Impact of follow-up consultations for ICU survivors on post-ICU syndrome: a systematic review and meta-analysis

Neuroanatomy and Physiology of Brain Dysfunction in Sepsis

Sepsis-associated encephalopathy (SAE), a complication of sepsis, is often complicated by acute and long-term brain dysfunction. SAE is associated with electroencephalogram pattern changes and abnormal neuroimaging findings. The major processes involved are neuroinflammation, circulatory dysfunction, and excitotoxicity. Neuroinflammation and microcirculatory alterations are diffuse, whereas excitotoxicity might occur in more specific structures involved in the response to stress and the control of vital functions. A dysfunction of the brainstem, amygdala, and hippocampus might account for the increased mortality, psychological disorders, and cognitive impairment. This review summarizes clinical and paraclinical features of SAE and describes its mechanisms at cellular and structural levels.

Towards a new orientation: a qualitative longitudinal study of an intensive care recovery programme

AIMS AND OBJECTIVES

To describe the patient experience of ICU recovery from a longitudinal perspective by analysing follow-up consultations at three time-points.

BACKGROUND

After a stay in the intensive care unit, patients risk physical and psychological problems during recovery. Follow-up after intensive care has emerged to aid psychological recovery, and improve health-related quality of life. More insight is needed into the mechanisms of intensive care recovery.

DESIGN

A descriptive multicenter longitudinal qualitative design.

METHODS

A subsample of 36 consultations with 12 patients strategically selected from a randomised controlled trial on intensive care recovery from 10 Danish intensive care units. Data were generated during an ICU recovery programme including three consultations (at 1-3, 4-5, 9-11 months). First consultation was face-to-face using patient photographs to aid memory. Second and third consultations were by telephone using reflection sheets to focus dialogue. Thematic analysis and narrative theory were used to explore mechanisms of recovery using audio-recordings of consultations, patient photographs and reflection sheets as the sources of data.

RESULTS

The basic narrative of recovery was 'toward a trajectory of new orientation'. This narrative contained the chronological narratives of being 'at death's door', 'still not out of the woods' and 'on the road to recovery'. The road to recovery was described as downhill, steady-state or progressive. New orientation was obtained in steady-state or progressive recovery.

CONCLUSIONS

This study provides a contemporary understanding of the process of intensive care recovery. Recovery evolves through narratives of mortal danger, risk of relapse and moving forward towards a new orientation in life.

RELEVANCE TO CLINICAL PRACTICE

These findings enable health care professionals to understand what patients experience during stages of recovery. This is important to improve health care professionals in the assessment of long-term outcome, and management of patients after intensive care.

PReventing early unplanned hOspital readmission aFter critical ILlnEss (PROFILE): protocol and analysis framework for a mixed methods study

INTRODUCTION

Survivors of critical illness experience multidimensional disabilities that reduce quality of life, and 25-30% require unplanned hospital readmission within 3 months following index hospitalisation. We aim to understand factors associated with unplanned readmission; develop a risk model to identify intensive care unit (ICU) survivors at highest readmission risk; understand the modifiable and non-modifiable readmission drivers; and develop a risk assessment tool for identifying patients and areas for early intervention.

METHODS AND ANALYSIS

We will use mixed methods with concurrent data collection. Quantitative data will comprise linked healthcare records for adult Scottish residents requiring ICU admission (1 January 2000-31 December 2013) who survived to hospital discharge. The outcome will be unplanned emergency readmission within 90 days of index hospital discharge. Exposures will include pre-ICU demographic data, comorbidities and health status, and critical illness variables representing illness severity. Regression analyses will be used to identify factors associated with increased readmission risk, and to develop and validate a risk prediction model. Qualitative data will comprise recorded/transcribed interviews with up to 60 patients and carers recently experiencing unplanned readmissions in three health board regions. A deductive and inductive thematic analysis will be used to identify factors contributing to readmissions and how they may interact. Through iterative triangulation of quantitative and qualitative data, we will develop a construct/taxonomy that captures reasons and drivers for unplanned readmission. We will validate and further refine this in focus groups with patients/carers who experienced readmissions in six Scottish health board regions, and in consultation with an independent expert group. A tool will be developed to screen for ICU survivors at risk of readmission and inform anticipatory interventions.

ETHICS AND DISSEMINATION

Data linkage has approval but does not require ethical approval. The qualitative study has ethical approval. Dissemination with key healthcare stakeholders and policymakers is planned.

TRIAL REGISTRATION NUMBER

UKCRN18023.

The Intensive care unit specialist: Report from the Task Force of World Federation of Societies of Intensive and Critical Care Medicine

The role of the critical care specialist has been unequivocally established in the management of severely ill patients throughout the world. Data show that the presence of a critical care specialist in the intensive care unit (ICU) environment has reduced morbidity and mortality, improved patient safety, and reduced length of stay and costs. However, many ICUs across the world function as "open ICUs," in which patients may be admitted under a primary physician who has not been trained in critical care medicine. Although the concept of the ICU has gained widespread acceptance amongst medical professionals, hospital administrators and the general public; recognition and the need for doctors specializing in intensive care medicine has lagged behind. The curriculum to ensure appropriate training around the world is diverse but should ideally meet some minimum standards. The World Federation of Societies of Intensive and Critical Care Medicine has set up a task force to address issues concerning the training, functions, roles, and responsibilities of an ICU specialist.

Survivors of intensive care with type 2 diabetes and the effect of shared care follow-up clinics: study protocol for the SWEET-AS randomised controlled feasibility study

BACKGROUND

Many patients who survive the intensive care unit (ICU) experience long-term complications such as peripheral neuropathy and nephropathy which represent a major source of morbidity and affect quality of life adversely. Similar pathophysiological processes occur frequently in ambulant patients with diabetes mellitus who have never been critically ill. Some 25 % of all adult ICU patients have diabetes, and it is plausible that ICU survivors with co-existing diabetes are at heightened risk of sequelae from their critical illness. ICU follow-up clinics are being progressively implemented based on the concept that interventions provided in these clinics will alleviate the burdens of survivorship. However, there is only limited information about their outcomes. The few existing studies have utilised the expertise of healthcare professionals primarily trained in intensive care and evaluated heterogenous cohorts. A shared care model with an intensivist- and diabetologist-led clinic for ICU survivors with type 2 diabetes represents a novel targeted approach that has not been evaluated previously. Prior to undertaking any definitive study, it is essential to establish the feasibility of this intervention.

METHODS

This will be a prospective, randomised, parallel, open-label feasibility study. Eligible patients will be approached before ICU discharge and randomised to the intervention (attending a shared care follow-up clinic 1 month after hospital discharge) or standard care. At each clinic visit, patients will be assessed independently by both an intensivist and a diabetologist who will provide screening and targeted interventions. Six months after discharge, all patients will be assessed by blinded assessors for glycated haemoglobin, peripheral neuropathy, cardiovascular autonomic neuropathy, nephropathy, quality of life, frailty, employment and healthcare utilisation. The primary outcome of this study will be the recruitment and retention at 6 months of all eligible patients.

DISCUSSION

This study will provide preliminary data about the potential effects of critical illness on chronic glucose metabolism, the prevalence of microvascular complications, and the impact on healthcare utilisation and quality of life in intensive care survivors with type 2 diabetes. If feasibility is established and point estimates are indicative of benefit, funding will be sought for a larger, multi-centre study.

TRIAL REGISTRATION

ANZCTR ACTRN12616000206426.