tools to evaluate QoL and QoL time points were heterogeneous. Four interventions showed a significant impact on QoL: Two interventions improved survival and QoL (pravastatin in subarachnoid hemorrhage, dexmedetomidine in elderly patients after noncardiac surgery), while two interventions reduced mortality but negatively influenced QoL (caloric restriction in patients with refeeding syndrome and systematic ICU admission in elderly patients). In conclusion, only a minority of RCTs in which an intervention demonstrated to affect mortality in critically ill patients reported also data on QoL. Future research in critical care should include patient-important outcomes like QoL besides mortality. Data on this topic should be collected in conformity with PROs statement and core outcome sets to guarantee quality and comparability of results.
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Affiliation(s)
- Ottavia Pallanch
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Ortalda
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Viale Benedetto XV 6, Genoa, Italy. .,Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy.
| | - Nicola Latronico
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy.,Department of Anesthesia, Intensive Care and Emergency, ASST Spedali Civili University Hospital, Piazzale Ospedali Civili, 1, Brescia, Italy.,"Alessandra Bono" University Research Center for LOng-Term Outcome (LOTO) in Survivors of Critical Illness, University of Brescia, Brescia, Italy
| | - Chiara Sartini
- ASST Sette Laghi, Ospedale di Circolo Fondazione Macchi, Varese, Italy
| | - Gaetano Lombardi
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Cristiano Marchetti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Nicolò Maimeri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Luca Cabrini
- ASST Sette Laghi, Ospedale di Circolo Fondazione Macchi, Varese, Italy.,Dipartimento di Biotecnologie e Scienze della Vita, Università degli Studi dell'insubria, Varese, Italy
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77
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Gaudry S, Grolleau F, Barbar S, Martin-Lefevre L, Pons B, Boulet É, Boyer A, Chevrel G, Montini F, Bohe J, Badie J, Rigaud JP, Vinsonneau C, Porcher R, Quenot JP, Dreyfuss D. Continuous renal replacement therapy versus intermittent hemodialysis as first modality for renal replacement therapy in severe acute kidney injury: a secondary analysis of AKIKI and IDEAL-ICU studies. Crit Care 2022; 26:93. [PMID: 35379300 PMCID: PMC8981658 DOI: 10.1186/s13054-022-03955-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 03/03/2022] [Indexed: 01/05/2023] Open
Abstract
Background Intermittent hemodialysis (IHD) and continuous renal replacement therapy (CRRT) are the two main RRT modalities in patients with severe acute kidney injury (AKI). Meta-analyses conducted more than 10 years ago did not show survival difference between these two modalities. As the quality of RRT delivery has improved since then, we aimed to reassess whether the choice of IHD or CRRT as first modality affects survival of patients with severe AKI. Methods This is a secondary analysis of two multicenter randomized controlled trials (AKIKI and IDEAL-ICU) that compared an early RRT initiation strategy with a delayed one. We included patients allocated to the early strategy in order to emulate a trial where patients would have been randomized to receive either IHD or CRRT within twelve hours after the documentation of severe AKI. We determined each patient’s modality group as the first RRT modality they received. The primary outcome was 60-day overall survival. We used two propensity score methods to balance the differences in baseline characteristics between groups and the primary analysis relied on inverse probability of treatment weighting. Results A total of 543 patients were included. Continuous RRT was the first modality in 269 patients and IHD in 274. Patients receiving CRRT had higher cardiovascular and total-SOFA scores. Inverse probability weighting allowed to adequately balance groups on all predefined confounders. The weighted Kaplan–Meier death rate at day 60 was 54·4% in the CRRT group and 46·5% in the IHD group (weighted HR 1·26, 95% CI 1·01–1·60). In a complementary analysis of less severely ill patients (SOFA score: 3–10), receiving IHD was associated with better day 60 survival compared to CRRT (weighted HR 1.82, 95% CI 1·01–3·28; p < 0.01). We found no evidence of a survival difference between the two RRT modalities in more severe patients. Conclusion Compared to IHD, CRRT as first modality seemed to convey no benefit in terms of survival or of kidney recovery and might even have been associated with less favorable outcome in patients with lesser severity of disease. A prospective randomized non-inferiority trial should be implemented to solve the persistent conundrum of the optimal RRT technique. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-03955-9.
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Affiliation(s)
- Stéphane Gaudry
- Département de Réanimation Médico-Chirurgicale, APHP Hôpital Avicenne, Bobigny, France. .,Health Care Simulation Center, UFR SMBH, Université Sorbonne Paris Nord, Bobigny, France. .,Common and Rare Kidney Diseases, INSERM, UMR-S 1155, Hôpital Tenon, Sorbonne Université, 4 rue de la Chine, 75020, Paris, France. .,Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Bobigny, France.
| | - François Grolleau
- Centre of Research in Epidemiology and Statistics (CRESS), Université de Paris, French Institute of Health and Medical Research (INSERM), National Institute of Agricultural Research (INRA), Paris, France
| | | | | | | | - Éric Boulet
- Réanimation Et USC, GH Carnelle Portes de L'Oise, 95260, Beaumont sur Oise, France
| | - Alexandre Boyer
- CHU de Bordeaux, Service de Réanimation Médicale, 33000, Bordeaux, France
| | | | - Florent Montini
- Réanimation Polyvalente, Centre Hospitalier d'Avignon, Avignon, France
| | - Julien Bohe
- Anesthésie Réanimation Médicale et Chirurgicale, CH Lyon Sud, Pierre Benite, France
| | - Julio Badie
- Réanimation Polyvalente, Hôpital Nord Franche-Comte CH Belfort, Belfort, France
| | | | - Christophe Vinsonneau
- Médecine Intensive Réanimation, CH Bethune Beuvry - Germont et Gauthier, Bethune, France
| | - Raphaël Porcher
- Centre of Research in Epidemiology and Statistics (CRESS), Université de Paris, French Institute of Health and Medical Research (INSERM), National Institute of Agricultural Research (INRA), Paris, France
| | - Jean-Pierre Quenot
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France.,Lipness Team, INSERM Research Center LNC-UMR1231 and LabExLipSTIC, University of Burgundy, Dijon, France.,INSERM CIC 1432, Clinical Epidemiology, University of Burgundy, Dijon, France
| | - Didier Dreyfuss
- Common and Rare Kidney Diseases, INSERM, UMR-S 1155, Hôpital Tenon, Sorbonne Université, 4 rue de la Chine, 75020, Paris, France.,Médecine Intensive-Réanimation, APHP, Hôpital Louis Mourier, Université de Paris, Colombes, France
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78
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Lu SY, Otero TMN, Yeh DD, Canales C, Elsayes A, Belcher DM, Quraishi SA. The association of macronutrient deficit with functional status at discharge from the intensive care unit: a retrospective study from a single-center critical illness registry. Eur J Clin Nutr 2022; 76:551-556. [PMID: 34462556 DOI: 10.1038/s41430-021-01001-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 08/02/2021] [Accepted: 08/18/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Nutrition is often thought to influence outcomes in critically ill patients. However, the relationship between macronutrient delivery and functional status is not well characterized. Our goal was to investigate whether caloric or protein deficit over the course of critical illness is associated with functional status at the time of intensive care unit (ICU) discharge. METHODS We performed a retrospective analysis of surgical ICU patients at a teaching hospital in Boston, MA. To investigate the association of caloric or protein deficit with Functional Status Score for the ICU (FSS-ICU), we constructed linear regression models, controlling for age, sex, race, body mass index, Nutritional Risk in the Critically Ill score, and ICU length of stay. We then dichotomized caloric as well as protein deficit, and performed logistic regressions to investigate their association with functional status, controlling for the same variables. RESULTS Linear regression models (n = 976) demonstrated a caloric deficit of 238 kcal (237.88; 95%CI 75.13-400.63) or a protein deficit of 14 g (14.23; 95%CI 4.46-24.00) was associated with each unit decrement in FSS-ICU. Logistic regression models demonstrated a 6% likelihood (1.06; 95%CI 1.01-1.14) of caloric deficit ≥6000 vs. <6000 kcal and an 8% likelihood (1.08; 95%CI 1.01-1.15) of protein deficit ≥300 vs. <300 g with each unit decrement in FSS-ICU. CONCLUSION In our cohort of patients, macronutrient deficit over the course of critical illness was associated with worse functional status at discharge. Future studies are needed to determine whether optimized macronutrient delivery can improve outcomes in ICU survivors.
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Affiliation(s)
- Shu Y Lu
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Tiffany M N Otero
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, 02114, USA.,Department of Anesthesiology, University of Arizona College of Medicine, Tucson, AZ, 85724, USA
| | - D Dante Yeh
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, 33136, USA
| | - Cecilia Canales
- Department of Anesthesiology & Perioperative Medicine, University of California David Geffen School of Medicine, Los Angeles, CA, 90095, USA
| | - Ali Elsayes
- Department of Anesthesiology & Perioperative Medicine, Tufts Medical Center, Boston, MA, 02111, USA
| | - Donna M Belcher
- Department of Nutrition and Food Services, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Sadeq A Quraishi
- Department of Anesthesiology & Perioperative Medicine, Tufts Medical Center, Boston, MA, 02111, USA.
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79
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Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2022. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2022 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 .
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Affiliation(s)
- Joo Heung Yoon
- grid.21925.3d0000 0004 1936 9000Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA USA
| | - Michael R. Pinsky
- grid.21925.3d0000 0004 1936 9000Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA USA
| | - Gilles Clermont
- grid.21925.3d0000 0004 1936 9000Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA USA
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80
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Clarissa C, Salisbury L, Rodgers S, Kean S. A Constructivist Grounded Theory of Staff Experiences Relating to Early Mobilisation of Mechanically Ventilated Patients in Intensive Care. Glob Qual Nurs Res 2022; 9:23333936221074990. [PMID: 35224137 PMCID: PMC8874193 DOI: 10.1177/23333936221074990] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Early mobilisation of mechanically ventilated patients has been suggested to be effective in mitigating muscle weakness, yet it is not a common practice. Understanding staff experiences is crucial to gain insights into what might facilitate or hinder its implementation. In this constructivist grounded theory study, data from two Scottish intensive care units were collected to understand healthcare staff experiences relating to early mobilisation in mechanical ventilation. Data included observations of mobilisation activities, individual staff interviews and two focus groups with multidisciplinary staff. Managing Risks emerged as the core category and was theorised using the concept of risk. The middle-range theory developed in this study suggests that the process of early mobilisation starts by staff defining patient status and includes a process of negotiating patient safety, which in turn enables performing accountable mobilisation within the dynamic context of an intensive care unit setting.
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81
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ADMA and homoarginine independently predict mortality in critically ill patients. Nitric Oxide 2022; 122-123:47-53. [DOI: 10.1016/j.niox.2022.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 02/20/2022] [Accepted: 03/07/2022] [Indexed: 12/23/2022]
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82
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Turnbull AE, Ji H, Dinglas VD, Wu AW, Mendez-Tellez PA, Himmelfarb CD, Shanholtz CB, Hosey MM, Hopkins RO, Needham DM. Understanding Patients' Perceived Health After Critical Illness: Analysis of Two Prospective, Longitudinal Studies of ARDS Survivors. Chest 2022; 161:407-417. [PMID: 34419426 PMCID: PMC8941599 DOI: 10.1016/j.chest.2021.07.2177] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 07/15/2021] [Accepted: 07/31/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Perceived health is one of the strongest determinants of subjective well-being, but it has received little attention among survivors of ARDS. RESEARCH QUESTION How well do self-reported measures of physical, emotional, and social functioning predict perceived overall health (measured using the EQ-5D visual analog scale [EQ-5D-VAS]) among adult survivors of ARDS? Are demographic features, comorbidity, or severity of illness correlated with perceived health after controlling for self-reported functioning? STUDY DESIGN AND METHODS We analyzed the ARDSNet Long Term Outcomes Study (ALTOS) and Improving Care of Acute Lung Injury Patients (ICAP) Study, two longitudinal cohorts with a total of 823 survivors from 44 US hospitals, which prospectively assessed survivors at 6 and 12 months after ARDS. Perceived health, evaluated using the EQ-5D-VAS, was predicted using ridge regression and self-reported measures of physical, emotional, and social functioning. The difference between observed and predicted perceived health was termed perspective deviation (PD). Correlations between PD and demographics, comorbidities, and severity of illness were explored. RESULTS The correlation between observed and predicted EQ-5D-VAS scores ranged from 0.68 to 0.73 across the two cohorts and time points. PD ranged from -80 to +34 and was more than the minimum clinically important difference for 52% to 55% of survivors. Neither demographic features, comorbidity, nor severity of illness were correlated strongly with PD, with |r| < 0.25 for all continuous variables in both cohorts and time points. The correlation between PD at 6- and 12-month assessments was weak (ALTOS: r = 0.22, P < .001; ICAP: r = 0.20, P = .02). INTERPRETATION About half of survivors of ARDS showed clinically important differences in actual perceived health vs predicted perceived health based on self-reported measures of functioning. Survivors of ARDS demographic features, comorbidities, and severity of illness were correlated only weakly with perceived health after controlling for measures of perceived functioning, highlighting the challenge of predicting how individual patients will respond psychologically to new impairments after critical illness.
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Affiliation(s)
- Alison E Turnbull
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD; Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD; Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD.
| | - Hongkai Ji
- Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Victor D Dinglas
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD; Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Albert W Wu
- Center for Health Services and Outcomes Research, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD; Division of General Internal Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Pedro A Mendez-Tellez
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD; Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Cheryl Dennison Himmelfarb
- Office for Science and Innovation, Johns Hopkins School of Nursing, Johns Hopkins University, Baltimore, MD
| | - Carl B Shanholtz
- Division of Pulmonary and Critical Care Medicine, University of Maryland, Baltimore, MD
| | - Megan M Hosey
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD; Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD; Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Ramona O Hopkins
- Center for Humanizing Critical Care, Intermountain Healthcare, Murray, UT; Psychology Department and Neuroscience Center, Brigham Young University, Provo, UT
| | - Dale M Needham
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD; Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD; Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, MD
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Ingraham NE, Vakayil V, Pendleton KM, Robbins AJ, Freese RL, Palzer EF, Charles A, Dudley RA, Tignanelli CJ. Recent Trends in Admission Diagnosis and Related Mortality in the Medically Critically Ill. J Intensive Care Med 2022; 37:185-194. [PMID: 33353475 DOI: 10.1177/0885066620982905] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE With decades of declining ICU mortality, we hypothesized that the outcomes and distribution of diseases cared for in the ICU have changed and we aimed to further characterize them. STUDY DESIGN AND METHODS A retrospective cohort analysis of 287,154 nonsurgical-critically ill adults, from 237 U.S. ICUs, using the manually abstracted Cerner APACHE Outcomes database from 2008 to 2016 was performed. Surgical patients, rare admission diagnoses (<100 occurrences), and low volume hospitals (<100 total admissions) were excluded. Diagnoses were distributed into mutually exclusive organ system/disease-based categories based on admission diagnosis. Multi-level mixed-effects negative binomial regression was used to assess temporal trends in admission, in-hospital mortality, and length of stay (LOS). RESULTS The number of ICU admissions remained unchanged (IRR 0.99, 0.98-1.003) while certain organ system/disease groups increased (toxicology [25%], hematologic/oncologic [55%] while others decreased (gastrointestinal [31%], pulmonary [24%]). Overall risk-adjusted in-hospital mortality was unchanged (IRR 0.98, 0.96-1.0004). Risk-adjusted ICU LOS (Estimate -0.06 days/year, -0.07 to -0.04) decreased. Risk-adjusted mortality varied significantly by disease. CONCLUSION Risk-adjusted ICU mortality rate did not change over the study period, but there was evidence of shifting disease burden across the critical care population. Our data provides useful information regarding future ICU personnel and resource needs.
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Affiliation(s)
- Nicholas E Ingraham
- Department of Medicine, 311816University of Minnesota Medical School, Minneapolis, MN, USA
- School of Public Health, 311816University of Minnesota, Minneapolis, MN, USA
| | - Victor Vakayil
- School of Public Health, 311816University of Minnesota, Minneapolis, MN, USA
- Department of Surgery, 311816University of Minnesota Medical School, Minneapolis, MN, USA
| | - Kathryn M Pendleton
- Department of Medicine, 311816University of Minnesota Medical School, Minneapolis, MN, USA
| | - Alexandria J Robbins
- Department of Surgery, 311816University of Minnesota Medical School, Minneapolis, MN, USA
| | - Rebecca L Freese
- Biostatistical Design and Analysis Center, Clinical and Translational Science Institute, 311816University of Minnesota, Minneapolis, MN, USA
| | - Elise F Palzer
- Biostatistical Design and Analysis Center, Clinical and Translational Science Institute, 311816University of Minnesota, Minneapolis, MN, USA
| | - Anthony Charles
- Department of Surgery, 2331University of North Carolina School of Medicine, Chapel Hill, NC, USA
- Gillings School of Global Public Health, 2331University of North Carolina, Chapel Hill, NC, USA
| | - R Adams Dudley
- Department of Medicine, 311816University of Minnesota Medical School, Minneapolis, MN, USA
- School of Public Health, 311816University of Minnesota, Minneapolis, MN, USA
- Institute for Health Informatics, 311816University of Minnesota Academic Health Center, Minneapolis, MN, USA
| | - Christopher J Tignanelli
- Department of Surgery, 311816University of Minnesota Medical School, Minneapolis, MN, USA
- Institute for Health Informatics, 311816University of Minnesota Academic Health Center, Minneapolis, MN, USA
- Department of Surgery, North Memorial Health Hospital, Robbinsdale, MN, USA
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Grunow JJ, Nydahl P, Schaller SJ. [Mobilization of Intensive Care Unit Patients: How Can the ICU Rooms and Modern Medical Equipment Help?]. Anasthesiol Intensivmed Notfallmed Schmerzther 2022; 57:41-51. [PMID: 35021239 DOI: 10.1055/a-1324-0627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Intensive Care Unit patients frequently develop physical impairments, mainly weakness, during their ICU stay. Early mobilization is a central therapeutic element in patients on an intensive care unit to prevent and treat these physical sequelae to conserve independence. Different barriers such as lacking patient motivation, insufficient staffing and fear of dislocating vascular access or the airway led to insufficient implementation of current guideline recommendation. Integration of modern medical equipment as well as the adequate ICU room concepts is a promising option to overcome those barriers.Allowing for sufficient free floor area when planning an ICU - maybe through the integration of mobile elements - is likely to ease early mobilization and should be thoroughly considered when building or remodeling an ICU. Furthermore, wireless monitoring has been deemed necessary and could potentially decrease the fear regarding dislocation due to less cable or lines that need to be managed during mobilization.Virtual reality is a rapidly evolving field and while in ICU patients it could so far only show to reduce stress level it has been shown to improve rehabilitation in stroke patients. It is imaginable that its integration in mobilization on the ICU will boost patients' motivation. Trials are still outstanding.Robotics integrated in the ICU bed or in form of exoskeletons are currently being piloted in critically ill patients with many expected benefits due to the ability to support patients tailored to their individual needs, reduce staff requirements as the robotics will cover support function and improved duration and intensity of mobilization as for example the patient can be ambulated without ever leaving the bed, which also translates into potentially reduced fear regarding dislocation of the airway or vascular access.Currently, evidence on the benefits regarding the integration of ICU rooms as well as modern medical technology into the process of (early) mobilization is lacking but especially in the sector of robotics a huge potential is to be suspected.
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Brown SM, Dinglas VD, Akhlaghi N, Bose S, Banner-Goodspeed V, Beesley S, Groat D, Greene T, Hopkins RO, Mir-Kasimov M, Sevin CM, Turnbull AE, Jackson JC, Needham DM. Association between unmet medication needs after hospital discharge and readmission or death among acute respiratory failure survivors: the addressing post-intensive care syndrome (APICS-01) multicenter prospective cohort study. Crit Care 2022; 26:6. [PMID: 34991660 PMCID: PMC8738999 DOI: 10.1186/s13054-021-03848-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 11/29/2021] [Indexed: 11/21/2022] Open
Abstract
Introduction Survivors of acute respiratory failure (ARF) commonly experience long-lasting physical, cognitive, and/or mental health impairments. Unmet medication needs occurring immediately after hospital discharge may have an important effect on subsequent recovery. Methods and analysis In this multicenter prospective cohort study, we enrolled ARF survivors who were discharged directly home from their acute care hospitalization. The primary exposure was unmet medication needs. The primary outcome was hospital readmission or death within 3 months after discharge. We performed a propensity score analysis, using inverse probability weighting for the primary exposure, to evaluate the exposure–outcome association, with an a priori sample size of 200 ARF survivors. Results We enrolled 200 ARF survivors, of whom 107 (53%) were female and 77 (39%) were people of color. Median (IQR) age was 55 (43–66) years, APACHE II score 20 (15–26) points, and hospital length of stay 14 (9–21) days. Of the 200 participants, 195 (98%) were in the analytic cohort. One hundred fourteen (57%) patients had at least one unmet medication need; the proportion of medication needs that were unmet was 6% (0–15%). Fifty-six (29%) patients were readmitted or died by 3 months; 10 (5%) died within 3 months. Unmet needs were not associated (risk ratio 1.25; 95% CI 0.75–2.1) with hospital readmission or death, although a higher proportion of unmet needs may have been associated with increased hospital readmission (risk ratio 1.7; 95% CI 0.96–3.1) and decreased mortality (risk ratio 0.13; 95% CI 0.02–0.99). Discussion Unmet medication needs are common among survivors of acute respiratory failure shortly after discharge home. The association of unmet medication needs with 3-month readmission and mortality is complex and requires additional investigation to inform clinical trials of interventions to reduce unmet medication needs. Study registration number: NCT03738774. The study was prospectively registered before enrollment of the first patient. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03848-3.
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Affiliation(s)
- Samuel M Brown
- Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, USA. .,Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, USA. .,Center for Humanizing Critical Care, Intermountain Medical Center, Salt Lake City, UT, USA. .,Shock Trauma ICU, Intermountain Medical Center, 5121 S. Cottonwood Street, Murray, UT, 84107, USA.
| | - Victor D Dinglas
- Outcomes After Critical Illness and Surgery (OACIS) Group and Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Narjes Akhlaghi
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Somnath Bose
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Sarah Beesley
- Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, USA.,Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, USA.,Center for Humanizing Critical Care, Intermountain Medical Center, Salt Lake City, UT, USA
| | - Danielle Groat
- Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, USA.,Center for Humanizing Critical Care, Intermountain Medical Center, Salt Lake City, UT, USA
| | - Tom Greene
- Biostatistics and Epidemiology, University of Utah, Salt Lake City, UT, USA
| | - Ramona O Hopkins
- Center for Humanizing Critical Care, Intermountain Medical Center, Salt Lake City, UT, USA.,Psychology Department and Neuroscience Center, Brigham Young University, Provo, UT, USA
| | - Mustafa Mir-Kasimov
- Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, USA.,Salt Lake City Veterans Administration, Salt Lake City, UT, USA
| | - Carla M Sevin
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alison E Turnbull
- Outcomes After Critical Illness and Surgery (OACIS) Group and Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | | | - Dale M Needham
- Outcomes After Critical Illness and Surgery (OACIS) Group and Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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Deep-Learning-Based Survival Prediction of Patients in Coronary Care Units. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2021:5745304. [PMID: 34976110 PMCID: PMC8720014 DOI: 10.1155/2021/5745304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 11/03/2021] [Accepted: 12/08/2021] [Indexed: 11/17/2022]
Abstract
Background A survival prediction model based on deep learning has higher accuracy than the CPH model in predicting the survival of CCU patients, and it also has a better discrimination ability. We collected information on patients with various diseases in coronary care units (CCUs) from the Medical Information Mart for Intensive Care III (MIMIC-III) database. The purpose of this study was to use this information to construct a neural-network model based on deep learning to predict the survival probabilities of patients with conditions that are common in CCUs. Method We collected information on patients in the United States with five common diseases in CCUs from 2001 to 2012. We randomly divided the patients into a training cohort and a testing cohort at a ratio of 7 : 3 and applied a survival prediction method based on deep learning to predict their survival probability. We compared our model with the Cox proportional-hazards regression (CPH) model and used the concordance indexes (C-indexes), receiver operating characteristic (ROC) curve, and calibration plots to evaluate the predictive performance of the model. Results The 3,388 CCU patients included in the study were randomly divided into 2,371 in the training cohort and 1,017 in the testing cohort. The stepwise regression results showed that the important factors affecting patient survival were the type of disease, age, race, anion gap, glucose, neutrophils, white blood cells, potassium, creatine kinase, and blood urea nitrogen (P < 0.05). We used the training cohort to construct a deep-learning model, for which the C-index was 0.833, or about 5% higher than that for the CPH model (0.786). The C-index of the deep-learning model for the test cohort was 0.822, which was also higher than that for the CPH model (0.782). The areas under the ROC curve for the 28-day, 90-day, and 1-year survival probabilities were 0.875, 0.865, and 0.874, respectively, in the deep-learning model, respectively, and 0.830, 0.843, and 0.806 in the CPH model. These values indicate that the survival analysis model based on deep learning is better than the traditional CPH model in predicting the survival of CCU patients. Conclusion A survival prediction model based on deep learning has higher accuracy than the CPH model in predicting the survival of CCU patients, and it also has a better discrimination ability.
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Crescioli E, Uldal Krejberg K, Lass Klitgaard T, Mølgaard Nielsen F, Barbateskovic M, Skrubbeltrang C, Hylander Møller M, Lilleholt Schjørring O, Steen Rasmussen B. The long-term effects of lower versus higher oxygenation levels in adult ICU patients - protocol for a systematic review. Acta Anaesthesiol Scand 2022; 66:145-151. [PMID: 34570915 PMCID: PMC8652878 DOI: 10.1111/aas.13984] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 09/20/2021] [Indexed: 01/04/2023]
Abstract
Background Many organs can remain impaired after discharge from the intensive care unit (ICU) leading to temporal or permanent dysfunctions. Long‐term impairments may be affected by supplemental oxygen, a common treatment in ICU, having both potential beneficial and harmful long‐lasting effects. This systematic review aims to assess the long‐term outcomes of lower versus higher oxygen supplementation and/or oxygenation levels in adults admitted to ICU. Methods We will include trials differentiating between a lower and a higher oxygen supplementation or a lower and a higher oxygenation strategy in adults admitted to the ICU. We will search major electronic databases and trial registers for randomised clinical trials. Two authors will independently screen and select references for inclusion using Covidence and predefined data will be extracted. The methodological quality and risk of bias of included trials will be evaluated using the Cochrane Risk of Bias tool 2. Meta‐analysis will be performed if two or more trials with comparable outcome measures will be included. Otherwise, a narrative description of the trials’ results will be presented instead. To assess the certainty of evidence, we will create a ‘Summary of findings’ table containing all prespecified outcomes using the GRADE system. The protocol is submitted on the PROSPERO database (ID 223630). Conclusion No systematic reviews on the impact of oxygen treatment in the ICU on long‐term outcomes, other than mortality and quality of life, have been reported yet. This systematic review will provide an overview of the current evidence and will help future research in the field.
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Affiliation(s)
- Elena Crescioli
- Department of Anaesthesia and Intensive Care Aalborg University Hospital Aalborg Denmark
- Department of Clinical Medicine Aalborg University Aalborg Denmark
- Collaboration for Research in Intensive Care Copenhagen Denmark
| | | | - Thomas Lass Klitgaard
- Department of Anaesthesia and Intensive Care Aalborg University Hospital Aalborg Denmark
- Department of Clinical Medicine Aalborg University Aalborg Denmark
- Collaboration for Research in Intensive Care Copenhagen Denmark
| | - Frederik Mølgaard Nielsen
- Department of Anaesthesia and Intensive Care Aalborg University Hospital Aalborg Denmark
- Department of Clinical Medicine Aalborg University Aalborg Denmark
- Collaboration for Research in Intensive Care Copenhagen Denmark
| | - Marija Barbateskovic
- Copenhagen Trial Unit Centre for Clinical Intervention Research Capital Region of Denmark Denmark
| | | | - Morten Hylander Møller
- Collaboration for Research in Intensive Care Copenhagen Denmark
- Department of Intensive Care, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Olav Lilleholt Schjørring
- Department of Anaesthesia and Intensive Care Aalborg University Hospital Aalborg Denmark
- Department of Clinical Medicine Aalborg University Aalborg Denmark
- Collaboration for Research in Intensive Care Copenhagen Denmark
| | - Bodil Steen Rasmussen
- Department of Anaesthesia and Intensive Care Aalborg University Hospital Aalborg Denmark
- Department of Clinical Medicine Aalborg University Aalborg Denmark
- Collaboration for Research in Intensive Care Copenhagen Denmark
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Hortová-Kohoutková M, De Zuani M, Lázničková P, Bendíčková K, Mrkva O, Andrejčinová I, Mýtniková A, Polanský O, Kočí K, Tomášková V, Šrámek V, Helán M, Frič J. Polymorphonuclear Cells Show Features of Dysfunctional Activation During Fatal Sepsis. Front Immunol 2021; 12:741484. [PMID: 34966382 PMCID: PMC8710474 DOI: 10.3389/fimmu.2021.741484] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 11/24/2021] [Indexed: 12/29/2022] Open
Abstract
Sepsis and septic shock remain leading causes of morbidity and mortality for patients in the intensive care unit. During the early phase, immune cells produce various cytokines leading to prompt activation of the immune system. Polymorphonuclear leukocytes (PMNs) respond to different signals producing inflammatory factors and executing their antimicrobial mechanisms, resulting in the engulfment and elimination of invading pathogens. However, excessive activation caused by various inflammatory signals produced during sepsis progression can lead to the alteration of PMN signaling and subsequent defects in their functionality. Here, we analyzed samples from 34 patients in septic shock, focusing on PMNs gene expression and proteome changes associated with septic shock. We revealed that, compared to those patients who survived longer than five days, PMNs from patients who had fulminant sepsis were characterized by a dysfunctional hyper-activation, show altered metabolism, and recent exit from the cell cycle and signs of cellular lifespan. We believe that this multi-omics approach, although limited, pinpoints the alterations in PMNs' functionality, which may be rescued by targeted treatments.
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Affiliation(s)
| | - Marco De Zuani
- International Clinical Research Center, St. Anne’s University Hospital, Brno, Czechia
| | - Petra Lázničková
- International Clinical Research Center, St. Anne’s University Hospital, Brno, Czechia
- Department of Biology, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Kamila Bendíčková
- International Clinical Research Center, St. Anne’s University Hospital, Brno, Czechia
| | - Ondřej Mrkva
- International Clinical Research Center, St. Anne’s University Hospital, Brno, Czechia
| | - Ivana Andrejčinová
- International Clinical Research Center, St. Anne’s University Hospital, Brno, Czechia
- Department of Biology, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Alexandra Mýtniková
- International Clinical Research Center, St. Anne’s University Hospital, Brno, Czechia
| | - Ondřej Polanský
- International Clinical Research Center, St. Anne’s University Hospital, Brno, Czechia
| | - Kamila Kočí
- International Clinical Research Center, St. Anne’s University Hospital, Brno, Czechia
| | - Veronika Tomášková
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Vladimír Šrámek
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Martin Helán
- International Clinical Research Center, St. Anne’s University Hospital, Brno, Czechia
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Jan Frič
- International Clinical Research Center, St. Anne’s University Hospital, Brno, Czechia
- Department of Modern Immunotherapy, Institute of Hematology and Blood Transfusion, Prague, Czechia
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Outcomes of daytime nurse practitioner-staffed versus resident-staffed nonsurgical intensive care units: A retrospective observational study. Aust Crit Care 2021; 35:630-635. [PMID: 34857440 DOI: 10.1016/j.aucc.2021.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 10/10/2021] [Accepted: 10/10/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Rapid developments in medical care-such as monitoring devices, medications, and working hours restrictions for intensive care personnel-have dramatically increased the demand for intensive care physicians. Therefore, nurse practitioner (NP)-staffed care is becoming increasingly important. This study was aimed to compare the outcomes of daytime NP-staffed and daytime resident-staffed nonsurgical intensive care units (ICU). METHODS We retrospectively assessed patients admitted to a nonsurgical ICU from March 2017 to December 2017. We collected basic patient data, including age, sex, admission diagnosis, transferring unit, and Acute Physiology and Chronic Health Evaluation II (APACHE II) score. Primary endpoints were ICU mortality, hospital mortality, and 30-day mortality. Secondary endpoints were 48-h readmission, discharge to nonhome locations, and lengths of ICU and hospital stay. RESULTS A total of 838 subjects were analysed: 334 subjects in the NP-staffed group and 504 in the resident-staffed group. The NP-staffed group was more likely to come from inpatient units (38.3% vs 16.5% for resident-staffed group; p < 0.001) and had lower disease severity (APACHE II score, 13.9 ± 8.4 vs 15.1 ± 8.2 for resident-staffed group; p = 0.047). After adjusting for age, sex, location before ICU admission, APACHE II score, and significantly different basic characteristics, there were no differences in ICU mortality, hospital mortality, or 30-day mortality between the two groups. Secondary analysis showed the NP-staffed group had a lower discharge rate to nonhome locations (2.1% vs 6.3%; p = 0.023) and shorter hospital stay (12.1 ± 14.1 vs 14.2 ± 14.3 days; p = 0.015). CONCLUSIONS We observed no difference in mortality between daytime NP-staffed and resident-staffed nonsurgical ICUs. Daytime NP-staffed care is an effective, safe, feasible method for staffing nonsurgical ICUs.
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91
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Vassiliadi DA, Vassiliou AG, Ilias I, Tsagarakis S, Kotanidou A, Dimopoulou I. Pituitary-Adrenal Responses and Glucocorticoid Receptor Expression in Critically Ill Patients with COVID-19. Int J Mol Sci 2021; 22:11473. [PMID: 34768903 PMCID: PMC8584241 DOI: 10.3390/ijms222111473] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 10/18/2021] [Accepted: 10/21/2021] [Indexed: 12/15/2022] Open
Abstract
The hypothalamus-pituitary-adrenal (HPA) axis was described as the principal component of the stress response 85 years ago, along with the acute-phase reaction, and the defense response at the tissue level. The orchestration of these processes is essential since systemic inflammation is a double-edged sword; whereas inflammation that is timely and of appropriate magnitude is beneficial, exuberant systemic inflammation incites tissue damage with potentially devastating consequences. Apart from its beneficial cardiovascular and metabolic effects, cortisol exerts a significant immunoregulatory role, a major attribute being that it restrains the excessive inflammatory reaction, thereby preventing unwanted tissue damage. In this review, we will discuss the role of the HPA axis in the normal stress response and in critical illness, especially in critically ill patients with coronavirus disease 2019 (COVID-19). Finally, a chapter will be dedicated to the findings from clinical studies in critical illness and COVID-19 on the expression of the mediator of glucocorticoid actions, the glucocorticoid receptor (GCR).
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Affiliation(s)
- Dimitra A. Vassiliadi
- Department of Endocrinology, Diabetes and Metabolism, National Expertise Centre for Rare Endocrine Diseases, Evangelismos Hospital, 106 76 Athens, Greece; (D.A.V.); (S.T.)
| | - Alice G. Vassiliou
- First Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National & Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece; (A.G.V.); (A.K.)
| | - Ioannis Ilias
- Department of Endocrinology, Helena Venizelos Hospital, 115 21 Athens, Greece;
| | - Stylianos Tsagarakis
- Department of Endocrinology, Diabetes and Metabolism, National Expertise Centre for Rare Endocrine Diseases, Evangelismos Hospital, 106 76 Athens, Greece; (D.A.V.); (S.T.)
| | - Anastasia Kotanidou
- First Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National & Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece; (A.G.V.); (A.K.)
| | - Ioanna Dimopoulou
- First Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National & Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece; (A.G.V.); (A.K.)
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Song W, Mobli K, Jupiter DC, Radhakrishnan RS. CVP and echo Measurements are Associated with Improved Outcomes in Patients with Gastrointestinal (GI) Hemorrhage: A Retrospective Analysis of the MIMIC- IV Database. J Intensive Care Med 2021; 37:925-935. [PMID: 34636687 DOI: 10.1177/08850666211046175] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Purpose: Mortality associated with acute Gastrointestinal (GI) hemorrhage in intensive care units (ICU) has remained high in patients suffering from hemodynamic instability. Prompt recognition and rapid assessment of bleeding severity are crucial to improve survival. Central venous pressure (CVP) monitoring is commonly used for early recognition of intravascular imbalances, but its effectiveness in predicting fluid responsiveness is often questioned. Echocardiography (echo) is a rapid, noninvasive method to repeatedly assess cardiac function and fluid responsiveness. This study investigated the impact of CVP and echo measurements on the outcomes of critically ill patients with GI hemorrhage. Methods: The study was based on the Medical Information Mart for Intensive Care IV (MIMIC- IV) database. Patients were divided into four groups according to the usage of CVP and/or echo. The primary outcomes were 7-day, 14-day, 28-day, and overall mortalities after ICU admission. Cox Proportional-Hazards Models were used to elucidate the relationship between CVP/ Echo monitoring and mortality. The severity of illness of patients were adjusted by qSOFA score, SOFA score and base deficit level at admission. Results: Among 1705 eligible patients, 82 patients had both CVP and echo, 85 had CVP only, and 116 had Echo only. The results of survival analysis indicated that, comparing with those without either CVP or echo, the echo utilization was associated with improved mortalities at all time points during ICU stay for patients with moderate GI hemorrhage, and the combined use of CVP and echo was associated with lower 7-day,14-day and overall mortalities for patients with severe GI hemorrhage. Conclusion: Early usage of CVP and echo monitoring or echo alone are associated with lower mortality in the short and long-term when compared to patients without either measurement. Clinicians should consider goal-directed resuscitation guided by echo with/without CVP in patients with GI hemorrhage early after admission to ICU.
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Affiliation(s)
- Wenye Song
- 12338 Department of Surgery and Pediatrics, University of Texas Medical Branch, Texas, USA.,12338 Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Texas, USA
| | - Keyan Mobli
- 12338 Department of Surgery and Pediatrics, University of Texas Medical Branch, Texas, USA
| | - Daniel C Jupiter
- 12338 Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Texas, USA
| | - Ravi S Radhakrishnan
- 12338 Department of Surgery and Pediatrics, University of Texas Medical Branch, Texas, USA
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Maguigan KL, Al-Shaer MH, Peloquin CA. Beta-Lactams Dosing in Critically Ill Patients with Gram-Negative Bacterial Infections: A PK/PD Approach. Antibiotics (Basel) 2021; 10:1154. [PMID: 34680734 PMCID: PMC8532626 DOI: 10.3390/antibiotics10101154] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 09/17/2021] [Accepted: 09/20/2021] [Indexed: 12/12/2022] Open
Abstract
Beta-lactam antibiotics are often the backbone of treatment for Gram-negative infections in the critically ill. Beta-lactams exhibit time-dependent killing, and their efficacy depends on the percentage of dosing interval that the concentration remains above the minimum inhibitory concentration. The Gram-negative resistance rates of pathogens are increasing in the intensive care unit (ICU), and critically ill patients often possess physiology that makes dosing more challenging. The volume of distribution is usually increased, and drug clearance is variable. Augmented renal clearance and hypermetabolic states increase the clearance of beta-lactams, while acute kidney injury reduces the clearance. To overcome the factors affecting ICU patients and decreasing susceptibilities, dosing strategies involving higher doses, and extended or continuous infusions may be required. In this review, we specifically examined pharmacokinetic models in ICU patients, to determine the desired beta-lactam regimens for clinical breakpoints of Enterobacterales and Pseudomonas aeruginosa, as determined by the European Committee on Antimicrobial Susceptibility Testing. The beta-lactams evaluated included penicillins, cephalosporins, carbapenems, and monobactams. We found that when treating less-susceptible pathogens, especially P. aeruginosa, continuous infusions are frequently needed to achieve the desired pharmacokinetic/pharmacodynamic targets. More studies are needed to determine optimal dosing strategies in the novel beta-lactams.
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Affiliation(s)
- Kelly L. Maguigan
- Pharmacy Department, University of Florida Health Shands Hospital, Gainesville, FL 32608, USA;
| | - Mohammad H. Al-Shaer
- Infectious Disease Pharmacokinetics Lab, College of Pharmacy and Emerging Pathogens Institute, University of Florida, Gainesville, FL 32610, USA;
| | - Charles A. Peloquin
- Infectious Disease Pharmacokinetics Lab, College of Pharmacy and Emerging Pathogens Institute, University of Florida, Gainesville, FL 32610, USA;
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94
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Evaluating the Balance Between Privacy and Access in Digital Information Sharing. Crit Care Med 2021; 50:e109-e116. [PMID: 34637416 PMCID: PMC8797001 DOI: 10.1097/ccm.0000000000005234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Supplemental Digital Content is available in the text. Access to personal health records in an ICU by persons involved in the patient’s care (referred to broadly as “family members” below) has the potential to increase engagement and reduce the negative psychologic sequelae of such hospitalizations. Currently, little is known about patient preferences for information sharing with a designated family member in the ICU. We sought to understand the information-sharing preferences of former ICU patients and their family members and to identify predictors of information-sharing preferences.
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95
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Gareau S, de Oliveira ÉM, Gallani MC. Humanization of care for adult ICU patients: a scoping review protocol. JBI Evid Synth 2021; 20:647-657. [PMID: 34555837 DOI: 10.11124/jbies-20-00481] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE The objective of this review is to review and map data from studies on the humanization of care in intensive care units based on a conceptual framework. INTRODUCTION The critical context of adult patients in intensive care units directs the focus on clinical medical interventions, drawing attention away from the humanization of care. Rethinking intensive care is imperative and the humanization of care is an absolute priority. Literature on this topic is scattered under umbrella terms such as "patient-centered care" or specific terms referring to target interventions. A scoping review based on a conceptual framework could map the literature on humanization in intensive care units. INCLUSION CRITERIA The review will consider studies on the humanization of care, or on one of the seven components of the conceptual framework (communication, visiting hours, patients' and health care professionals' well-being, family involvement and satisfaction, post-intensive care unit syndrome, and physical environment) focusing on adult patients in intensive care units. Studies on co-existing states or end-of-life care will be excluded. METHODS A search of Embase, PubMed, and CINAHL will be conducted to identify relevant studies in English or French on the humanization of care, holistic care, or person-centered care in an adult intensive-care environment. The time period covered will be January 1, 2010 to the present. An iterative team approach will be used to screen and select studies and extract data. Data will be charted according to study design, distribution in time, cultural context, concepts, use of theoretical models, and intervention. The results will be summarized and reported, identifying the implications for policy, practice, and research.
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Affiliation(s)
- Stéphanie Gareau
- School of Nursing Sciences, Faculty of Nursing, Université Laval, Quebec, Canada Quebec Heart and Lung Research Centre- Université Laval, Quebec, Canada CHU de Québec- Université Laval, Quebec, Canada
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96
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Ramnarain D, Aupers E, den Oudsten B, Oldenbeuving A, de Vries J, Pouwels S. Post Intensive Care Syndrome (PICS): an overview of the definition, etiology, risk factors, and possible counseling and treatment strategies. Expert Rev Neurother 2021; 21:1159-1177. [PMID: 34519235 DOI: 10.1080/14737175.2021.1981289] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Post-intensive care syndrome (PICS) has only recently been recognized as a new clinical entity in patients surviving their intensive care unit (ICU) stay due to critical illness. With increasing survival rates of ICU patients worldwide, there is a rising interest regarding post-ICU recovery. AREAS COVERED First, based on the current literature a definition is provided of PICS, including the domains of impairments that comprise PICS along with the etiology and risk factors. Second, preventive measures and possible treatment strategies integrated in the follow-up care are described. Third, the authors will discuss the current SARS-Cov-2 pandemic and the increased risk of PICS in these post-ICU patients and their families. EXPERT OPINION PICS is a relatively new entity, which not only encompasses various physical, cognitive, and psychological impairments but also impacts global health due to long-lasting detrimental socioeconomic burdens. Importantly, PICS also relates to caregivers of post-ICU patients. Strategies to reduce this burden will not only be needed within the ICU setting but will also have to take place in an interdisciplinary, multifaceted approach in primary care settings. Additionally, the SARS-Cov-2 pandemic has a high burden on post-ICU patients and their relatives.
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Affiliation(s)
- Dharmanand Ramnarain
- Department of Intensive Care Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands.,Department of Medical and Clinical Psychology, Center of Research on Psychological and Somatic Disease (Corps), Tilburg University, Tilburg, The Netherlands.,Department of Intensive Care Medicine, Saxenburg Medisch Centrum Hardenberg, The Netherlands
| | - Emily Aupers
- Department of Intensive Care Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Brenda den Oudsten
- Department of Medical and Clinical Psychology, Center of Research on Psychological and Somatic Disease (Corps), Tilburg University, Tilburg, The Netherlands
| | - Annemarie Oldenbeuving
- Department of Intensive Care Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Jolanda de Vries
- Department of Medical and Clinical Psychology, Center of Research on Psychological and Somatic Disease (Corps), Tilburg University, Tilburg, The Netherlands.,Board, ADRZ (Admiraal De Ruyter Ziekenhuis), Goes, The Netherlands
| | - Sjaak Pouwels
- Department of Intensive Care Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
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97
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Ireland M, Jalilvand A, Gonzalez-Gallo K, Strassels S, Villarreal M, Wisler J. Transfer Status and 90-Day Mortality in ICU Patients with Sepsis: A Propensity Matched Analysis. J Surg Res 2021; 268:595-605. [PMID: 34464897 DOI: 10.1016/j.jss.2021.07.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 07/10/2021] [Accepted: 07/14/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Timely identification and management of sepsis in surgical patients is crucial, and transfer status may delay optimal treatment of these patients. The objective of this study was to compare in-house and 90-day mortality between patients primarily admitted or transferred into the surgical ICU (SICU) at a tertiary referral center. MATERIAL AND METHODS All patients admitted to the SICU with a diagnosis of sepsis (Sepsis III) were reviewed at a single institution between 2014 to 2019 (n = 1489). Demographics, comorbidities, and sepsis presentation were compared between transferred (n = 696) and primary patients (n = 793). Primary outcomes evaluated were in-house and 90 day mortality in an unmatched and propensity score matched cohorts. A P value < 0.05 was considered statistically significant. RESULTS Transfer patients were more likely to have obesity (60% versus 49%, P < 0.005), a higher median SOFA (6 (4-8) versus 5 (3-8), P = 0.007), and require vasopressors on admission (42% versus 35%, P = 0.004). Compared to primary patients, transfer patients exhibited higher rates of respiratory failure (76% versus 69%, P = 0.003), in-house (30% versus 17%, P < 0.005), and 90 day mortality (36% versus 24%, P < 0.005). After matching, transferred patients were associated with 75% and 83% increased odds of in-house and 90 day mortality after controlling for age, sex, race, comorbidities, BMI, and sepsis severity. CONCLUSIONS Transfer status is associated with an over 80% increase in the odds of 90 day mortality for patients admitted to the SICU with sepsis. Aggressive patient identification and earlier transfer of those at higher risk of death may reduce this effect.
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Affiliation(s)
| | - Anahita Jalilvand
- The Ohio State University, Department of General Surgery, Columbus, OH
| | | | - Scott Strassels
- The Ohio State University, Department of General Surgery, Columbus, OH
| | | | - Jon Wisler
- The Ohio State University, Department of General Surgery, Columbus, OH.
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98
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Kazibwe J, Shah HA, Kuwawenaruwa A, Schell CO, Khalid K, Tran PB, Ghosh S, Baker T, Guinness L. Resource availability, utilisation and cost in the provision of critical care in Tanzania: a protocol for a systematic review. BMJ Open 2021; 11:e050881. [PMID: 34433607 PMCID: PMC8388301 DOI: 10.1136/bmjopen-2021-050881] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 08/16/2021] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Critical care is essential in saving lives of those that are critically ill, however, provision of critical care can be costly and heterogeneous across lower-resource settings. This paper describes the protocol for a systematic review of the literature that aims to identify the reported costs and resources available for the provision of critical care and the forms of critical care provision in Tanzania. METHODS AND ANALYSIS The review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Three databases (MEDLINE, Embase and Global Health) will be searched to identify articles that report the forms of critical care, resources used in the provision of critical care in Tanzania, their availability and the associated costs. The search strategy will be developed from four key concepts; critical care provision, critical illness, resource use, Tanzania. The articles that fulfil the inclusion and exclusion criteria will be assessed for quality using the Reference Case for Estimating the Costs of Global Health Services and Interventions checklist. The extracted data will be summarised using descriptive statistics including frequencies, mean and median of the quantity and costs of resources used in the components of critical care services, depending on the data availability. This study will be carried out between February and November 2021. ETHICS AND DISSEMINATION This study is a review of secondary data and ethical clearance was sought from and granted by the Tanzanian National Institute of Medical Research (reference: NIMR/HQ/R.8a/Vol. IX/3537) and London School of Hygiene and Tropical Medicine (ethics ref: 22866). We will publish the review in a peer-reviewed journal as an open access article in addition to presenting the findings at conferences and public scientific gatherings. PROSPERO REGISTRATION NUMBER The protocol was registered with PROSPERO; registration number: CRD42020221923.
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Affiliation(s)
- Joseph Kazibwe
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Hiral A Shah
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
- Department of Infectious Disease Epidemiology, Center for Global Development, London, UK
| | - A Kuwawenaruwa
- Health System Impact Evaluation and Policy Unit, Ifakara Health Institute, Ifakara, United Republic of Tanzania
| | - Carl Otto Schell
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Global Public Health, Uppsala University, Uppsala, Sweden
| | - Karima Khalid
- Health System Impact Evaluation and Policy Unit, Ifakara Health Institute, Ifakara, United Republic of Tanzania
- Department of Anaesthesia and Critical Care, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Phuong Bich Tran
- Department of Family and Population Health, University of Antwerp, Antwerpen, Belgium
| | - Srobana Ghosh
- Global Health Department, Center for Global Development, London, UK
| | - Tim Baker
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Lorna Guinness
- Global Health Department, Center for Global Development, London, UK
- Global Health & Development, London School of Hygiene and Tropical Medicine, London, UK
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99
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Téblick A, Langouche L, Van den Berghe G. Endocrine interventions in the intensive care unit. HANDBOOK OF CLINICAL NEUROLOGY 2021; 182:417-431. [PMID: 34266609 DOI: 10.1016/b978-0-12-819973-2.00028-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Following the onset of any life-threatening illness that requires intensive medical care, alterations within the neuroendocrine axes occur which are thought to be essential for survival, as they postpone energy-consuming anabolism, activate energy-producing catabolic pathways, and optimize immunological and cardiovascular functions. The hormonal changes present in the acute phase of critical illness at least partially resemble those of the fasting state, and recent evidence suggests that they are part of a beneficial, evolutionary-conserved adaptive stress response. However, a fraction of patients who survive the acute phase of critical illness remain dependent on vital organ support and enter the prolonged phase of critical illness. In these patients, the hypothalamic-pituitary-peripheral axes are functionally suppressed, which may have negative consequences by which recovery may be hampered and the risk of morbidity and mortality in the long-term increased. Most randomized controlled trials of critically ill patients that investigated the impact on the outcome of treatment with peripheral hormones did not reveal a robust morbidity or mortality benefit. In contrast, small studies of patients in the prolonged phase of critical illness documented promising results with the infusion of hypothalamic-releasing hormones. The currently available data corroborate the need for well-designed and adequately powered RCTs to further investigate the impact of these releasing factors on patient-centered outcomes.
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Affiliation(s)
- Arno Téblick
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University, Leuven, Belgium
| | - Lies Langouche
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University, Leuven, Belgium
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University, Leuven, Belgium.
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Shahn Z, Lehman LWH, Mark RG, Talmor D, Bose S. Delaying initiation of diuretics in critically ill patients with recent vasopressor use and high positive fluid balance. Br J Anaesth 2021; 127:569-576. [PMID: 34256925 DOI: 10.1016/j.bja.2021.04.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 04/18/2021] [Accepted: 04/28/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Fluid overload is associated with poor outcomes. Clinicians might be reluctant to initiate diuretic therapy for patients with recent vasopressor use. We estimated the effect on 30-day mortality of withholding or delaying diuretics after vasopressor use in patients with probable fluid overload. METHODS This was a retrospective cohort study of adults admitted to ICUs of an academic medical centre between 2008 and 2012. Using a database of time-stamped patient records, we followed individuals from the time they first required vasopressor support and had >5 L cumulative positive fluid balance (plus additional inclusion/exclusion criteria). We compared mortality under usual care (the mix of care actually delivered in the cohort) and treatment strategies restricting diuretic initiation during and for various durations after vasopressor use. We adjusted for baseline and time-varying confounding via inverse probability weighting. RESULTS The study included 1501 patients, and the observed 30-day mortality rate was 11%. After adjusting for observed confounders, withholding diuretics for at least 24 h after stopping most recent vasopressor use was estimated to increase 30-day mortality rate by 2.2% (95% confidence interval [CI], 0.9-3.6%) compared with usual care. Data were consistent with moderate harm or slight benefit from withholding diuretic initiation only during concomitant vasopressor use; the estimated mortality rate increased by 0.5% (95% CI, -0.2% to 1.1%). CONCLUSIONS Withholding diuretic initiation after vasopressor use in patients with high cumulative positive balance (>5 L) was estimated to increase 30-day mortality. These findings are hypothesis generating and should be tested in a clinical trial.
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Affiliation(s)
- Zachary Shahn
- MIT-IBM Watson AI Lab, Cambridge, MA, USA; IBM Research, Yorktown Heights, NY, USA
| | - Li-Wei H Lehman
- MIT-IBM Watson AI Lab, Cambridge, MA, USA; Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Roger G Mark
- Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Daniel Talmor
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Somnath Bose
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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