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Post-ICU Care: If You Build It, Will They Come… and How Do You Build It? Crit Care Med 2020; 47:1269-1270. [PMID: 31415311 DOI: 10.1097/ccm.0000000000003876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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152
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Learning from Discharge Experiences of Intensive Care Unit Survivors and Their Families: Is Consistency a Solution? Ann Am Thorac Soc 2020; 16:1369-1371. [PMID: 31674819 DOI: 10.1513/annalsats.201908-603ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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153
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Health Insurance and Out-of-Pocket Costs in the Last Year of Life Among Decedents Utilizing the ICU. Crit Care Med 2020; 47:749-756. [PMID: 30889026 DOI: 10.1097/ccm.0000000000003723] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Use of intensive care is increasing in the United States and may be associated with high financial burden on patients and their families near the end of life. Our objective was to estimate out-of-pocket costs in the last year of life for individuals who required intensive care in the months prior to death and examine how these costs vary by insurance coverage. DESIGN Observational cohort study using seven waves of post-death interview data (2002-2014). PARTICIPANTS Decedents (n = 2,909) who spent time in the ICU at some point between their last interview and death. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Two-part models were used to estimate out-of-pocket costs for direct medical care and health-related services by type of care and insurance coverage. Decedents with only traditional Medicare fee-for-service coverage have the highest out-of-pocket spending in the last year of life, estimated at $12,668 (95% CI, $9,744-15,592), second to only the uninsured. Medicare Advantage and private insurance provide slightly more comprehensive coverage. Individuals who spend-down to Medicaid coverage have 4× the out-of-pocket spending as those continuously on Medicaid. CONCLUSIONS Across all categories of insurance coverage, out-of-pocket spending in the last 12 months of life is high and represents a significant portion of assets for many patients requiring intensive care and their families. Medicare fee-for-service alone does not insulate individuals from the financial burden of high-intensity care, due to lack of an out-of-pocket maximum and a relatively high co-payment for hospitalizations. Medicaid plays an important role in the social safety net, providing the most complete hospital coverage of all the insurance groups, as well as significantly financing long-term care.
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154
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Potential role of adipose tissue and its hormones in burns and critically III patients. Burns 2020; 46:259-266. [DOI: 10.1016/j.burns.2019.01.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Revised: 12/17/2018] [Accepted: 01/30/2019] [Indexed: 12/26/2022]
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155
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Almansour IM, Ahmad MM, Alnaeem MM. Characteristics, Mortality Rates, and Treatments Received in Last Few Days of Life for Patients Dying in Intensive Care Units: A Multicenter Study. Am J Hosp Palliat Care 2020; 37:761-766. [DOI: 10.1177/1049909120902976] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background: Information is presently lacking about the end-of-life care in intensive care unit (ICU). We explored the characteristics, mortality rates, and treatments received in the last few days of life for patients who died in ICU. Methods: This was a retrospective multicenter cohort study. We included patients who died from different medical illnesses between January 2014 and January 2017 in 8 medical ICUs across 3 major health-care systems in Jordan. Of 11 029 patients who were admitted for the study in ICUs, data from 3885 health records were retrieved and analyzed. Pediatric patients aged younger than 18 years and patients admitted to an ICU for less than 4 hours were excluded. Results: The mean ICU mortality rate was 34.6% (29%-38%), with a slight decline from 2014 through 2016. Most of the patients who died were male (56.6%), transferred from the emergency department (46.8%), and had multiple comorbidities (74%). Cardiopulmonary resuscitation, invasive mechanical ventilation, pharmacological hemodynamic support, and artificial hydration were pursued until death for most patients (91.5%, 80.1%, 78.8%, and 94.1%, respectively). Conclusions: Aggressive treatment modalities were usually pursued for critically ill patients at the end of their lives. There is a need to explore further the current end-of-life care needs and practices in ICUs in Jordan and to tailor end-of-life care and management suitably to meet the needs of Islamic and Arabic cultures.
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156
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Gaudry S, Quenot JP, Hertig A, Barbar SD, Hajage D, Ricard JD, Dreyfuss D. Timing of Renal Replacement Therapy for Severe Acute Kidney Injury in Critically Ill Patients. Am J Respir Crit Care Med 2020; 199:1066-1075. [PMID: 30785784 DOI: 10.1164/rccm.201810-1906cp] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Acute kidney injury (AKI) affects many ICU patients and is responsible for increased morbidity and mortality. Although lifesaving in many situations, renal replacement therapy (RRT) may be associated with complications, and the appropriate timing of its initiation is still the subject of intense debate. An early initiation strategy can prevent some metabolic complications, whereas a delayed one may allow for renal function recovery in some patients without need for this costly and potentially dangerous technique. For years, most of the knowledge on this issue stemmed from observational studies or small randomized controlled trials. Recent randomized controlled trials have indicated that a watchful waiting strategy (in the absence of life-threatening conditions such as severe hyperkalemia or pulmonary edema) during severe AKI allowed many patients to escape RRT and did not seem to adversely affect survival compared with a strategy of immediate RRT. In addition, data suggest that a delayed strategy may reduce the rate of complications (such as catheter infection) and favor renal function recovery. Ongoing studies will have to both confirm these conclusions and clarify to what extent the delay in initiating RRT can be prolonged. Pending those results, the bulk of evidence suggests that, in the absence of potential severe complications of AKI, delaying RRT is a valid and safe strategy that may also allow for considerable cost savings.
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Affiliation(s)
- Stéphane Gaudry
- 1 AP-HP, Hôpital Avicenne, Service de Réanimation Médico-Chirurgicale, Bobigny, France.,2 INSERM UMR S 1155 "Common and Rare Kidney Diseases: from Molecular Events to Precision Medicine," and.,3 Health Care Simulation Center, UFR SMBH, Université Paris 13, Sorbonne Paris Cité, Bobigny, France
| | - Jean-Pierre Quenot
- 4 Department of Intensive Care, François Mitterrand University Hospital, Dijon, France.,5 Lipness Team, INSERM Research Center, LNC-UMR1231 and LabEx LipSTIC, and.,6 INSERM CIC 1432, Clinical Epidemiology, University of Burgundy, Dijon, France
| | - Alexandre Hertig
- 2 INSERM UMR S 1155 "Common and Rare Kidney Diseases: from Molecular Events to Precision Medicine," and.,7 Renal ICU and Transplantation, Sorbonne Universités, Hôpital Tenon, AP-HP, Paris, France
| | - Saber Davide Barbar
- 8 Unité de Réanimation Médicale, CHU de Nîmes - Hôpital Carémeau, Nîmes, France
| | - David Hajage
- 9 Département Biostatistique Santé Publique et Information Médicale, Centre de Pharmacoépidémiologie (Cephepi), Sorbonne Université, CIC-1421, AP-HP, Hôpital Pitié Salpêtrière, Paris, France.,10 INSERM, UMR 1123, ECEVE, Paris, France
| | - Jean-Damien Ricard
- 11 AP-HP, Hôpital Louis Mourier, Service de Réanimation Médico-Chirurgicale, Colombes, France.,12 IAME, UMRS 1137, University Paris Diderot, Sorbonne Paris Cité, Paris, France.,13 INSERM, IAME, U1137, Paris, France; and
| | - Didier Dreyfuss
- 2 INSERM UMR S 1155 "Common and Rare Kidney Diseases: from Molecular Events to Precision Medicine," and.,11 AP-HP, Hôpital Louis Mourier, Service de Réanimation Médico-Chirurgicale, Colombes, France.,14 University Paris Diderot, Sorbonne Paris Cité, Paris, France
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Brown SM, Beesley SJ, Stubben C, Wilson EL, Presson AP, Grissom C, Maguire C, Rondina MT, Hopkins RO. Postseptic Cognitive Impairment and Expression of APOE in Peripheral Blood: The Cognition After SepsiS (CASS) Observational Pilot Study. J Intensive Care Med 2020; 36:262-270. [PMID: 31916880 PMCID: PMC8721590 DOI: 10.1177/0885066619897604] [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] [Indexed: 01/08/2023]
Abstract
BACKGROUND Cognitive impairment after sepsis is an important clinical problem. Determinants of postseptic cognitive impairment are not well understood. We thus undertook a systems biology approach to exploring a possible role for apolipoprotein E (APOE) in postseptic cognitive impairment. DESIGN Prospective, observational cohort. SETTING Intermountain Medical Center, a tertiary referral center in Utah. PATIENTS/PARTICIPANTS Patients with sepsis admitted to study intensive care units. INTERVENTIONS None. METHODS We obtained peripheral blood for deep sequencing of RNA and followed up survivors at 6 months with a battery of cognitive instruments. We defined cognitive impairment based on the 6-month Hayling test of executive function. In our primary analysis, we employed weighted network analysis. Secondarily, we compared variation in gene expression between patients with normal versus impaired cognition. MEASUREMENTS AND MAIN RESULTS We enrolled 40 patients, of whom 34 were follow-up eligible and 31 (91%) completed follow-up; 1 patient's RNA sample was degraded-the final analytic cohort was 30 patients. Mean Hayling test score was 5.8 (standard deviation 1.1), which represented 20% with impaired executive function. The network module containing APOE was dominated by low-expression genes, with no association on primary analysis (P = .8). Secondary analyses suggested several potential lines of future investigation, including oxidative stress. CONCLUSIONS In this prospective pilot cohort, executive dysfunction affected 1 in 5 survivors of sepsis. The APOE gene was sparsely transcribed in peripheral leukocytes and not associated with cognitive impairment. Future lines of research are suggested.
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Affiliation(s)
- Samuel M Brown
- Center for Humanizing Critical Care, Intermountain Healthcare, Murray, UT, USA.,Department of Medicine, Pulmonary and Critical Care Division, 98078Intermountain Medical Center, Murray, UT, USA.,Department of Medicine, Pulmonary and Critical Care Division, 7060University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Sarah J Beesley
- Center for Humanizing Critical Care, Intermountain Healthcare, Murray, UT, USA.,Department of Medicine, Pulmonary and Critical Care Division, 98078Intermountain Medical Center, Murray, UT, USA.,Department of Medicine, Pulmonary and Critical Care Division, 7060University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Chris Stubben
- Bioinformatics Shared Resource, 20270Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Emily L Wilson
- Center for Humanizing Critical Care, Intermountain Healthcare, Murray, UT, USA.,Department of Medicine, Pulmonary and Critical Care Division, 98078Intermountain Medical Center, Murray, UT, USA
| | - Angela P Presson
- Division of Epidemiology, Study Design and Biostatistics Center, 7060University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Colin Grissom
- Department of Medicine, Pulmonary and Critical Care Division, 98078Intermountain Medical Center, Murray, UT, USA.,Department of Medicine, Pulmonary and Critical Care Division, 7060University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Colin Maguire
- Center for Translational and Clinical Sciences, 7060University of Utah, Salt Lake City, UT, USA.,University of Utah Molecular Medicine Program, 7060University of Utah, Salt Lake City, UT USA.,Departments of Internal Medicine and Pathology, 7060University of Utah, Salt Lake City, UT USA
| | - Matthew T Rondina
- University of Utah Molecular Medicine Program, 7060University of Utah, Salt Lake City, UT USA.,Departments of Internal Medicine and Pathology, 7060University of Utah, Salt Lake City, UT USA.,Department of Internal Medicine and the GRECC, George E. Wahlen VAMC, Salt Lake City, UT, USA
| | - Ramona O Hopkins
- Center for Humanizing Critical Care, Intermountain Healthcare, Murray, UT, USA.,Department of Medicine, Pulmonary and Critical Care Division, 98078Intermountain Medical Center, Murray, UT, USA.,Department of Psychology and Neuroscience Center, Brigham Young University, Provo, UT, USA
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158
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Epidemiology and outcomes of sepsis among hospitalizations with systemic lupus erythematosus admitted to the ICU: a population-based cohort study. J Intensive Care 2020; 8:3. [PMID: 31921427 PMCID: PMC6945625 DOI: 10.1186/s40560-019-0424-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 12/29/2019] [Indexed: 12/27/2022] Open
Abstract
Background Sepsis is the most common cause of premature death among patients with systemic lupus erythematosus (SLE) aged ≤ 50 years in the United States, and infection is the most common cause of admission to the ICU among SLE patients. However, there are no population-level data on the patterns of the demand for critical care services among hospitalized septic patients with SLE or the outcomes of those admitted to the ICU. Methods We performed a retrospective cohort study, using the Texas Inpatient Public Use Data File, to identify SLE hospitalizations aged ≥ 18 years and the subgroups with sepsis and ICU admission during 2009–2014. The patterns of ICU admission among septic hospitalizations were examined. Logistic regression modeling was used to identify predictors of short-term mortality (defined as hospital death or discharge to hospice) among ICU admissions with sepsis and to estimate the risk-adjusted short-term mortality among ICU admissions with and without sepsis. Results Among 94,338 SLE hospitalizations, 17,037 (18.1%) had sepsis and 9409 (55.2%) of the latter were admitted to the ICU. Sepsis accounted for 51.5% of the growth in volume of ICU admissions among SLE hospitalizations during the study period. Among ICU admissions with sepsis, 25.3% were aged ≥ 65 years, 88.6% were female, and 64.4% were non-white minorities. The odds of short-term mortality among septic ICU admissions were increased among those lacking health insurance (adjusted odds ratio 1.40 [95% confidence interval 1.07–1.84]), while being unaffected by gender and race/ethnicity, and remaining unchanged over the study period. On adjusted analyses among ICU admissions, the short-term mortality among those with and without sepsis was 13% (95% CI 12.6–13.3) and 2.7% (95% CI 2.6–2.8), respectively. Sepsis was associated with 63.6% of all short-term mortality events. Conclusions Sepsis is a major, incremental driver of the demand for critical care services among SLE hospitalizations. Despite its relatively low mortality, sepsis was associated with most of the short-term deaths among ICU patients with SLE.
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159
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Prophylactic Haloperidol Effects on Long-term Quality of Life in Critically Ill Patients at High Risk for Delirium: Results of the REDUCE Study. Anesthesiology 2019; 131:328-335. [PMID: 31246603 DOI: 10.1097/aln.0000000000002812] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Delirium incidence in intensive care unit patients is high and associated with impaired long-term outcomes. The use of prophylactic haloperidol did not improve short-term outcome among critically ill adults at high risk of delirium. This study evaluated the effects of prophylactic haloperidol use on long-term quality of life in this group of patients and explored which factors are associated with change in quality of life. METHODS A preplanned secondary analysis of long-term outcomes of the pRophylactic haloperidol usE for DeliriUm in iCu patients at high risk for dElirium (REDUCE) study was conducted. In this multicenter randomized clinical trial, nondelirious intensive care unit patients were assigned to prophylactic haloperidol (1 or 2 mg) or placebo (0.9% sodium chloride). In all groups, patients finally received study medication for median duration of 3 days [interquartile range, 2 to 6] until onset of delirium or until intensive care unit discharge. Long-term outcomes were assessed using the Short Form-12 questionnaire at intensive care unit admission (baseline) and after 1 and 6 months. Quality of life was summarized in the physical component summary and mental component summary scores. Differences between the haloperidol and placebo group and factors associated with changes in quality of life were analyzed. RESULTS Of 1,789 study patients, 1,245 intensive care unit patients were approached, of which 887 (71%) responded. Long-term quality of life did not differ between the haloperidol and placebo group (physical component summary mean score of 39 ± 11 and 39 ± 11, respectively, and P = 0.350; and mental component summary score of 50 ± 10 and 51 ± 10, respectively, and P = 0.678). Age, medical and trauma admission, quality of life score at baseline, risk for delirium (PRE-DELIRIC) score, and the number of sedation-induced coma days were significantly associated with a decline in long-term quality of life. CONCLUSIONS Prophylactic haloperidol use does not affect long-term quality of life in critically ill patients at high risk for delirium. Several factors, including the modifiable factor number of sedation-induced coma days, are associated with decline in long-term outcomes.
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160
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Emergent airway management outside of the operating room - a retrospective review of patient characteristics, complications and ICU stay. BMC Anesthesiol 2019; 19:220. [PMID: 31795993 PMCID: PMC6889440 DOI: 10.1186/s12871-019-0894-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 11/26/2019] [Indexed: 11/24/2022] Open
Abstract
Background Emergent airway management outside of the operating room is a high-risk procedure. Limited data exists about the indication and physiologic state of the patient at the time of intubation, the location in which it occurs, or patient outcomes afterward. Methods We retrospectively collected data on all emergent airway management interventions performed outside of the operating room over a 6-month period. Documentation included intubation performance, and intubation related complications and mortality. Additional information including demographics, ASA-classification, comorbidities, hospital-stay, ICU-stay, and 30-day in-hospital mortality was obtained. Results 336 intubations were performed in 275 patients during the six-month period. The majority of intubations (n = 196, 58%) occurred in an ICU setting, and the rest 140 (42%) occurred on a normal floor or in a remote location. The mean admission ASA status was 3.6 ± 0.5, age 60 ± 16 years, and BMI 30 ± 9 kg/m2. Chest X-rays performed immediately after intubation showed main stem intubation in 3.3% (n = 9). Two immediate (within 20 min after intubation) intubation related cardiac arrest/mortality events were identified. The 30-day in-hospital mortality was 31.6% (n = 87), the overall in-hospital mortality was 37.1% (n = 102), the mean hospital stay was 22 ± 20 days, and the mean ICU-stay was 14 days (13.9 ± 0.9, CI 12.1–15.8) with a 7.3% ICU-readmission rate. Conclusion Patients requiring emergent airway management are a high-risk patient population with multiple comorbidities and high ASA scores on admission. Only a small number of intubation-related complications were reported but ICU length of stay was high.
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161
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Oud L. Herpes Simplex Virus Encephalitis: Patterns of Epidemiology and Outcomes of Patients Admitted to the Intensive Care Unit in Texas, 2008 - 2016. J Clin Med Res 2019; 11:773-779. [PMID: 31803321 PMCID: PMC6879041 DOI: 10.14740/jocmr4025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 10/31/2019] [Indexed: 12/01/2022] Open
Abstract
Background Patients with herpes simplex virus encephalitis (HSVE) often require admission to the intensive care unit (ICU) and have considerably worse outcomes than those not critically ill. The short-term outcomes of critically ill patients in the general population have markedly improved over the past decades. However, the population-level patterns of demand for critical care services among patients with HSVE have not been examined, and it is unknown whether there were corresponding outcome gains among those admitted to the ICU. Methods The Texas Inpatient Public Use Data File was used to identify hospitalizations with HSVE aged ≥ 18 years during 2008 - 2016. ICU admissions were identified using unit-specific revenue codes. The patterns of ICU utilization and those of short-term outcomes (with short-term mortality defined as in-hospital death or discharge to hospice) were examined across demographic strata and over time. Results Among 1,964 hospitalizations with HSVE, 1,176 (59.9%) were admitted to ICU (45.8% aged ≥ 65 years; 53.1% female, among ICU admissions). ICU utilization increased with age (from 47.9% (age 18 - 44 years) through 61.2% (older adults (age ≥ 65 years)); P = 0.0003 for trend), and increased over time only among older adults (odds ratio: 1.06/year (95% confidence interval (CI): 1.01 - 1.12)). Among ICU admissions, routine home discharge, transfer to a post-acute care facility, and short-term mortality occurred in 26.8%, 39.5%, and 18.7%, respectively; the corresponding outcomes for older adults were 10.6%, 51.4%, and 26.2%, respectively. The outcomes for the whole cohort of ICU admissions remained unchanged over time. Conclusions Adults with HSVE had high demand for critical care services, and those admitted to ICU had high short-term mortality and substantial residual morbidity among survivors, which remained unchanged over time. These findings can inform clinicians’ decision-making and discussions about goals of care with affected patients and their surrogates.
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Affiliation(s)
- Lavi Oud
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Texas Tech University Health Sciences Center at the Permian Basin, 701 W. 5th St., Odessa, TX 79763, USA.
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162
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Abstract
Objectives One goal of early mobilization programs is to facilitate discharge home after an ICU hospitalization, but little is known about which factors are associated with this outcome. Our objective was to evaluate factors associated with discharge home among medical ICU patients in an early mobilization program who were admitted to the hospital from home. Design Retrospective cohort study of medical ICU patients in an early mobilization program. Setting Tertiary care center medical ICU. Patients Medical ICU patients receiving early mobilization who were community-dwelling prior to admission. Interventions None. Measurements and Main Results A comprehensive set of baseline, ICU-related, and mobilization-related factors were tested for their association with discharge home using multivariable logistic regression. Among the analytic cohort (n = 183), the mean age was 61.9 years (sd 16.67 yr) and the mean Acute Physiology and Chronic Health Evaluation II score was 23.5 (sd 7.11). Overall, 65.0% of patients were discharged home after their critical illness. In multivariable analysis, each incremental increase in the maximum level of mobility achieved (range, 1-6) during the medical ICU stay was associated with nearly a 50% greater odds of discharge home (odds ratio, 1.46; 95% CI, 1.13-1.88), whereas increased age (odds ratio, 0.95; 95% CI, 0.93-0.98) and greater hospital length of stay (odds ratio, 0.94; 95% CI, 0.90-0.99) were associated with decreased odds of discharge home. Prehospital ambulatory status was not associated with discharge home. Conclusions Among medical ICU patients who resided at home prior to their ICU admission, the maximum level of mobility achieved in the medical ICU was the factor most strongly associated with discharge back home. Identification of this factor upon ICU-to-ward transfer may help target mobilization plans on the ward to facilitate a goal of discharge home.
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163
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Hope AA, Munro CL. Understanding and Improving Critical Care Survivorship. Am J Crit Care 2019; 28:410-412. [PMID: 31676513 DOI: 10.4037/ajcc2019442] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Aluko A. Hope
- Aluko A. Hope is coeditor in chief of the American Journal of Critical Care. He is an associate professor at Albert Einstein College of Medicine and an intensivist and assistant bioethics consultant at Montefiore Medical Center, both in New York City. Cindy L. Munro is coeditor in chief of the American Journal of Critical Care. She is dean and professor, School of Nursing and Health Studies, University of Miami, Coral Gables, Florida
| | - Cindy L. Munro
- Aluko A. Hope is coeditor in chief of the American Journal of Critical Care. He is an associate professor at Albert Einstein College of Medicine and an intensivist and assistant bioethics consultant at Montefiore Medical Center, both in New York City. Cindy L. Munro is coeditor in chief of the American Journal of Critical Care. She is dean and professor, School of Nursing and Health Studies, University of Miami, Coral Gables, Florida
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164
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Hirschberger S, Hübner M, Strauß G, Effinger D, Bauer M, Weis S, Giamarellos-Bourboulis EJ, Kreth S. Identification of suitable controls for miRNA quantification in T-cells and whole blood cells in sepsis. Sci Rep 2019; 9:15735. [PMID: 31672997 PMCID: PMC6823537 DOI: 10.1038/s41598-019-51782-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 09/20/2019] [Indexed: 12/29/2022] Open
Abstract
Complex immune dysregulation is a hallmark of sepsis. The occurring phases of immunosuppression and hyperinflammation require rapid detection and close monitoring. Reliable tools to monitor patient’s immune status are yet missing. Currently, microRNAs are being discussed as promising new biomarkers in sepsis. However, no suitable internal control for normalization of miRNA expression by qPCR has been validated so far, thus hampering their potential benefit. We here present the first evaluation of endogenous controls for miRNA analysis in human sepsis. Novel candidate reference miRNAs were identified via miRNA microArray. TaqMan qPCR assays were performed to evaluate these microRNAs in T-cells and whole blood cells of sepsis patients and healthy controls in two independent cohorts. In T-cells, U48 and miR-320 proved suitable as endogenous controls, while in whole blood cells, U44 and miR-942 provided best stability values for normalization of miRNA quantification. Commonly used snRNA U6 exhibited worst stability in all sample groups. The identified internal controls have been prospectively validated in independent cohorts. The critical importance of housekeeping gene selection is emphasized by exemplary quantification of imuno-miR-150 in sepsis patients. Use of appropriate internal controls could facilitate research on miRNA-based biomarker-use and might even improve treatment strategies in the future.
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Affiliation(s)
- Simon Hirschberger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital, Ludwig Maximilian University (LMU), Munich, Germany.,Walter-Brendel-Center of Experimental Medicine, Ludwig Maximilian University (LMU), Munich, Germany
| | - Max Hübner
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital, Ludwig Maximilian University (LMU), Munich, Germany.,Walter-Brendel-Center of Experimental Medicine, Ludwig Maximilian University (LMU), Munich, Germany
| | - Gabriele Strauß
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital, Ludwig Maximilian University (LMU), Munich, Germany.,Walter-Brendel-Center of Experimental Medicine, Ludwig Maximilian University (LMU), Munich, Germany
| | - David Effinger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital, Ludwig Maximilian University (LMU), Munich, Germany.,Walter-Brendel-Center of Experimental Medicine, Ludwig Maximilian University (LMU), Munich, Germany
| | - Michael Bauer
- Department of Anaesthesiology and Intensive Care Medicine, Friedrich-Schiller University, Jena, Germany.,Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
| | - Sebastian Weis
- Department of Anaesthesiology and Intensive Care Medicine, Friedrich-Schiller University, Jena, Germany.,Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany.,Institute for Infectious Disease and Infection Control, Jena University Hospital, Jena, Germany
| | | | - Simone Kreth
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital, Ludwig Maximilian University (LMU), Munich, Germany. .,Walter-Brendel-Center of Experimental Medicine, Ludwig Maximilian University (LMU), Munich, Germany.
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165
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Silveira DC, Sagi A, Romero R. Are seizures predictors of mortality in critically ill patients in the intensive care unit (ICU)? Seizure 2019; 73:14-16. [PMID: 31689583 DOI: 10.1016/j.seizure.2019.10.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 10/08/2019] [Accepted: 10/10/2019] [Indexed: 11/24/2022] Open
Abstract
PURPOSE This study aimed to determine if seizures in critically ill patients are predictive of in-hospital mortality. METHODS Patients above the age of 55 who underwent continuous electroencephalogram (cEEG) monitoring between 2015 and 2018 at the Hackensack Meridian Health and JFK Neuroscience Institute were included in the present study. Patients were subdivided into those with and without seizures. Age, sex, seizure types, CNS disorders, and other associated comorbidities were collected by chart review. After descriptive analysis, we used multiple logistic regression analyses to evaluate if seizures and mortality were associated. P-values less than 0.05 were considered statistically significant. RESULTS One hundred and one critically ill patients (62.4% female) were included in this study. Sixty-six (65.3%) were between 55 and 75 years of age, while 35 (34.7%) were above 75 years of age. Most patients (n = 31, 83.8%) had focal-onset seizures, and 10 had nonconvulsive status epilepticus (NCSE). Twelve (11.9%) patients with seizures did not survive. However, seizures were not independently associated with mortality in either unadjusted (OR 1.13, CI 0.47-2.72, p = 0.773) or adjusted (OR 1.20, CI 0.35-4.05, p = 0.760) regression models. Secondary predictors of mortality included mechanical ventilation (OR 5.36, CI 1.69-16.96, p = 0.001) and acute ischemic stroke (OR 2.77, CI 1.08-7.09, p = 0.034). CONCLUSION Seizures did not predict in-hospital mortality in critically ill patients. Larger prospective studies are needed to confirm our current findings.
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Affiliation(s)
- Diosely C Silveira
- Hackensack Meridian Health and JFK Neuroscience Institute, 65 James Street, Edison NJ 08820, United States.
| | | | - Raquel Romero
- Hackensack Meridian Health and JFK Neuroscience Institute, 65 James Street, Edison NJ 08820, United States
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166
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Kang J, Yun S, Cho YS, Jeong YJ. Post-intensive care unit depression among critical care survivors: A nationwide population-based study. Jpn J Nurs Sci 2019; 17:e12299. [PMID: 31621193 DOI: 10.1111/jjns.12299] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 08/04/2019] [Indexed: 11/28/2022]
Abstract
AIM To investigate the incidence of post-intensive care unit (ICU) depression and its risk factors among critical care survivors. METHODS The study data were extracted from the database of the National Health Insurance Service of Korea. We retrospectively analyzed data from 161,977 adult patients who were admitted to the ICU for more than 24 hr from January 1, 2012 to December 31, 2014 and survived for more than 1 year after discharge. Risk factors for newly diagnosed depression (Code F32) were analyzed using multiple logistic regression analysis. RESULTS The incidence of post-ICU depression was 18.5%. The major risk factors were enteral nutrition (odds ratio [OR] = 2.28, 95% confidence interval [CI] = 2.19-2.36), cerebrovascular disease (OR = 1.59, 95% CI = 1.54-1.64), and hemi/paraplegia (OR = 1.48, 95% CI = 1.41-1.56). It was observed that cardiopulmonary resuscitation (OR = 0.55, 95% CI = 0.50-0.61) and myocardial infarction (OR = 0.75, 95% CI = 0.71-0.79) lowered depression. CONCLUSIONS The incidence of post-ICU depression was high and influenced by ICU treatment and physical impairments. Healthcare providers must pay attention to the psychological changes in survivors with major risk factors in the recovery process.
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Affiliation(s)
- Jiyeon Kang
- College of Nursing, Dong-A University, Busan, Republic of Korea
| | - Seonyoung Yun
- Department of Nursing, Youngsan University, Yangsan, Kyungnam, Republic of Korea
| | - Young Shin Cho
- Surgical Intensive Care Unit, Kosin University Gospel Hospital, Busan, Republic of Korea
| | - Yeon Jin Jeong
- Department of Nursing, DongJu College, Busan, Republic of Korea
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167
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Granholm A, Perner A, Krag M, Marker S, Hjortrup PB, Haase N, Holst LB, Collet MO, Jensen AKG, Møller MH. External validation of the Simplified Mortality Score for the Intensive Care Unit (SMS-ICU). Acta Anaesthesiol Scand 2019; 63:1216-1224. [PMID: 31273763 DOI: 10.1111/aas.13422] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 04/26/2019] [Accepted: 05/16/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND The Simplified Mortality Score for the Intensive Care Unit (SMS-ICU) is a clinical prediction model, which estimates the risk of 90-day mortality in acutely ill adult ICU patients using 7 readily available variables. We aimed to externally validate the SMS-ICU and compare its discrimination with existing prediction models used with 90-day mortality as the outcome. METHODS We externally validated the SMS-ICU using data from 3282 patients included in the Stress Ulcer Prophylaxis in the Intensive Care Unit trial, which randomised acutely ill adult ICU patients with risk factors for gastrointestinal bleeding to prophylactic pantoprazole or placebo in 33 ICUs in Europe. We assessed discrimination, calibration and overall performance of the SMS-ICU and compared discrimination with the commonly used and more complex SAPS II and SOFA scores. RESULTS Mortality at day 90 was 30.7%. The discrimination (area under the receiver operating characteristic curve) for the SMS-ICU was 0.67 (95% CI: 0.65-0.69), as compared with 0.68 (95% CI: 0.66-0.70, P = 0.35) for SAPS II and 0.63 (95% CI: 0.61-0.65, P < 0.001) for the SOFA score. Calibration (intercept and slope) was 0.001 and 0.786, respectively, and Nagelkerke's R2 (overall performance) was 0.06. The proportions of missing data for the SMS-ICU, SAPS II and SOFA scores were 0.2%, 8.5% and 6.8%, respectively. CONCLUSIONS Discrimination for 90-day mortality of the SMS-ICU in this cohort was poor, but similar to SAPS II and better than that of the SOFA score with markedly less missing data.
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Affiliation(s)
- Anders Granholm
- Department of Intensive Care 4131 Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
| | - Anders Perner
- Department of Intensive Care 4131 Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care Copenhagen Denmark
| | - Mette Krag
- Department of Intensive Care 4131 Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care Copenhagen Denmark
| | - Søren Marker
- Department of Intensive Care 4131 Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care Copenhagen Denmark
| | - Peter Buhl Hjortrup
- Centre for Research in Intensive Care Copenhagen Denmark
- Department of Anaesthesia and Intensive Care Zealand University Hospital Køge Denmark
| | - Nicolai Haase
- Department of Intensive Care 4131 Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
| | - Lars Broksø Holst
- Department of Intensive Care 4131 Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
| | - Marie Oxenbøll Collet
- Department of Intensive Care 4131 Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care Copenhagen Denmark
| | - Aksel Karl Georg Jensen
- Centre for Research in Intensive Care Copenhagen Denmark
- Section of Biostatistics University of Copenhagen Copenhagen Denmark
| | - Morten Hylander Møller
- Department of Intensive Care 4131 Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care Copenhagen Denmark
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Oh TK, Song IA, Jeon YT. Impact of Glasgow Coma Scale scores on unplanned intensive care unit readmissions among surgical patients. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:520. [PMID: 31807502 DOI: 10.21037/atm.2019.10.06] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Physiological instability at discharge from intensive care units (ICU) is known to increase readmission rates among critically ill patients. However, associations between consciousness levels at discharge and readmission rates remain unclear. This study aimed to investigate the association between the Glasgow Coma Scale (GCS) score at discharge and unplanned ICU readmissions in surgical patients. Methods This retrospective cohort study in a single tertiary academic hospital analyzed the electronic health records of adults aged 18 years or older, who were discharged from the ICU between January 2012 and December 2018. The primary endpoint was unplanned readmission within 48 hours after discharge. Multivariable logistic regression analysis was performed. Results Among 9,512 patients, unplanned readmissions occurred in 161 (1.7%). At discharge, GCS and verbal response scores of ≤13 (vs. ≥14) were associated with 2.28-fold higher unplanned readmissions within 48 hours [odds ratio (OR): 2.35, 95% confidence interval (CI): 1.51-3.65, P<0.001]. Sensitivity analysis showed that verbal response scores of ≤4 (vs. 5) at ICU discharge were associated with 2.21-fold higher unplanned readmissions within 48 hours (OR: 2.21, 95% CI: 1.49-3.29, P<0.001), whereas eye or motor responses at time of ICU discharge were not significantly associated with unplanned readmissions (P>0.05). Conclusions In this surgical ICU population cohort, GCS scores at ICU discharge were significantly associated with unplanned readmissions within 48 hours. This association was stronger with GCS scores of ≤13 and with verbal response scores of ≤4 at time of discharge. These findings suggest that surgical ICU patients with GCS scores of ≤13 or verbal response scores of ≤4 should be monitored carefully for discharge in order to avoid unplanned ICU readmissions.
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Affiliation(s)
- Tak Kyu Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - In-Ae Song
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Young-Tae Jeon
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea.,Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul, South Korea
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169
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Sidiras G, Patsaki I, Karatzanos E, Dakoutrou M, Kouvarakos A, Mitsiou G, Routsi C, Stranjalis G, Nanas S, Gerovasili V. Long term follow-up of quality of life and functional ability in patients with ICU acquired Weakness – A post hoc analysis. J Crit Care 2019; 53:223-230. [DOI: 10.1016/j.jcrc.2019.06.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 06/19/2019] [Accepted: 06/20/2019] [Indexed: 12/29/2022]
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170
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Return to Employment after Critical Illness and Its Association with Psychosocial Outcomes. A Systematic Review and Meta-Analysis. Ann Am Thorac Soc 2019; 16:1304-1311. [DOI: 10.1513/annalsats.201903-248oc] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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171
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Kara İ, Kara İ, Bayraktar YŞ, Çiçekci F, Yılmaz H, Duman A, Çelik JB. Bir üniversite hastanesinin yoğun bakım ünitelerinde maliyet analizi. CUKUROVA MEDICAL JOURNAL 2019. [DOI: 10.17826/cumj.463401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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172
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Jarvie L, Robinson C, MacTavish P, Dunn L, Quasim T, McPeake J. Understanding the patient journey: a mechanism to reduce staff burnout? ACTA ACUST UNITED AC 2019; 28:396-397. [PMID: 30925257 DOI: 10.12968/bjon.2019.28.6.396] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | | | | | - Lelia Dunn
- Lead Nurse, Critical Care, NHS Greater Glasgow and Clyde
| | - Tara Quasim
- Senior Clinical Lecturer, University of Glasgow
| | - Joanne McPeake
- Nurse Consultant (Clinical Research and Innovation), NHS Greater Glasgow and Clyde
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173
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Magnitude and Pace of Improvement in Performance of Hospitals Treating Mechanically Ventilated Children in the United States: Analysis From Two National Databases. Crit Care Med 2019; 46:e1112-e1120. [PMID: 30222635 DOI: 10.1097/ccm.0000000000003389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To use two national databases to quantify the pace and magnitude of improvement in hospital performance (as measured by mortality) across hospitals caring for critically ill children in the United States. DESIGN We used empirical Bayes shrinkage estimators to obtain shrinkage estimators of observed/expected mortality ratios for each hospital assuming a Gamma Poisson posterior distribution. Revised mortality rates for each hospital were obtained from the shrunken incidence ratios. SETTING Pediatric Health Information System participating hospital and Kids' Inpatient Database participating hospital. PATIENTS Patients less than or equal to 18 years old who received invasive mechanical ventilation during their hospital stay at a Pediatric Health Information System participating hospital (2005-2015) or a Kids' Inpatient Database participating hospital (1997-2012) were included. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 486,838 patients from 48 Pediatric Health Information System hospitals and 798,840 patients from 947 Kids' Inpatient Database hospitals were included. For the Pediatric Health Information System hospitals, the median shrunken adjusted mortality decreased from 11.66% in 2005 to 7.11% in 2015; for the Kids' Inpatient Database hospitals, it decreased from 5.79% in 1997 to 3.86% in 2012. By 2015, more than 95% of the Pediatric Health Information System hospitals performed better than or as well as the best 25% of the hospitals in 2005. By 2012, 33.7% of Kids' Inpatient Database hospitals performed better than or as well as the best 25% of the hospitals in 1997. CONCLUSIONS This study provides insight into the magnitude of improvement in patient mortality in hospitals caring for critically ill children in the United States. This study quantifies hospital performance in pediatric critical care over time, and it provides benchmarks against which individual hospitals can assess their own performance. In future pediatric epidemiologic studies, we should identify outcomes other than mortality to quantify improvement in hospital performance.
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174
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Preventing Posttraumatic Stress in ICU Survivors: A Single-Center Pilot Randomized Controlled Trial of ICU Diaries and Psychoeducation. Crit Care Med 2019; 46:1914-1922. [PMID: 30119073 DOI: 10.1097/ccm.0000000000003367] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Critical illness can have a significant psychological impact on patients and their families. To inform the design of a larger trial, we assessed feasibility of ICU diaries and psychoeducation to prevent posttraumatic stress disorder, depression, and anxiety following ICU stays. DESIGN Four-arm pilot randomized controlled trial. SETTING A 10-bed tertiary ICU in Winnipeg, MB, Canada. PATIENTS Critically ill patients greater than 17 years old with predicted ICU stays greater than 72 hours and mechanical ventilation duration greater than 24 hours. INTERVENTIONS Patients were randomized to usual care, ICU diary, psychoeducation, or both ICU diary and psychoeducation. MEASUREMENTS AND MAIN RESULTS Our primary objective was to determine feasibility measured by enrollment/mo. Secondary outcomes included acceptability of the ICU diary intervention and psychological distress, including patients' memories 1 week post ICU using the ICU Memory Tool, posttraumatic stress disorder (Impact of Events Scale-Revised), depression, and anxiety symptoms (Hospital Anxiety and Depression Scale) 30 and 90 days post ICU. Over 3.5 years, we enrolled 58 patients, an average of 1.9 participants/mo. Families and healthcare providers wrote a mean of 3.2 diary entries/d (SD, 2.9) and indicated positive attitudes and low perceived burden toward ICU diary participation. A majority of patients reported distressing memories of their ICU stay. Those who received the diary intervention had significantly lower median Hospital Anxiety and Depression Scale anxiety (3.0 [interquartile range, 2-6.25] vs 8.0 [interquartile range, 7-10]; p = 0.01) and depression (3.0 [interquartile range, 1.75-5.25] vs 5.0 [interquartile range, 4-9]; p = 0.04) symptom scores at 90 days than patients who did not receive a diary. CONCLUSIONS ICU diaries are a feasible intervention in a tertiary Canadian ICU context. Preliminary evidence supports the efficacy of ICU diaries to reduce psychological morbidity following discharge.
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175
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Oud L. Contemporary Trends of Outcomes Among ICU Admissions. Chest 2019; 154:464. [PMID: 30080517 DOI: 10.1016/j.chest.2017.09.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 09/20/2017] [Indexed: 10/28/2022] Open
Affiliation(s)
- Lavi Oud
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Texas Tech University Health Sciences Center at the Permian Basin, Odessa, TX.
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176
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Lilly CM, Swami S, Liu X, Riker RR, Badawi O. Response. Chest 2019; 154:465. [PMID: 30080519 DOI: 10.1016/j.chest.2018.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 06/12/2018] [Indexed: 11/25/2022] Open
Affiliation(s)
- Craig M Lilly
- Departments of Medicine, Anesthesiology, and Surgery, the Clinical and Population Health Research Program, and the Graduate School of Biomedical Sciences, University of Massachusetts Medical School, Worcester, MA.
| | | | | | - Richard R Riker
- Maine Medical Center, Tufts University School of Medicine, Portand, ME
| | - Omar Badawi
- Philips Healthcare, Baltimore, MD; Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD
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177
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Five-year mortality and morbidity impact of prolonged versus brief ICU stay: a propensity score matched cohort study. Thorax 2019; 74:1037-1045. [DOI: 10.1136/thoraxjnl-2018-213020] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 06/03/2019] [Accepted: 06/26/2019] [Indexed: 11/03/2022]
Abstract
PurposeLong-term outcomes of critical illness may be affected by duration of critical illness and intensive care. We aimed to investigate differences in mortality and morbidity after short (<8 days) and prolonged (≥8 days) intensive care unit (ICU) stay.MethodsFormer EPaNIC-trial patients were included in this preplanned prospective cohort, 5-year follow-up study. Mortality was assessed in all. For morbidity analyses, all long-stay and—for feasibility—a random sample (30%) of short-stay survivors were contacted. Primary outcomes were total and post-28-day 5-year mortality. Secondary outcomes comprised handgrip strength (HGF, %pred), 6-minute-walking distance (6MWD, %pred) and SF-36 Physical Function score (PF SF-36). One-to-one propensity-score matching of short-stay and long-stay patients was performed for nutritional strategy, demographics, comorbidities, illness severity and admission diagnosis. Multivariable regression analyses were performed to explore ICU factors possibly explaining any post-ICU observed outcome differences.ResultsAfter matching, total and post-28-day 5-year mortality were higher for long-stayers (48.2% (95%CI: 43.9% to 52.6%) and 40.8% (95%CI: 36.4% to 45.1%)) versus short-stayers (36.2% (95%CI: 32.4% to 40.0%) and 29.7% (95%CI: 26.0% to 33.5%), p<0.001). ICU risk factors comprised hypoglycaemia, use of corticosteroids, neuromuscular blocking agents, benzodiazepines, mechanical ventilation, new dialysis and the occurrence of new infection, whereas clonidine could be protective. Among 276 long-stay and 398 short-stay 5-year survivors, HGF, 6MWD and PF SF-36 were significantly lower in long-stayers (matched subset HGF: 83% (95%CI: 60% to 100%) versus 87% (95%CI: 73% to 103%), p=0.020; 6MWD: 85% (95%CI: 69% to 101%) versus 94% (95%CI: 76% to 105%), p=0.005; PF SF-36: 65 (95%CI: 35 to 90) versus 75 (95%CI: 55 to 90), p=0.002).ConclusionLonger duration of intensive care is associated with excess 5-year mortality and morbidity, partially explained by potentially modifiable ICU factors.Trail registration numberNCT00512122.
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178
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Sivanathan L, Wunsch H, Vigod S, Hill A, Pinto R, Scales DC. Mental illness after admission to an intensive care unit. Intensive Care Med 2019; 45:1550-1558. [PMID: 31482222 DOI: 10.1007/s00134-019-05752-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Accepted: 08/16/2019] [Indexed: 12/20/2022]
Abstract
PURPOSE Survivors of critical illness may be at higher risk of developing subsequent mental illness. We sought to determine the risk of new mental illness diagnoses across a large population of intensive care unit (ICU) survivors compared with hospitalized patients. METHODS Population-based study (2005-2015) conducted in adults hospitalized in Ontario, Canada. The primary exposure was ICU admission for ≥ 48 h; secondary exposures were ICU procedures including mechanical ventilation and duration of ICU. The primary outcome was mental illness diagnosed during the year after hospital discharge. To account for case mix differences between ICU and other hospitalized patients, sensitivity analyses were conducted restricting to six pre-specified diagnoses that can lead to hospitalization with or without ICU. RESULTS 1,847,462 patients survived hospitalization, of whom 121,101 were admitted to ICU for ≥ 48 h. ICU patients had a higher rate of new mental illness diagnoses in the year after discharge compared to hospitalized patients (17 vs. 15%, adjusted hazard ratio (aHR) 1.08, 95% CI 1.07-1.10). In analyses restricted to pre-specified most responsible diagnoses, the increased risk associated with ICU was only significant for patients with pneumonia. Among ICU survivors, exposure to mechanical ventilation (aHR: 1.08; 95% CI 1.05-1.12) or longer ICU stays (aHR: 1.004 per day; 95% CI 1.003-1.005) increased the risk of new mental illness diagnosis. CONCLUSIONS ICU was associated with a marginally increased risk of mental illness diagnosis after hospitalization that was often no longer apparent when reason for admission was considered. Patients exposed to mechanical ventilation or longer ICU stays may be at higher risk of subsequent mental illnesses.
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Affiliation(s)
- Lavarnan Sivanathan
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada. .,Department of Anesthesia, University of Toronto, 12th Floor, 123 Edward Street, Toronto, ON, M5G 1E2, Canada.
| | - Hannah Wunsch
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia, University of Toronto, 12th Floor, 123 Edward Street, Toronto, ON, M5G 1E2, Canada.,ICES, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Department of Critical Care Medicine, Sunnybrook Hospital, Toronto, ON, Canada
| | - Simone Vigod
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,ICES, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Department of Psychiatry, Women's College Hospital, Toronto, ON, Canada
| | - Andrea Hill
- Department of Critical Care Medicine, Sunnybrook Hospital, Toronto, ON, Canada
| | - Ruxandra Pinto
- Department of Critical Care Medicine, Sunnybrook Hospital, Toronto, ON, Canada
| | - Damon C Scales
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,ICES, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Department of Critical Care Medicine, Sunnybrook Hospital, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
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179
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Kim DY, Lee MH, Lee SY, Yang BR, Kim HA. Survival rates following medical intensive care unit admission from 2003 to 2013: An observational study based on a representative population-based sample cohort of Korean patients. Medicine (Baltimore) 2019; 98:e17090. [PMID: 31517831 PMCID: PMC6750348 DOI: 10.1097/md.0000000000017090] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 06/22/2019] [Accepted: 08/16/2019] [Indexed: 11/26/2022] Open
Abstract
The decision as to whether patients should be admitted to a medical intensive care unit (ICU), in the absence of information concerning survival rates or prognostic factors in survival, is often challenging. We analyzed survival trends in relation to hospital discharge and examined patient and hospital characteristics associated with survival following ICU care, using a sample of nationwide claims data in Korea from 2002 through 2013. The Korean government implements a compulsory social insurance program that covers the country's entire population, and the Korean National Health Insurance Service-National Sample Cohort (NHIS-NSC) data from 2002 based on this program were used for this study. The NHIS-NSC is a stratified random sample of 1,025,340 subjects selected from around 46 million Koreans. We evaluated annual survival trends using the Kaplan-Meier test. Analyses of the relationship between survival and patient and hospital characteristics were performed using Cox regression analyses. Employing a multivariate model, variables were selected using the forward selection method to consider the multicollinearity of variables. A total of 32,553 patients admitted to an ICU between 2002 and 2013 were identified among the eligible beneficiaries. The number of patients who had histories of ICU admission steadily increased throughout the study period, and patients older than 80 years constituted a progressively increasing proportion of ICU admissions, from 7.3% in 2002 to 16.9% in 2007 to 23.1% in 2013. The mean number of mechanical equipment items applied consistently increased, while no difference was observed in the trend for overall 1-year survival in patients following ICU treatment across the study period: the 1-year survival rate ranged from 66.7% (year 2003) to 64.2% (year 2010). Advanced age, cancer, renal failure, pneumonia, and influenza were all associated with heightened risk of mortality within 1 year. Our results should prove useful to older patients and their clinicians in their decisions regarding whether to seek ICU care, with the goals of improving the end-of life care and optimizing resource utilization.
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Affiliation(s)
- Do Yeun Kim
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang City
| | - Mi Hyun Lee
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang
- Institute for Skeletal Aging, Hallym University, Chunchon
| | - Sung Yeon Lee
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang
| | - Bo Ram Yang
- Medical Research Collaborating Center, Seoul National University Hospital, Seoul 4, Republic of Korea
| | - Hyun Ah Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang
- Institute for Skeletal Aging, Hallym University, Chunchon
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180
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Brown SM, Azoulay E, Benoit D, Butler TP, Folcarelli P, Geller G, Rozenblum R, Sands K, Sokol-Hessner L, Talmor D, Turner K, Howell MD. The Practice of Respect in the ICU. Am J Respir Crit Care Med 2019; 197:1389-1395. [PMID: 29356557 DOI: 10.1164/rccm.201708-1676cp] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Although "respect" and "dignity" are intuitive concepts, little formal work has addressed their systematic application in the ICU setting. After convening a multidisciplinary group of relevant experts, we undertook a review of relevant literature and collaborative discussions focused on the practice of respect in the ICU. We report the output of this process, including a summary of current knowledge, a conceptual framework, and a research program for understanding and improving the practice of respect and dignity in the ICU. We separate our report into findings and proposals. Findings include the following: 1) dignity and respect are interrelated; 2) ICU patients and families are vulnerable to disrespect; 3) violations of respect and dignity appear to be common in the ICU and overlap substantially with dehumanization; 4) disrespect may be associated with both primary and secondary harms; and 5) systemic barriers complicate understanding and the reliable practice of respect in the ICU. Proposals include: 1) initiating and/or expanding a field of research on the practice of respect in the ICU; 2) treating "failures of respect" as analogous to patient safety events and using existing quality and safety mechanisms for improvement; and 3) identifying both benefits and potential unintended consequences of efforts to improve the practice of respect. Respect and dignity are important considerations in the ICU, even as substantial additional research remains to be done.
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Affiliation(s)
- Samuel M Brown
- 1 Center for Humanizing Critical Care, Intermountain Medical Center, Murray, Utah.,2 Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Elie Azoulay
- 3 Medical School, Paris Diderot University, Sorbonne Paris-Cité, Paris, France
| | - Dominique Benoit
- 4 Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium.,5 Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | | | | | - Gail Geller
- 8 Berman Institute of Bioethics and.,9 School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Ronen Rozenblum
- 10 Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ken Sands
- 11 Clinical Services Group, Hospital Corporation of America, Nashville, Tennessee
| | | | - Daniel Talmor
- 12 Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Kathleen Turner
- 13 Department of Nursing, University of California San Francisco Medical Center, San Francisco, California; and
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Chhetri I, Hunt JEA, Mendis JR, Patterson SD, Puthucheary ZA, Montgomery HE, Creagh-Brown BC. Repetitive vascular occlusion stimulus (RVOS) versus standard care to prevent muscle wasting in critically ill patients (ROSProx):a study protocol for a pilot randomised controlled trial. Trials 2019; 20:456. [PMID: 31340849 PMCID: PMC6657179 DOI: 10.1186/s13063-019-3547-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 06/29/2019] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Forty per cent of critically ill patients are affected by intensive care unit-acquired weakness (ICU-AW), to which skeletal muscle wasting makes a substantial contribution. This can impair outcomes in hospital, and can cause long-term physical disability after hospital discharge. No effective mitigating strategies have yet been identified. Application of a repetitive vascular occlusion stimulus (RVOS) a limb pressure cuff inducing brief repeated cycles of ischaemia and reperfusion, can limit disuse muscle atrophy in both healthy controls and bed-bound patients recovering from knee surgery. We wish to determine whether RVOS might be effective in mitigating against muscle wasting in the ICU. Given that RVOS can also improve vascular function in healthy controls, we also wish to assess such effects in the critically ill. We here describe a pilot study to assess whether RVOS application is safe, tolerable, feasible and acceptable for ICU patients. METHODS This is a randomised interventional feasibility trial. Thirty-two ventilated adult ICU patients with multiorgan failure will be recruited within 48 h of admission and randomised to either the intervention arm or the control arm. Intervention participants will receive RVOS twice daily (except only once on day 1) for up to 10 days or until ICU discharge. Serious adverse events and tolerability (pain score) will be recorded; feasibility of trial procedures will be assessed against pre-specified criteria and acceptability by semi-structured interview. Together with vascular function, muscle mass and quality will be assessed using ultrasound and measures of physical function at baseline, on days 6 and 11 of study enrolment, and at ICU and hospital discharge. Blood and urine biomarkers of muscle metabolism, vascular function, inflammation and DNA damage/repair mechanism will also be analysed. The Health questionnaire will be completed 3 months after hospital discharge. DISCUSSION If this study demonstrates feasibility, the derived data will be used to inform the design (and sample size) of an appropriately-powered prospective trial to clarify whether RVOS can help preserve muscle mass/improve vascular function in critically ill patients. TRIAL REGISTRATION ISRCTN Registry, ISRCTN44340629. Registered on 26 October 2017.
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Affiliation(s)
- Ismita Chhetri
- Intensive Care Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, GU2 7XX UK
- Faculty of Health and Medical Sciences, School of Biosciences and Medicine, University of Surrey, Guildford, UK
| | - Julie E. A. Hunt
- Faculty of Health and Medical Sciences, School of Biosciences and Medicine, University of Surrey, Guildford, UK
| | - Jeewaka R. Mendis
- Faculty of Health and Medical Sciences, School of Biosciences and Medicine, University of Surrey, Guildford, UK
| | | | - Zudin A. Puthucheary
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Institute for Sport, Exercise and Health, University College London, London, UK
- Department of Medicine, Centre for Human Health and Performance, University College London, London, UK
- Intensive Care Unit, Royal Free London NHS Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, King’s College London, London,, UK
| | - Hugh E. Montgomery
- Institute for Sport, Exercise and Health, University College London, London, UK
- Department of Medicine, Centre for Human Health and Performance, University College London, London, UK
| | - Benedict C. Creagh-Brown
- Intensive Care Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, GU2 7XX UK
- Faculty of Health and Medical Sciences, School of Biosciences and Medicine, University of Surrey, Guildford, UK
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182
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Postoperative ward monitoring - Why and what now? Best Pract Res Clin Anaesthesiol 2019; 33:229-245. [PMID: 31582102 DOI: 10.1016/j.bpa.2019.06.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 06/11/2019] [Accepted: 06/17/2019] [Indexed: 12/20/2022]
Abstract
The postoperative ward is considered an ideal nursing environment for stable patients transitioning out of the hospital. However, approximately half of all in-hospital cardiorespiratory arrests occur here and are associated with poor outcomes. Current monitoring practices on the hospital ward mandate intermittent vital sign checks. Subtle changes in vital signs often occur at least 8-12 h before an acute event, and continuous monitoring of vital signs would allow for effective therapeutic interventions and potentially avoid an imminent cardiorespiratory arrest event. It seems tempting to apply continuous monitoring to every patient on the ward, but inherent challenges such as artifacts and alarm fatigue need to be considered. This review looks to the future where a continuous, smarter, and portable platform for monitoring of vital signs on the hospital ward will be accompanied with a central monitoring platform and machine learning-based pattern detection solutions to improve safety for hospitalized patients.
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183
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Huang CY, Daniels R, Lembo A, Hartog C, O'Brien J, Heymann T, Reinhart K, Nguyen HB. Life after sepsis: an international survey of survivors to understand the post-sepsis syndrome. Int J Qual Health Care 2019; 31:191-198. [PMID: 29924325 DOI: 10.1093/intqhc/mzy137] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Revised: 04/30/2018] [Accepted: 06/02/2018] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE In this study, we aim to describe the post-sepsis syndrome from the perspective of the sepsis survivors. DESIGN AND SETTING The study is a prospective, observational online international survey. PARTICIPANTS Sepsis survivors enrolled via social media from 13 September 2014 to 13 September 2016. INTERVENTIONS None. MAIN OUTCOME MEASURES Physiologic, physical and psychological function post-sepsis; and patient satisfaction with sepsis-centered care. RESULTS 1731 completed surveys from 41 countries were analyzed, with 79.9% female respondents, age 47.6 ± 14.4 years. The majority of respondents (47.8%) had sepsis within the last year. Survivors reported an increase in sensory, integumentary, digestive, breathing, chest pain, kidney and musculoskeletal problems after sepsis (all P-value <0.0001). Physical functions such as daily chores, running errands, spelling, reading and reduced libido posed increased difficulty (all P-value <0.0001). Within 7 days prior to completing the survey, the survivors reported varying degrees of anxiety, depression, fatigue and sleep disturbance. Sepsis survivors reported dissatisfaction with a number of hospital support services, with up to 29.3% of respondents stating no social services support was provided for their condition. CONCLUSIONS Sepsis survivors suffer from a myriad of physiologic, physical and psychological challenges. Survivors overall reveal dissatisfaction with sepsis-related care, suggesting areas for improvement both in-hospital and post-discharge.
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Affiliation(s)
- Cynthia Y Huang
- Division of Pulmonary, Critical Care, Hyperbaric and Sleep Medicine, Department of Medicine, Loma Linda University, Loma Linda, California, USA
| | - Ron Daniels
- The UK Sepsis Trust, Birmingham B2 5SN, UK; and Department of Critical Care, Heart of England NHS Foundation Trust, Sutton Coldfield, UK
| | - Angie Lembo
- Sepsis Survivor, Sepsis Survivors Inc., Corona, California, USA
| | - Christiane Hartog
- Center for Sepsis Control and Care, University Hospital of Jena, 07747 Jena; and Patient- and Family-Centered Care, Klinik Bavaria Kreischa, Kreischa, Germany
| | | | | | - Konrad Reinhart
- Center for Sepsis Control and Care, University Hospital of Jena, 07747 Jena; and Patient- and Family-Centered Care, Klinik Bavaria Kreischa, Kreischa, Germany.,Global Sepsis Alliance, Jena, Germany
| | - H Bryant Nguyen
- Division of Pulmonary, Critical Care, Hyperbaric and Sleep Medicine, Department of Medicine, Loma Linda University, Loma Linda, California, USA
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184
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Werner D, Alawi SA. Four Extremity Amputation and Bionic Prosthesis Supply after Disseminated Intravascular Coagulation: A Follow-Up on Functionality and Quality of Life after Bionic Prosthesis Supply. World J Plast Surg 2019; 8:146-162. [PMID: 31309051 PMCID: PMC6620819 DOI: 10.29252/wjps.8.2.146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Disseminated intravascular coagulopathy (DIC) is a rare symptom complex that causes embolisms within the microvasculature and extensive necrosis of the skin and the acres. During surgical decision-making, preserving functionally important structures must be weighed against radical debridement. The aim was to analyze functional recovery and quality of life of patients sustaining amputations from disseminated intravascular coagulopathy and supplied with bionic prostheses. METHODS A monocentric, retrospective review of patients with disseminated intravascular coagulopathy after sepsis was conducted from 2016 to 2018. After initial reconstruction and intensive care treatment, patients were provided with bionic prosthetic devices. A follow-up survey measuring function and quality of life was performed. RESULTS Three patients (mean: 45 years; median: 50 years) were analyzed. The first necrectomy and amputation were performed, on average, after >4 weeks post-symptom onset. All patients required re-amputation, averaging two or one re-amputations in the right or left upper extremity, respectively, and one in the lower extremities. On average, 12 operations for reconstruction of skin defects were required (x͂=8). On average, patients tolerated their prostheses for 5.67 h per day. Satisfaction metrics were either sufficient (SF-36, x̅=69) or moderate (TAPES-R, x̅=4.7). Physical skills were rated poor to fair (average TAPES-R=2.67). CONCLUSION Supplying bionic prostheses after DIC yielded sufficient to moderate results. However, prothesis weight, signal transmission disorders, and repeated functional failures were suboptimal. For extensive stump scarring, implantable signal electrodes may improve signal transmission.
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Affiliation(s)
- Dennis Werner
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover Medical School, Hannover, Germany
| | - Seyed Arash Alawi
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover Medical School, Hannover, Germany
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185
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Connelly C, Jarvie L, Daniel M, Monachello E, Quasim T, Dunn L, McPeake J. Understanding what matters to patients in critical care: An exploratory evaluation. Nurs Crit Care 2019; 25:214-220. [PMID: 31304999 DOI: 10.1111/nicc.12461] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 05/14/2019] [Accepted: 06/07/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND The delivery of person-centred care is a key priority for managers, policy makers, and clinicians in health care. The delivery person-centred care in critical care is challenging because of competing demands. AIMS AND OBJECTIVES The aim of this quality improvement project was to understand what mattered to patients on a daily basis within the critical care environment. It aimed to understand personal goals and what patients needed to improve their experience. This paper reports on the outputs from this quality improvement project. DESIGN AND DATA ANALYSIS During each daily ward round, patients were asked "what matters to you today?" Outputs from this were entered into the Daily Goals Sheet, which is utilized for every patient in our critical care unit or in the nursing notes. Using Framework Analysis, prevalent themes were extracted from the patient statements documented. RESULTS A total of 196 unique patients were included in this analysis alongside 592 patient statements. Four broad themes were generated: medical outcomes and information, the critical care environment, personal care, and family and caregivers. CONCLUSION The analysis of the data from this quality improvement project has demonstrated that, by asking a simple question within the context of a ward round, care can be enhanced and personalized and long-term outcomes potentially improved. More research is required to understand what the optimal methods are of implementing these requests. RELEVANCE TO CLINICAL PRACTICE Two main recommendations from practice emerged from this quality improvement project: asking patients "what matters to you?" on a daily basis may help support the humanization of the critical care environment, and visiting and access by families must be discussed with patients to ensure this is appropriate for their needs.
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Affiliation(s)
- Christine Connelly
- Critical Care, Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Lyndsey Jarvie
- Critical Care, Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Malcolm Daniel
- Critical Care, Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Emma Monachello
- Critical Care, Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Tara Quasim
- Critical Care, Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, UK.,School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Lelia Dunn
- Critical Care, Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Joanne McPeake
- Critical Care, Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, UK.,School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
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186
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Warrillow S, Bailey M, Pilcher D, Kazemi A, McArthur C, Young P, Bellomo R. Characteristics and outcomes of patients with acute liver failure admitted to Australian and New Zealand intensive care units. Intern Med J 2019; 49:874-885. [DOI: 10.1111/imj.14167] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Revised: 11/20/2018] [Accepted: 11/20/2018] [Indexed: 12/22/2022]
Affiliation(s)
- Stephen Warrillow
- Department of Intensive Care, Austin Health Melbourne Australia
- School of MedicineUniversity of Melbourne Melbourne Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research CentreMonash University School of Public Health and Preventive Medicine Melbourne Australia
| | - David Pilcher
- Australian and New Zealand Intensive Care Research CentreMonash University School of Public Health and Preventive Medicine Melbourne Australia
- Department of Intensive Care, Alfred Health Melbourne Australia
| | - Alex Kazemi
- Intensive Care Unit, Middlemore Hospital Auckland New Zealand
| | - Colin McArthur
- Department of Critical Care MedicineAuckland City Hospital Auckland New Zealand
- Medical Research Institute of New Zealand Auckland New Zealand
| | - Paul Young
- Medical Research Institute of New Zealand Auckland New Zealand
- Intensive Care Unit, Wellington Hospital Wellington New Zealand
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Health Melbourne Australia
- School of MedicineUniversity of Melbourne Melbourne Australia
- Department of Intensive Care, Alfred Health Melbourne Australia
- Department of Intensive Care Royal Melbourne Hospital Melbourne Australia
- Data Analytics Research and Evaluation (DARE) CentreAustin Hospital and University of Melbourne Melbourne Australia
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187
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Wood MD, Khan J, Lee KFH, Maslove DM, Muscedere J, Hunt M, Scott SH, Day A, Jacobson JA, Ball I, Slessarev M, O'Regan N, English SW, McCredie V, Chasse M, Griesdale D, Boyd JG. Assessing the relationship between near-infrared spectroscopy-derived regional cerebral oxygenation and neurological dysfunction in critically ill adults: a prospective observational multicentre protocol, on behalf of the Canadian Critical Care Trials Group. BMJ Open 2019; 9:e029189. [PMID: 31243036 PMCID: PMC6597627 DOI: 10.1136/bmjopen-2019-029189] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Survivors of critical illness frequently exhibit acute and chronic neurological complications. The underlying aetiology of this dysfunction remains unknown but may be associated with cerebral ischaemia. This study will use near-infrared spectroscopy to non-invasively quantify regional cerebral oxygenation (rSO2) to assess the association between poor rSO2 during the first 72 hours of critical illness with delirium severity, as well as long-term sensorimotor and cognitive impairment among intensive care unit (ICU) survivors. Further, the physiological determinants of rSO2 will be examined. METHODS AND ANALYSIS This multicentre prospective observational study will consider adult patients (≥18 years old) eligible for enrolment if within 24 hours of ICU admission, they require mechanical ventilation and/or vasopressor support. For 72 hours, rSO2 will be continuously recorded, while vital signs (eg, heart rate) and peripheral oxygenation saturation will be concurrently captured with data monitoring software. Arterial and central venous gases will be sampled every 12 hours for the 72 hours recording period and will include: pH, PaO2, PaCO2, and haemoglobin concentration. Participants will be screened daily for delirium with the confusion assessment method (CAM)-ICU, whereas the brief-CAM will be used on the ward. At 3 and 12 months post-ICU discharge, neurological function will be assessed with the Repeatable Battery for the Assessment of Neuropsychological Status and KINARM sensorimotor and cognitive robot-based behavioural tasks. ETHICS AND DISSEMINATION The study protocol has been approved in Ontario by a central research ethics board (Clinical Trials Ontario); non-Ontario sites will obtain local ethics approval. The study will be conducted under the guidance of the Canadian Critical Care Trials Group (CCCTG) and the results of this study will be presented at national meetings of the CCCTG for internal peer review. Results will also be presented at national/international scientific conferences. On completion, the study findings will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT03141619.
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Affiliation(s)
- Michael D Wood
- Centre For Neuroscience Studies, Queen's University, Kingston, Ontario, Canada
| | - Jasmine Khan
- Centre For Neuroscience Studies, Queen's University, Kingston, Ontario, Canada
| | - Kevin F H Lee
- School of Medicine, Queen's University, Kingston, Ontario, Canada
| | - David M Maslove
- Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | - John Muscedere
- Critical Care Medicine, Kingston General Hospital, Kingston, Ontario, Canada
| | - Miranda Hunt
- Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | - Stephen H Scott
- Centre For Neuroscience Studies, Queen's University, Kingston, Ontario, Canada
| | - Andrew Day
- Department of Community Health and Epidemiology and CERU, Queen's University, Kingston, Ontario, Canada
| | | | - Ian Ball
- Medicine, London Health Sciences Centre, London, Ontario, Canada
| | - Marat Slessarev
- Medicine, Division of Geriatric Medicine, Western University, London, Ontario, Canada
| | - Niamh O'Regan
- Medicine, Division of Geriatric Medicine, Western University, London, Ontario, Canada
| | - Shane W English
- Medicine (Critical Care), University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Victoria McCredie
- Medicine; Critical Care, University of Toronto; Toronto Western Hospital, University Health Network, Toronto, Canada
| | - Michaël Chasse
- Medicine (Critical Care), Centre Hospitalier de L'Universite de Montreal, Montréal, Quebec, Canada
| | - Donald Griesdale
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - J Gordon Boyd
- Critical Care Medicine, Kingston General Hospital, Kingston, Ontario, Canada
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Abstract
PURPOSE OF REVIEW Many hospitals, particularly large academic centers, have begun to provide 24-h in-house intensive care attending coverage. Proposed advantages for this model include improved patient care, greater provider, nursing and patient satisfaction, better communication, and greater cost-effectiveness. This review will evaluate current evidence with respect to 24/7 coverage, including patient outcomes, cost-effectiveness, and impact on training/education. RECENT FINDINGS Evidence surrounding 24-h intensivist staffing has been mixed. Although a subset of studies suggest a possible benefit to 24-h intensivist coverage, recent prospective studies have shown no difference in major patient outcomes, including mortality and ICU length of stay between patients in ICUs with and those without 24-h intensivist coverage. SUMMARY Although some studies cite increased caregiver and patient satisfaction, outcome studies find no consistent effect on patient-centered outcomes such as mortality or length of stay. Downsides to in-house nighttime attending staffing include physician burnout, adverse effects on physician health, decreased trainee autonomy, and effects on trainee specialty choices because of undesirable lifestyle considerations. Tele-ICU and other novel approaches may allow for attending supervision without physical presence.
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189
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El-Gabalawy R, Sommer JL, Pietrzak R, Edmondson D, Sareen J, Avidan MS, Jacobsohn E. Post-traumatic stress in the postoperative period: current status and future directions. Can J Anaesth 2019; 66:1385-1395. [DOI: 10.1007/s12630-019-01418-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 04/19/2019] [Accepted: 04/22/2019] [Indexed: 11/24/2022] Open
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Covino M, Carbone L, Simeoni B. Could hypoglycemia and hypoalbuminemia allow the identification of septic patients at high mortality risk in addition of clinical scores? Intern Emerg Med 2019; 14:499-501. [PMID: 30927168 DOI: 10.1007/s11739-019-02081-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 03/23/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Marcello Covino
- Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| | - Luigi Carbone
- Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Benedetta Simeoni
- Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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191
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Morin L, Pierre A, Tissieres P, Miatello J, Durand P. Actualités sur le sepsis et le choc septique de l’enfant. MEDECINE INTENSIVE REANIMATION 2019. [DOI: 10.3166/rea-2018-0080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
L’incidence du sepsis de l’enfant augmente en réanimation pédiatrique. La définition du sepsis et du choc septique de l’enfant est amenée à évoluer à l’instar de celle du choc septique de l’adulte pour détecter les patients nécessitant une prise en charge urgente et spécialisée. La prise en charge d’un patient septique repose sur une oxygénothérapie, une expansion volémique au sérum salé isotonique, une antibiothérapie et un transfert dans un service de réanimation ou de surveillance continue pédiatrique. Le taux et la cinétique d’élimination du lactate plasmatique est un bon critère diagnostic et pronostic qui permet de guider la prise en charge. La présence de plusieurs défaillances d’organes ou une défaillance circulatoire aiguë signe le diagnostic de sepsis encore dit sévère, et leur persistance et/ou la non-correction de l’hypotension artérielle malgré un remplissage vasculaire d’au moins 40 ml/kg définit le choc septique chez l’enfant. Dans ce cas, la correction rapide de l’hypotension artérielle persistante repose sur la noradrénaline initiée sur une voie intraveineuse périphérique dans l’attente d’un accès veineux central. L’échographie cardiaque est un examen clé de l’évaluation hémodynamique du patient, pour guider la poursuite de l’expansion volémique ou détecter une cardiomyopathie septique. Des thérapeutiques additionnelles ont été proposées pour prendre en charge certains patients avec des défaillances d’organes particulières. L’immunomonitorage et la modulation sont un ensemble de techniques qui permettent la recherche et le traitement de certaines complications. La Surviving Sepsis Campaign a permis d’améliorer la prise en charge de ces patients par l’implémentation d’algorithmes de détection et de prise en charge du sepsis de l’enfant. Une révision pédiatrique de cette campagne est attendue prochainement.
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192
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Nelliot A, Dinglas VD, O’Toole J, Patel Y, Mendez-Tellez PA, Nabeel M, Friedman LA, Hough CL, Hopkins RO, Eakin MN, Needham DM. Acute Respiratory Failure Survivors' Physical, Cognitive, and Mental Health Outcomes: Quantitative Measures versus Semistructured Interviews. Ann Am Thorac Soc 2019; 16:731-737. [PMID: 30844293 PMCID: PMC6543476 DOI: 10.1513/annalsats.201812-851oc] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 03/06/2019] [Indexed: 02/02/2023] Open
Abstract
Rationale: Increasingly, patients are surviving acute respiratory failure (ARF), prompting the need to better understand standardized outcome measures commonly used during ARF follow-up studies. Objectives: Investigate standardized outcome measures (patient-reported physical and mental health measures, and cognitive testing) compared with findings from semistructured, qualitative interviews. Methods: As part of two ARF multicenter follow-up studies, standardized outcome measures were obtained, followed by qualitative evaluation via an in-depth, semistructured interview conducted and coded by two independent researchers. Qualitative interviews revealed the following post-ARF survivorship themes: physical impairment; anxiety, depression, and post-traumatic stress disorder symptoms; and cognitive impairment. Scores from standardized measures related to these themes were compared for ARF survivors reporting versus not reporting these themes in their qualitative interviews. Results: Of 59 invited ARF survivors, 48 (81%) completed both standardized outcome measures and qualitative interviews. Participants' median (interquartile range) age was 53 (43-64) years; 54% were female, and 88% were living independently before hospitalization. The two independent reviewers classifying the presence or absence of themes from the qualitative interviews had excellent agreement (κ = 0.80). There were significantly worse scores on standardized outcome measures for survivors reporting (vs. not reporting) physical and mental health impairments in their qualitative interviews. However, standardized cognitive test scores did not differ between patients reporting versus not reporting cognitive impairments in their qualitative interviews. Conclusions: These findings support the use of recommended, commonly used standardized outcome measures for physical and mental health impairments in ARF survivorship research. However, caution is needed in interpreting self-reported cognitive function compared with standardized cognitive testing.
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Affiliation(s)
- Archana Nelliot
- Outcomes After Critical Illness and Surgery Group, and
- Division of Pulmonary and Critical Care Medicine
| | - Victor D. Dinglas
- Outcomes After Critical Illness and Surgery Group, and
- Division of Pulmonary and Critical Care Medicine
| | | | - Yashika Patel
- Campbell University School of Osteopathic Medicine, Lillington, North Carolina
| | - Pedro A. Mendez-Tellez
- Outcomes After Critical Illness and Surgery Group, and
- Department of Anesthesiology and Critical Care Medicine, and
| | - Mohammed Nabeel
- Department of Pulmonary and Critical Care Medicine, University of Maryland Medical Center, Baltimore, Maryland
| | - Lisa Aronson Friedman
- Outcomes After Critical Illness and Surgery Group, and
- Division of Pulmonary and Critical Care Medicine
| | - Catherine L. Hough
- Division of Pulmonary, Critical Care, and Sleep Medicine, Harborview Medical Center, University of Washington, Seattle, Washington
| | - Ramona O. Hopkins
- Pulmonary and Critical Care Division, Department of Medicine, Intermountain Medical Center, Murray, Utah
- Center for Humanizing Critical Care, Intermountain Health Care, Murray, Utah; and
- Psychology Department and Neuroscience Center, Brigham Young University, Provo, Utah
| | - Michelle N. Eakin
- Outcomes After Critical Illness and Surgery Group, and
- Division of Pulmonary and Critical Care Medicine
| | - Dale M. Needham
- Outcomes After Critical Illness and Surgery Group, and
- Division of Pulmonary and Critical Care Medicine
- Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, Maryland
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193
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ICU mortality and variables associated with ICU survival in Poland: A nationwide database study. Eur J Anaesthesiol 2019; 35:949-954. [PMID: 30234666 DOI: 10.1097/eja.0000000000000889] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Recently published international comparison data across European countries revealed high mortality rates in Polish ICUs. OBJECTIVES Estimation of the rate of ICU mortality and identification of variables associated with ICU survival in Poland. DESIGN Retrospective analyses of a database reporting ICU stays in Poland. SETTINGS AND PATIENTS The study included data from all adult patients admitted to an ICU in Poland from 1 January 2012 to 31 December 2012. MAIN OUTCOME MEASURES ICU mortality and variables associated with ICU survival. RESULTS A total of 48 282 patients were treated in 347 ICUs (mean age 63.1 ± 16.8 years, 59% men) with 20 278 deaths (42.0%). Variables associated with ICU survival were: tertiary level of hospital care [relative risk (RR) 0.86, 95% confidence interval (CI) 0.80 to 0.92, P < 0.001]; high annual patient volume in the ICU (RR 0.9995 patient year, 95% CI 0.9994 to 0.9996, P < 0.001); younger patient age (RR 1.025 year, 95% CI 1.024 to 1.026, P < 0.001); female sex (RR 0.92, 95% CI 0.88 to 0.96; P < 0.001); and lower number of comorbidities (RR 1.33, 95% CI 1.31 to 1.35, P < 0.001). CONCLUSION ICU mortality was high in Poland. Structural variables, such as the level of hospital care and annual patient volume, may be associated with ICU survival.
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Kemp HI, Laycock H, Costello A, Brett SJ. Chronic pain in critical care survivors: a narrative review. Br J Anaesth 2019; 123:e372-e384. [PMID: 31126622 DOI: 10.1016/j.bja.2019.03.025] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 02/22/2019] [Accepted: 03/19/2019] [Indexed: 01/28/2023] Open
Abstract
Chronic pain is an important problem after critical care admission. Estimates of the prevalence of chronic pain in the year after discharge range from 14% to 77% depending on the type of cohort, the tool used to measure pain, and the time point when pain was assessed. The majority of data available come from studies using health-related quality of life tools, although some have included pain-specific tools. Nociceptive, neuropathic, and nociplastic pain can occur in critical care survivors, but limited information about the aetiology, body site, and temporal trajectory of pain is currently available. Older age, pre-existing pain, and medical co-morbidity have been associated with pain after critical care admission. No trials were identified of interventions to target chronic pain in survivors specifically. Larger studies, using pain-specific tools, over an extended follow-up period are required to confirm the prevalence, identify risk factors, explore any association between acute and chronic pain in this setting, determine the underlying pathological mechanisms, and inform the development of future analgesic interventions.
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Affiliation(s)
- Harriet I Kemp
- Department of Surgery and Cancer, Imperial College London, London, UK.
| | - Helen Laycock
- Department of Surgery and Cancer, Imperial College London, London, UK
| | | | - Stephen J Brett
- Department of Surgery and Cancer, Imperial College London, London, UK
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195
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Prognostication of Critically Ill Patients With Cancer: A Long Road Ahead. Crit Care Med 2019; 45:1787-1788. [PMID: 28915176 DOI: 10.1097/ccm.0000000000002611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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196
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Stick to What You Know: Do Visiting Intensivists Worsen Outcomes? Crit Care Med 2019; 45:1095-1096. [PMID: 28509732 DOI: 10.1097/ccm.0000000000002424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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197
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Miyamoto Y, Iwagami M, Aso S, Yasunaga H, Matsui H, Fushimi K, Hamasaki Y, Nangaku M, Doi K. Temporal change in characteristics and outcomes of acute kidney injury on renal replacement therapy in intensive care units: analysis of a nationwide administrative database in Japan, 2007-2016. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:172. [PMID: 31092273 PMCID: PMC6521368 DOI: 10.1186/s13054-019-2468-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 05/07/2019] [Indexed: 11/18/2022]
Abstract
Background We aimed to examine recent trends in patient characteristics and mortality in patients with acute kidney injury (AKI) receiving renal replacement therapy (RRT), including continuous RRT (CRRT) and intermittent RRT (IRRT), in intensive care units (ICUs). Methods From the Diagnosis Procedure Combination database in Japan during 6 months (July–December) from 2007 to 2016, we identified patients with AKI who received RRT in ICUs. We restricted the study participants to those admitted to hospitals (in which both CRRT and IRRT were available) that participated in the Diagnosis Procedure Combination database for all 10 years. We examined the trends in patient characteristics and mortality overall, by RRT modality, and by main diagnosis category subgroup. Logistic regression was used to adjust for patient characteristics. Results We identified 51,758 patients starting RRT in 287 hospitals, including 39,471 (76.3%) and 12,287 (23.7%) patients starting CRRT and IRRT. The crude in-hospital mortality declined from 44.9 to 36.1% (P for trend < 0.001). Compared with 2007, the adjusted odds ratio (aOR) for in-hospital mortality was 0.66 (95% confidence interval (CI) 0.60–0.72) in 2016, and the decreasing trend was observed in both patients starting CRRT (aOR 0.67, 95% CI 0.61–0.75) and IRRT (0.58, 0.45–0.74), and in all subgroups except for coronary artery disease: sepsis aOR 0.68 (95% CI 0.57–0.81); cardiovascular surgery 0.58 (0.45–0.76); coronary artery disease 0.84 (0.60–1.19); non-coronary heart disease 0.78 (0.64–0.94); central nervous system disorders 0.42 (0.28–0.62); trauma 0.39 (0.21–0.72); and other 0.64 (0.50–0.82). Conclusions This nationwide study confirmed a consistent decline in mortality among patients with AKI on RRT in ICUs. The adjusted mortality also declined during the study period; however, physiological variables were not measured in this study and it is possible that RRT may have been indicated for patients with less severe AKI in more recent years. Electronic supplementary material The online version of this article (10.1186/s13054-019-2468-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yoshihisa Miyamoto
- Division of Nephrology and Endocrinology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Masao Iwagami
- Department of Health Services Research, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Shotaro Aso
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - Yoshifumi Hamasaki
- Division of Nephrology and Endocrinology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.,Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.,Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - Kent Doi
- Department of Hemodialysis and Apheresis, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan. .,Department of Acute Care Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.
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198
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Demsey D, Mordhorst A, Griesdale DEG, Papp A. Improved outcomes of renal injury following burn trauma. Burns 2019; 45:1024-1030. [PMID: 31054958 DOI: 10.1016/j.burns.2019.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 03/26/2019] [Accepted: 04/02/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is common in major burn injuries and associated with increased mortality. With advances in surgical and critical care it is unclear if mortality in this population remains this high. This study aims to describe incidence and outcomes of patients admitted to intensive care (ICU) with a burn injury who develop AKI. We additionally sought to determine risk factors for developing AKI. METHODS A historical cohort study of patients admitted to ICU from 2010 to 2016 with major burn injury was conducted. Demographic, laboratory, and clinical information was collected. AKI was defined by Acute Kidney Injury Network (AKIN) classification. Multivariable logistic regression was used to model association between baseline risk factors and risk of AKI. RESULTS Of the 151 patients included, 64 people developed AKI (42%) defined by stages 1-3 of AKIN criteria. The median TBSA was 20% (IQR 9-41). Renal replacement therapy was required in 18/64 (28%) who developed AKI. Multivariable logistic regression demonstrated association between AKI and the following variables: APACHE II score (OR 1.2, 95%CI 1.1-1.3, P = 0.001), age (OR 1.8 per 10-year increase, 95%CI: 1.2-2.5, P = 0.002) and log(TBSA). Fractional polynomial regression analysis demonstrates that the best functional form of TBSA was in the natural logarithm (OR 2.7, 95%CI: 1.5-4.7, p = 0.001). Compared to those without AKI, patients with AKI had longer duration of mechanical ventilation, (median 11 [IQR 6-19] vs. 4 [IQR 2-9] days), ICU stay (15 [IQR 9-22] vs. 6 [IQR 3-10] days), and increased mortality (14 of 64(22%) vs. 4 of 87(5%). CONCLUSIONS AKI is common in patients with a major burn injury. However, mortality is lower than described in the literature, particularly for those who required renal replacement therapy.
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Affiliation(s)
- Daniel Demsey
- Department of Surgery, Division of Plastic Surgery, University of British Columbia, Canada.
| | - Alexa Mordhorst
- University of British Columbia Medical Undergraduate Program, Canada
| | - Donald E G Griesdale
- Department of Anesthesiology, Pharmacology & Therapeutics, Department of Medicine, Division of Critical Care Medicine and Neurology, Center for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, Canada
| | - Anthony Papp
- Department of Surgery, Division of Plastic Surgery, University of British Columbia, Canada
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199
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Poncette AS, Spies C, Mosch L, Schieler M, Weber-Carstens S, Krampe H, Balzer F. Clinical Requirements of Future Patient Monitoring in the Intensive Care Unit: Qualitative Study. JMIR Med Inform 2019; 7:e13064. [PMID: 31038467 PMCID: PMC6658223 DOI: 10.2196/13064] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 03/05/2019] [Accepted: 03/30/2019] [Indexed: 01/25/2023] Open
Abstract
Background In the intensive care unit (ICU), continuous patient monitoring is essential to detect critical changes in patients’ health statuses and to guide therapy. The implementation of digital health technologies for patient monitoring may further improve patient safety. However, most monitoring devices today are still based on technologies from the 1970s. Objective The aim of this study was to evaluate statements by ICU staff on the current patient monitoring systems and their expectations for future technological developments in order to investigate clinical requirements and barriers to the implementation of future patient monitoring. Methods This prospective study was conducted at three intensive care units of a German university hospital. Guideline-based interviews with ICU staff—5 physicians, 6 nurses, and 4 respiratory therapists—were recorded, transcribed, and analyzed using the grounded theory approach. Results Evaluating the current monitoring system, ICU staff put high emphasis on usability factors such as intuitiveness and visualization. Trend analysis was rarely used; inadequate alarm management as well as the entanglement of monitoring cables were rated as potential patient safety issues. For a future system, the importance of high usability was again emphasized; wireless, noninvasive, and interoperable monitoring sensors were desired; mobile phones for remote patient monitoring and alarm management optimization were needed; and clinical decision support systems based on artificial intelligence were considered useful. Among perceived barriers to implementation of novel technology were lack of trust, fear of losing clinical skills, fear of increasing workload, and lack of awareness of available digital technologies. Conclusions This qualitative study on patient monitoring involves core statements from ICU staff. To promote a rapid and sustainable implementation of digital health solutions in the ICU, all health care stakeholders must focus more on user-derived findings. Results on alarm management or mobile devices may be used to prepare ICU staff to use novel technology, to reduce alarm fatigue, to improve medical device usability, and to advance interoperability standards in intensive care medicine. For digital transformation in health care, increasing the trust and awareness of ICU staff in digital health technology may be an essential prerequisite. Trial Registration ClinicalTrials.gov NCT03514173; https://clinicaltrials.gov/ct2/show/NCT03514173 (Archived by WebCite at http://www.webcitation.org/77T1HwOzk)
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Affiliation(s)
- Akira-Sebastian Poncette
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin (corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany.,Einstein Center Digital Future, Berlin, Germany
| | - Claudia Spies
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin (corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany
| | - Lina Mosch
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin (corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany
| | - Monique Schieler
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin (corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany
| | - Steffen Weber-Carstens
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin (corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany
| | - Henning Krampe
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin (corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany
| | - Felix Balzer
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin (corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany.,Einstein Center Digital Future, Berlin, Germany
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200
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Sartini C, Lomivorotov V, Pisano A, Riha H, Baiardo Redaelli M, Lopez-Delgado JC, Pieri M, Hajjar L, Fominskiy E, Likhvantsev V, Cabrini L, Bradic N, Avancini D, Wang CY, Lembo R, Novikov M, Paternoster G, Gazivoda G, Alvaro G, Roasio A, Wang C, Severi L, Pasin L, Mura P, Musu M, Silvetti S, Votta CD, Belletti A, Corradi F, Brusasco C, Tamà S, Ruggeri L, Yong CY, Pasero D, Mancino G, Spadaro S, Conte M, Lobreglio R, Di Fraja D, Saporito E, D'Amico A, Sardo S, Ortalda A, Yavorovskiy A, Riefolo C, Monaco F, Bellomo R, Zangrillo A, Landoni G. A Systematic Review and International Web-Based Survey of Randomized Controlled Trials in the Perioperative and Critical Care Setting: Interventions Increasing Mortality. J Cardiothorac Vasc Anesth 2019; 33:2685-2694. [PMID: 31064730 DOI: 10.1053/j.jvca.2019.03.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 03/10/2019] [Accepted: 03/11/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Reducing mortality is a key target in critical care and perioperative medicine. The authors aimed to identify all nonsurgical interventions (drugs, techniques, strategies) shown by randomized trials to increase mortality in these clinical settings. DESIGN A systematic review of the literature followed by a consensus-based voting process. SETTING A web-based international consensus conference. PARTICIPANTS Two hundred fifty-one physicians from 46 countries. INTERVENTIONS The authors performed a systematic literature search and identified all randomized controlled trials (RCTs) showing a significant increase in unadjusted landmark mortality among surgical or critically ill patients. The authors reviewed such studies during a meeting by a core group of experts. Studies selected after such review advanced to web-based voting by clinicians in relation to agreement, clinical practice, and willingness to include each intervention in international guidelines. MEASUREMENTS AND MAIN RESULTS The authors selected 12 RCTs dealing with 12 interventions increasing mortality: diaspirin-crosslinked hemoglobin (92% of agreement among web voters), overfeeding, nitric oxide synthase inhibitor in septic shock, human growth hormone, thyroxin in acute kidney injury, intravenous salbutamol in acute respiratory distress syndrome, plasma-derived protein C concentrate, aprotinin in high-risk cardiac surgery, cysteine prodrug, hypothermia in meningitis, methylprednisolone in traumatic brain injury, and albumin in traumatic brain injury (72% of agreement). Overall, a high consistency (ranging from 80% to 90%) between agreement and clinical practice was observed. CONCLUSION The authors identified 12 clinical interventions showing increased mortality supported by randomized controlled trials with nonconflicting evidence, and wide agreement upon clinicians on a global scale.
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Affiliation(s)
- Chiara Sartini
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Antonio Pisano
- Division of Cardiac Anesthesia and Intensive Care Unit, AORN dei Colli - Monaldi Hospital, Naples, Italy
| | - Hynek Riha
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Martina Baiardo Redaelli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Marina Pieri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Ludhmila Hajjar
- Instituto do Coracao do Hospital das Clinicas, Sao Paulo, Brazil
| | - Evgeny Fominskiy
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Valery Likhvantsev
- Department of Anesthesiology and Intensive Care, Sechenov First Moscow State Medical University, and Moscow Regional Clinical and Research Institute, Moscow, Russian Federation
| | - Luca Cabrini
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Nikola Bradic
- Department of Cardiovascular Anesthesiology and Cardiac Intensive Medicine, University Hospital Dubrava, Zagreb, Croatia
| | - Daniele Avancini
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Chew Yin Wang
- Anaesthesia and Intensive Care, University of Malaya, Kuala Lumpur, Malaysia
| | - Rosalba Lembo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maxim Novikov
- Saint Petersburg State University, Saint Petersburg, Russia
| | | | - Gordana Gazivoda
- Institute of Cardiovascular Diseases "Dedinje", Belgrade, Serbia
| | | | - Agostino Roasio
- Department of Anaesthesia and Intensive Care, Ospedale Cardinal Massaia di Asti, Asti, Italy
| | - Chengbin Wang
- Center for Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Luca Severi
- Anesthesia and Intensive Care, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| | | | - Paolo Mura
- Department of Anesthesia and Intensive Care Unit, Policlinico Duilio Casula AOU, Cagliari, Italy
| | - Mario Musu
- Department of Medical Sciences and Public Health, University of Cagliari, Monserrato, Italy
| | - Simona Silvetti
- IRCCS Istituto Giannina Gaslini, Ospedale Pediatrico, Genoa, Italy
| | - Carmine Domenico Votta
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Belletti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Corradi
- E.O. Ospedali Galliera, Genova, Italy and Università degli Studi di Pisa, Italy
| | - Claudia Brusasco
- E.O. Ospedali Galliera, Genova, Italy and Università degli Studi di Pisa, Italy
| | - Simona Tamà
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Laura Ruggeri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Chow-Yen Yong
- Anaesthesia and Intensive Care, Hospital Pulau Pinang, Georgetown, Malaysia
| | - Daniela Pasero
- Department of Anesthesia and Intensive Care, A.O.U. Cittàdella Salute e della Scienza, Turin, Italy
| | | | - Savino Spadaro
- Department Morphology, Surgery and Experimental Medicine, Intensive Care Unit, University of Ferrara, Italy
| | | | - Rosetta Lobreglio
- Anesthesia and Intensive Care A.O.U Città della salute e della Scienza, Turin, Italy
| | - Diana Di Fraja
- Division of Cardiac Anesthesia and Intensive Care Unit, AORN dei Colli - Monaldi Hospital, Naples, Italy
| | | | | | - Salvatore Sardo
- Department of Medical Sciences and Public Health, University of Cagliari, Monserrato, Italy
| | - Alessandro Ortalda
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Andrey Yavorovskiy
- Department of Anesthesiology and Intensive Care, Sechenov First Moscow State Medical University, and Moscow Regional Clinical and Research Institute, Moscow, Russian Federation
| | - Claudio Riefolo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fabrizio Monaco
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, Melbourne, Australia
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
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